Neuralgia Inducing Cavitational Osteonecrosis

For the most complete information please visit the site of Dr Jerry Bouquot. (http://maxillofacialcenter.com/)

NICO is a new term for an old disease. NICO stands for Neuralgia Inducing (pain causing) Cavitational (forming a cavity) Osteonecrosis (dead and dying bone). In other words it is a hole in the bone which may cause severe facial pains and other disease states. The condition has been known by many different names in the past and has always been a controversial issue in dentistry. There are similarities between NICO lesions and osteomyelitis but histological examination reveals differences. Surgically one finds a cavity in the bone often below what appears to be normal healthy bone. There is rarely any sign of it on the gums or face in the involved area. X-ray will sometimes reveal a NICO lesion. The person reading the ray must be familiar with what to look for as they can be very subtle.

Other diagnostic techniques are showing value and include

Thermography - detection of temperature differences in different parts of the face or the body generally
Neural Focus Diagnosis ­ this involves using local anesthetic in a particular way to attempt to switch of a symptom which may be caused by the NICO lesion. This is most striking in the case of pain control as the result is often immediate.
Electro dermal screening (electro-acupuncture) ­ the use of different technologies which measure the electrical potential at acupuncture points. These include Listen Systems, Mora, Vega. The area of vibrational medicine has much to offer.
Ultrasound ­ There is now a new approach using ultrasound technology to diagnose NICO lesions ­ it is showing a high degree of reliability.

Although the dental profession in Australia, America and Britain do not acknowledge the reality of the problem there are many European countries which teach about the relationships of dentistry to the rest of the body and the reality of NICO lesions at an undergraduate level.

In Australia the treatment of choice for Trigeminal Neuralgia is initially a course of Tegratol and then possibly Neural Surgery to sever the Trigeminal Nerve at the base of the brain. This approach often does stop the pain for a while but has the side effect of leaving the person with a numb face on the effected area. For some obscure reason that I really do not understand both the dental and medical professions refuse to accept the reality that dead teeth, root therapied teeth and NICO lesions can easily and often be the primary cause of Trigeminal Neuralgia. If the dental focus is the cause of the pain, it is a much simpler matter to remove a dead tooth or clean out a NICO lesion than to do brain surgery, which has serious consequences. If you suffer from Trigeminal or other facial pains I would strongly recommend that you read everything contained at the web site of Dr Jerry Bouquot. (http://maxillofacialcenter.com/). DR Bouquot is by far the worlds leading expert regarding NICO lesions. The website is rather awesome and gets a rave review for quality and information. It is to my knowledge the only site in cyberspace which answers the NICO questions.

As these lesions can act as a neural interference they may be associated with many other disease states. Again this is in line with electro-acupuncture teachings. Careful diagnosis is therefore essential and the dental focus must not be overlooked.

Following are a small sample of the abstracted references associated with NICO. Make sure that you do visit the site of Dr Jerry Bouquot. (http://maxillofacialcenter.com/).

Effects of jawbone curettage on the pain of facial neuralgia.
     Bouquot JE Christian  J Oral Maxillofac Surg (1995 Apr) 53(4):387-97; discussion 397-9

PURPOSE: To evaluate the dimension and duration of pain reduction in patients with facial neuralgias after localization, decortication, and curettage of histologically confirmed inflammatory jawbone lesions of the newly identified form of alveolar avascular osteonecrosis called neuralgia-inducing cavitational osteonecrosis (NICO).

MATERIALS AND METHODS: One hundred ninety patients who could be located retrospectively and who had histories of jawbone curettage for chronic "idiopathic" facial pain, either trigeminal neuralgia (TN) or atypical facial neuralgia/pain (AFN), were identified through surgical pathology reports from four institutions. To assess pain reduction after jawbone surgery, these patients were mailed a modified McGill Pain Survey by investigators with whom they had had no previous professional contact. Patient demographics and clinicopathologic characteristics were also reviewed through surgical pathology specimens and reports.

RESULTS: More than two thirds of the respondents to whom the questionnaire was mailed experienced complete or almost complete disappearance of neuralgic pain immediately or shortly after curettage of jawbone osteonecrosis (NICO), regardless of whether they had previously been diagnosed with TN or AFN. Thirty percent, however, experienced local recurrence of jaw inflammation and facial pain, and one third developed at least one and as many as 12 additional foci of histologically confirmed osteonecrosis. Despite this, however, the long-term (average, 4.6 years) abatement of neuralgic pain was total or almost total in 74% of treated patients.

