Cavitation

What is it?

A cavitation or ISCHAEMIC OSTEONECROSIS describes the result of a disease process in which the lack of blood supply (ISCHAEMia) to an area of bone resulted in a dead portion of the jawbone or other bones in the body. Neuralgia Inducing Cavitational Osteonecrosis (NICO) is basically the same but it produces neuralgic facial pain. In simplest terms, a cavitation, it’s a hole in the jaw bone, mainly after tooth extraction that hasn’t healed correctly. Dr. G.V. Black (The Father of Modern Dentistry) described this process as early as 1915. Pathogens (a biofilm form of bacteria) are also present in these dead tissues which release highly toxic waste products that can pass into the bloodstream and have detrimental effects to the heart, kidney, joints, immune, nervous, and endocrine systems.

Why does it occurs?

Researches incriminates the dental ligament left behind after an extraction but most likely, cavitations occur due to a combination of initiating events, predisposing risk factors and environmental factors.

a - Trauma:
Notably, if patients had infections following their extractions or traumatic events like dry sockets, there is a greater likelihood of cavitation development. Especially by wisdom teeth extraction which are usually removed at a young age, for orthodontic purposes, between the years 14 to 20 years. This is not ideal, as at this time, young people suffer from several mineral deficiencies due to a strong growth spurt. In many practices, all four wisdom teeth are usually removed at once under general anesthesia, focusing on the shortest surgery possible. Usually, the wound is not fully cleaned and sterilized.

An effective way to sterilized the extraction socket is by using either Laser or Ozone. Many dentists also massively use antibiotics and cortisone preventively by wisdom teeth extraction, blocking the immune system and the natural healing process. Under these circumstances, the bone defect is unable to heal properly, while the gum tissue and the surrounding hard bone is closing there remains a cavity in the cancellous bone, which is either completely empty or filled with fatty degenerative cells mixed with
dead tissue (4).

b - Toxic trauma
Periodontal disease, abscess, root canal bacteria or remain dental materials after extraction can lead to a « bug » in the healing process and create a bone cavitation.

 c- Risk factors:
Such as smoking, stress, alcoholism, blood clotting disorders, age (arteries in the jaw tend to decrease in size with age), chemotherapy or radiation treatment for cancer, rheumatoid arthritis, bone dysplasia, changes in atmospheric pressures, osteoporosis,
thyroid dysfunction, bisphosphonates (medication for osteoporosis).

What are the symptoms?

Jaw cavitations can lead to chronicle neuralgic pain in the head, face or neck (3, 5). The term to describe this is NICO (neuralgia-inducing cavitational osteonecrosis). But in many cases it can also be asymptomatic for many years before symptoms show up. Even if systemic symptoms may appear, they seem to not be related on first sight. Cavitations can also cause blockages on the body's energy meridians and can stress far-reaching organs of the body. Most frequently we can observe unexplained chronicle fatigue and low immune system which make the body subject to frequent infections.

How Toxic Are Cavitations?

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, non resorbing necrotic bone flakes (4). Studies
show that cavitation tissue samples tested contain toxins from polymicrobial aerobic and anaerobic flora (5).
Anaerobic bacteria are known to produce toxins (metabolic waste), which negatively affect the blood supply in the jawbone and leads to ischemia.


Dr. B. Haley (renowned biochemist) found that other types of toxins also accumulate in cavitations, and when these toxins combine with certain chemicals or heavy metals (for example, mercury), much more potent toxins may form. Some authors describe high levels of mercury where found in cavitations by patient with mercury amalgam fillings. Mercury is known to be extremely toxic and can causes chronic adverse local and systemic health effects. Yeast and fungi have also been found to accumulate in cavitations and have significant systemic effects. Finally, the toxins released by anaerobic bacteria in cavitations have been found to have major effects on necessary body enzymes and the immune system (16).


Inflammatory and pro-inflammatory messengers:

J. Lechner and all (8), showed highest concentration for IL 1-ra (Interleukin-1-receptor antagonist) and RANTES CCL5, as well as FGFba- sic and PDGF-BB. RANTES belongs to the group of chemotactic cytokines with pro-inflammatory effects. Increased RANTES concentrations in the serum are described in a large number of inflammatory diseases, like autoimmune diseases, cardiovascular diseases, chronic infections etc. [11–14].

In contrast to RANTES, IL1-ra (interleukin-1-receptor antagonist) acts strongly anti-inflammatory by blocking signal transduction at the interleukin-1 receptor, by inhibiting IL2-secretion and IL2-receptor expression on the cell surface.

In other words, IL1-ra has strong immunosuppressive effects.

Growth factors FGFbasic and PDGF-BB stimulate the migration of osteoblasts and the formation of collagen. Both are assigned an important role in osteogenesis.

All this factors sign an inflammatory activity and can be defined as sort of inflammatory focus or “disturbing fields” in the jaw area.

Factoring chronicity into the considerations, increased RANTES level in the local jaw area is a chronic challenge for the immune system.