CONCLUSIONS: Neuraglia-inducing cavitational osteonecrosis appears to be associated with at least some cases of facial neuralgia, or with a pain so similar as to be clinically indistinguishable. Decortication and curettage dramatically reduces or eliminates this intense pain in two of every three patients, although multiple surgeries may be required, and additional sites of osteonecrosis may occur. It is recommended that NICO be included in the differential diagnosis of idiopathic facial pain syndromes.

Institutional address: Maxillofacial Center for Diagnostics and Research Morgantown WV USA

Turp JC Gobetti JP Trigeminal neuralgia versus atypical facial pain. A review of the literature and case repor.

The general characteristics, etiologic characteristics, pathophysiology, differential diagnostic criteria, and therapeutic options of trigeminal neuralgia and atypical facial pain are described. A case report demonstrates the difficulties that can arise in the diagnosis and differentiation between the two disease entities. The article underscores the responsibility clinicians have in correctly diagnosing and managing patients with facial pain conditions.

Comment in: Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996 Oct;82(4):

Shaber EP Krol AJ Trigeminal neuralgia--a new treatment concept. Oral Surg Oral Med Oral Pathol (1980 Apr) 49(4):286-93

A concept for the treatment of trigeminal neuralgia is presented. On the basis of distinctive pain patterns, localized areas of pathosis within the jawbones are detected and obilterated. To date, we have treated eight patients with idiopathic trigeminal neuralgia. All patients have experienced total or near total abatement of pain

Roberts AM Person P Chandran NB Hori JM Further observations on dental parameters of trigeminal and atypical facial neuralgias. Oral Surg Oral Med Oral Pathol (1984 Aug) 58(2):121-9

One hundred thirty-one patients with primary trigeminal neuralgia and 77 patients with atypical facial neuralgia or pain were treated by oral surgical procedures, with complete or almost complete pain remission in 88% of the cases and without persistent residual anesthesias, dysesthesias, or dysalgesias. The following conditions were related to patients' pain perceptions: cavities in alveolar bone at tooth extraction sites, bone fistulas, periodontal infections, and maxillary sinus infections draining into alveolar bone. The bone cavities and fistulas mentioned above were usually not visualized by standard x-ray diagnostic procedures, and their detection required a new diagnostic approach which is described. Microbiologic findings indicated involvement of a mixed, variable flora in the above conditions. Histopathologic observations of scrapings from involved bone showed a variable incidence of bone necrosis, predominantly chronic inflammatory cell populations and fibrous tissue. Department of Dentistry Davis Memorial Hospital Elkins W. Va.

Roberts AM Person P Etiology and treatment of idiopathic trigeminal and atypical facial neuralgias.Oral Surg Oral Med Oral Pathol (1979 Oct) 48(4):298-308

In a series of sixteen patients with idiopathic trigeminal neuralgia and twenty-one patients with atypical facial neuralgia, it was found that the painful phenomena associated with both disorders were, in nearly all instances, closely related to the presence of maxillary or mandibular bone cavities at previous tooth extraction sites. Standard oral surgical procedures for curettage of the cavities, together with administration of antibiotics, were employed in the successful treatment of both the trigeminal and atypical facial neuralgias, with complete pain remissions for periods varying from 2 months (for most recently treated cases) up to 9 years. The observations and results of this study suggest that dental and oral disorders may play a role in the genesis of trigeminal and atypical facial neuralgias.

Ratner EJ Person P Kleinman DJ Shklar G Socransky SS Jawbone cavities and trigeminal and atypical facial neuralgias. In: Oral Surg Oral Med Oral Pathol (1979 Jul) 48(1):3-20

The possible role of dental and oral disease in the etiology of idiopathic trigeminal and atypical facial neuralgias has been examined. Among thirty-eight patients with idiopathic trigeminal neuralgia and twenty-three patients with atypical facial neuralgia, there was in nearly all instances a close relationship between pain experienced and the existence of cavities in alveolar bone and jawbone of the patients. The cavities were at the sites of previous tooth extractions and, although at times more than 1 cm. in a given diameter, were usually not detectable by x-rays. A new method for their detection and localization was developed empirically, based on the observation that peripheral infiltration of local anesthetic into or very close to the bone cavity rapidly abolished trigger and pain perception by patients during persistence of the anesthetic action. Histopathologic examination of bone removed from cavities by curettage revealed, in both idiopathic trigeminal and atypical facial neuralgias, a similar pattern characterized by a highly vascular abnormal healing response of bone. Some lesions presented a mild chronic inflammatory (lymphocytic) infiltration. Preliminary microbiologic studies of material from the walls of the cavities showed the existence within them of a complex, mixed polymicrobial aerobic and anaerobic flora. Treatment consisted of vigorous curettage of the bone cavities, repeated if necessary, plus administration of antibiotics to induce healing and filling-in of the cavities by new bone. Responses of patients to the above treatment consisted of marked to complete pain remissions, the longest of which has been for 9 years. Complete healing leads to complete and persistent pain remissions. It was concluded that in both idiopathic trigeminal and atypical facial neuralgias, dental and oral pathoses may be major etiologic factors.