One other concern, is that RANTES are found in many other systemic diseases: Multiple Sclerosis (9) Cancer metastasis and breast cancer (10) Immunological-based disease: rheumatic arthritis (8, 15), asthma (8). Human melanoma cells also excrete RANTES (18) Hodgkin lymphoma (19) Lime disease (20) chronic fatigue syndrom (22)

Having one or more foyer of RANTES in the jaw bone could potentially be a burden for the whole system.

How Common are Cavitations?

One study involved an analysis of 112 randomly selected dental patient charts who had been tested for cavitations, with patient age ranging from 19 to 83 years among 40 males and 72 females. The cavitations were tested for using exploratory drilling. Cavitations were found at approximately 75% of all extraction sites examined. The most commonly extracted teeth, the wisdom teeth, showed cavitations in 88% extraction sites (17). Not all the cavitations found were related to pain or chronic known conditions.

Diagnosing Cavitations:

Diagnosis is difficult due to the fact that some cavitations are almost invisible on standard radiographic films commonly used in dentistry.

Cone-Beam Computed Tomography (CBCT)
Cone beam computed tomography consisting of X-ray computed tomography where the X-rays are divergent, forming a cone. It produces three dimensional (3-D) images of your teeth, soft tissues, nerve pathways and bone in a single scan. This helps to identifies size and 3 dimensional position.

Blood tests:
- RANTES
- Fibroblast growth factor (FGF-2), hsCRP, TNF-α

Increased RANTES levels in blood have been proven a useful indicator of local inflammatory processes. This may involve residual osteitis of the jaw, however RANTES as a systemic inflammatory marker is not specific for this type of inflammation. RANTES levels in blood may increase in context with other inflammatory diseases (bacterial infections, systemic autoimmune diseases) as well.
Therefore, in case of increased RANTES levels in blood, a residual jawbone osteitis (cavitation) and corresponding diagnostics are worth considering.
We recommend simultaneous testing of other inflammatory markers (FGF-2, hsCRP, TNF-α), especially since a jaw cavitation should be considered regarding the patients symptoms and x-ray results (25).

Cavitat Device:
Was an ultrasonic device that has been used in the past to diagnose osseous pathology, but is now considered controversial.

Through-transmission alveolar ultrasonography (TAU) (24): not available in the UAE

Treatment:

Treatment of cavitations is to surgically scrape clean the area, removing all unhealthy bone (chronic fatty degenerative inflammation) and all pathology such as abscesses, cysts, etc. The yellow coloring has to be completely removed until no more fat drops floating on the blood.
The lesion is drained by injecting physiologic serum into the lesion. After removing the unhealthy bone, the goal is bone regeneration.
Ozone and/or Laser therapy is then used as a sterilizing agent, and the defect is filled with A-PRF membranes and sealed with absorbable sutures, preventing later contamination.

Prior to surgery, it is advised to enhance the patient immune system and bone regeneration capacity. This suggests a special diet and the intake of some food supplements that will be determined at your first consultation.

Click here if you want to see an example of therapy:

https://www.youtube.com/watch?v=m0Gzbo8m7bI (performed by Dr Nitschwitz, Germany )

Bibliography

  1. Black GV. A work on special dental pathology. 2nd ed. Chicago: Medico-Dental Publ Co, 1920.
  2. Bender JB, Seltzer S: Roentgenographic and direct observation of experimental lesions in bone. J Am Dent Assoc 1961; 62:152-160, 708-716.
  3. Yazad R. Gandhi,U. S. Pal,1 and Nimisha Singh1 Neuralgia-inducing cavitational osteonecrosis in a patient seeking dental implants. Natl J Maxillofac Surg. 2012 Jan-Jun; 3(1): 84–86. (case report, pain lower jaw since 2 years)
  4. Bouquot JE, Christian J. Long-term effects of jawbone curettage on the pain of facial neuralgia. J Oral Maxillofac Surg. 1995;53:387–99. [PubMed] [Google Scholar]
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  6.  Roberts AM, Person P. Etiology and treatment of idiopathic trigeminal and atypical facial neuralgias. Oral Surg Oral Med Oral Pathol. 1979;48:298–308. [PubMed] [Google Scholar]
  7. William R. Adams Kenneth J. Spolnik Jerry E. Bouquot. Maxillofacial osteonecrosis in a patient with multiple “idiopathic” facial pains. J Oral Pathol Med 1999; 28;423
  8. J. Lechner and W. Mayer “Immune messengers in neuralgia inducing cavitational osteonecrosis (NICO) in jaw bone and systemic interference”, Eur. J. Integr. Med. 2010, 2 (2): 71-77.)
  9. Bolin LM, Murray R, Lukacs NW, Strieter RM, Kunkel SL, Schall TJ, et al. Primary sensory neurons migrate in response to the chemokine RANTES. J Neuroimmunol 1998;81(1–2):49–57.

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