Bouquot JE, Roberts AM,Person P, Christian J Neuralgia-inducing cavitational osteonecrosis (NICO). Osteomyelitis

In 224 jawbone samples from patients with facial neuralgia [see comments]

A somewhat obscure etiologic theory for facial neuralgias presumes a low-grade osteomyelitis of the jaws that produces neural degeneration with subsequent production of inappropriate pain signals. Animal investigations and treatment successes with human patients based on this theory lend it credence. The present study examined 224 tissue samples removed from alveolar bone cavities in 135 patients with

trigeminal neuralgia or atypical facial neuralgia. All tissue samples demonstrated clear evidence of chronic intraosseous inflammation.

The most common microscopic features included dense marrow fibrosis or "scar" formation, a sprinkling of lymphocytes in a relative absence of other inflammatory cells (especially histiocytes), and smudged, nonresorbing necrotic bone flakes. Very little healing or new bone formation was visible. These lesions were able to burrow several centimeters to initiate distant cavities. The present preliminary investigation cannot prove etiology, but the presence of intraosseous inflammation in every single jawbone specimen in these patients and certain clinical and treatment aspects of these lesions (to be reported later) has led the authors to recommend the term neuralgia-inducing cavitational osteonecrosis or NICO for these lesions. AD - Department of Oral Surgery AD - West Virginia University School of Dentistry. SO - Oral Surg Oral Med Oral Pathol 1992 Mar;73(3):307-19; discussion

Ratner's reports "in 24 out of 25 cases of idiopathic Trigeminal Neuralgia ,

Bone cavities at the sites of previous extraction sites that were associated with trigger and pain distribution patterns experienced by patients" Other studies by Shklar & Socransky support the findings of Ratner that infected bone cavities were the cause of most Atypical Facial Pain and Idiopathic Trigeminal Neuralgia:

Ratner E., Person, Kleinman DJ "Oral Pathology and Trigeminal neuralgia

Clinical Experiences." J. Dent Res. Vol 55 1976 Shklar G., Person., Ratner E., "Oral Pathology and Trigeminal neuralgia

Histopathologic Observations." J. Dent Res. 55 1976 SocranskyS ., Stone C., Ratner., "Oral Pathology and Trigeminal neuralgia

Microbilogical examination". J. Dent Res. Vol 55 1976 Ratner E., Person P., Kleinman D. Shklar G., Socransky., "Jawbone Cavities and Trigeminal and Atypical facial Neuralgias"" Oral Surg, Oral Med., and

Oral Path., 48(1) 1979 3-20 Ratner Langan B and Evins M., "Alveolar Cavitational Osteopathies;

manifestation of an infectious Proces and it's implications in the causation of chronic pain"

J. of Perio. 57(10) 1986 593-603 Roberts A., Persons P., "Etiology and treatment of Idioathic Trigeminal

and atypical facial Neuralgias.

"Oral Surg, Oral Med., and Oral Path 48(4)1979 Roberts A., Persons P., Chandran N. Hori J., Further observations on Dental Parameters of atypical facial Neuralgias.

Oral Surg, Oral Med., and Oral Path 58(2) 1984 Harris W., Neuritis and Neuralgia (London; Oxford Univ. Press 1926

Supporting treatment literature representing over 200 treated cases; Shaber E., Krol A., "Trigeminal Neuralgia - a new treatment concept"

Oral Surg, Oral Med., and Oral Path. 49(4)1980 Mathis B., Oatis G., Grisius R., "Jaw bone cavities associated with facial pain syndromes'

Military Med. 146 (1981) Xiwei J. Quinrong I., the influence of pathological bone cavities of jaw

bone on the etiopathology of trigeminal neuralgia.

Acta Acad Med Sichuan 12(2) 1981 Mortang W.,. Xiwei J., et al. "A study between the relation of the

various trigger zones of idiopathic trigeminal neuralgia and jaw bone cavities,"

Acta Acad Med Sichuan 13(3) 1982 Mortang W.,. Xiwei J., et al. "Localisation method in the diagnosis of the pathological jaw bone cavity"

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