In this article, I will talk about NICOs (also called FDOJ or cavitation) seen in the jawbone, which is one of the important topics of biological dentistry. Cavitations are not taught to us in school, so they are not known in general dentistry. However, it is an important topic since studies have shown that it may be associated with systemic disorders and may lead to conditions such as toothache or trigeminal neuralgia, the cause of which cannot be found. Since they can occur especially after tooth extractions, I recommend you to read this article if you have had or will have a tooth extraction before.
What is NICO – Cavitation – FDOJ?
In fact, cavitation is the name given to the cavities seen in the bone, known in the field of orthopedics. It is especially seen in the knee and hip region. Even in the 1920s, researchers found these cavities in the jaw bones, but the first researcher to study them in detail was Jerry Bouquot (1), an oral pathologist with more than 300 articles. Bouquot mostly worked on patients with neuralgia, that is, pain caused by nerves. Therefore, he named these bone areas NICO, which means “Neuralgia-inducing cavitational osteonecrosis”. “Osteonecrosis” here means a dead bone. Cavitation is a cavity or hollow.
Later, another dentist, Johann Lechner, who also did a lot of work in this field, realised that these lesions were not only seen in patients with neuralgia, but that most of them were asymptomatic. He believes that these lesions are misnamed because bone tissue meets fatty tissue where it should be and does not always cause neuralgia. Instead, it is called “Fatty degenerative osteolysis in jawbone”. This can be explained as fatty degenerative osteolysis in the jawbone.
When we open these areas surgically, we encounter a bone that easily disintegrates. It may contain soft tissue or fat drops floating on the blood. Normally, there are also fat cells in the bone, but here they are visibly more abundant. Bouquot suggests that these fat cells may have come together due to the lack of blood supply (2).
Why NICO – FDOJ – Cavitations Matter?
As mentioned above, they already cause pain in some of the patients and affect the quality of life badly. These patients may have to use heavy medications unnecessarily. Sometimes, unnecessary root canal treatments and extractions are performed, assuming that the pain is caused by the teeth.
But are they harmless when they do not cause symptoms? We can find the answer to this in Lechner’s studies. Lechner showed that a very high amount of an inflammatory cytokine called RANTES/CCL5 was found in cavitations (35 times higher than normal). Cytokines such as TNF-α and IL-6, which we normally expect to see in inflamed areas, were found far below the level seen in healthy jawbone (3). A very interesting picture… In other words, there is no inflammation that we are normally used to. There is a different type of inflammation and it is called “silent inflammation”. In addition, the absence of cytokines such as TNF-α and IL-6 here causes the immune system not to be informed that there is a problem here, and the problem grows silently because it is overlooked.
What is the cytokine RANTES / CCL5 seen in FDOJ / NICO lesions? Rantes is a “chemokine” that signals inflammatory cells such as T cells, basophils and monocytes to come to the site. It is involved in acute inflammation as a natural part of the process and is involved in many diseases. However, it has been observed that it can have damaging effects in many chronic diseases such as rheumatoid arthritis, multiple sclerosis, chronic fatigue syndrome, and in some types of cancer such as breast cancer, stomach cancer, pancreatic cancer by enabling the migration of cells that facilitate the inflammatory process (4). It is observed that the amount of RANTES/CCL5 increases in the blood or cerebrospinal fluid depending on the region where the disease is observed. It is even thought to play a role in cancer metastasis (5).
Therefore, it is suggested that when such a cavitation with high amounts of RANTES occurs in the jawbone after tooth extraction, it activates the signalling mechanism that feeds inflammatory processes in the body. Lechner has many studies on the relationship between different diseases and FDOJ. I think it is an important finding that RANTES levels in the blood decrease when cavitations in the jawbone are physically cleaned(6).
How are NICO – Cavitation – FDOJ lesions diagnosed?
In very advanced cases, it is possible to see the lesions even on X-rays. Sometimes they can be detected in 3D tomographs. It is also possible to diagnose with the dental ultrasound device developed by Lechner, which is only used in Germany and Switzerland (as far as I know).
The X-rays belong to my own patients.
How are NICO – Cavitation – FDOJ lesions treated?
Before explaining why these lesions occur and how they can be prevented, I would like to talk briefly about how they are treated, because I think the importance of prevention can be better understood when you realise that treatment is not simple.
Unfortunately, it is not possible to cure these lesions with an external medication because they are areas that do not bleed and therefore do not feed. Some people have tried to apply ozone by entering the area with an injector, but it was not successful.
Therefore, this area needs to be surgically opened, curetted (scraped clean) and filled with blood in order to remove the dead bone and regenerate healthy bone. In order to support this process, the application of ozone to the opened and cleaned area and the placement of PRFs obtained from the blood taken from the patient in the area are procedures that are applied as standard in biological dentistry and which I also apply in my clinic.
However, the environment that causes this lesion to form in the bone also needs to be corrected. To understand how we can do this, let’s look at the theories about the causes of cavitations. I will then talk about how we can promote bone healing…
Below you can watch a video of how I performed the operation [if it doesn’t scare you 🙂 ].
Why does NICO – Cavitation – FDOJ occur?
Cavitations occur 95% of the time after tooth extraction. A small proportion of them can be caused by the bud of the 4th molar behind the wisdom teeth in some people.
One of the most important causes is thought to be insufficient blood supply or clotting problems in the area. In his studies, Bouquot found that 73% of patients had hypercoagulability (blood clotting tendency is higher than normal). Examples include stroke survivors who are prone to clotting. Bouquot also saw that in NICO cases, that is, in cases where cavitation is accompanied by pain, the pain decreased when he used blood thinners. However, he says that since the doses given were experimental, they were very high doses and could not be used for more than a month, so they could not be treated in this way.
According to Lechner, bone healing is impaired by imbalances in cytokines and hormones (7). Normally, there are stem cells waiting to differentiate in the bone marrow and they can differentiate into bone cells or adipocytes (fat cells) according to the orders they receive (8). Here, factors that cause stem cells to differentiate into adipocytes may affect the healing after tooth extraction and lead to the formation of FDOJ. These factors include vitamin D deficiency, inadequate expression of osteocalcin (vitamin K2 is required for its production), high dose glucocorticoids, estrogen deficiency and diabetes (8). Although estrogen deficiency increases the tendency of stem cells to transform into fat cells, its excess facilitates the formation of cavitation as it increases the tendency of blood to clot (9).
Lechner also mentions in one of his articles that the vitamin D receptor – VDR – can be inactivated by various bacteria, which can impair bone metabolism. Some of the infections that can inactivate the VDR are tuberculosis, borreliosis, chlamydia, herpes, Epstein-Barr, cytomegalovirus and aspergillus infections. When the VDR is inactivated, 1,25 (OH) D, the active form of vitamin D, rises too high and works to support osteoclastic activity, i.e. bone destruction. While 1,25 (OH) D is high, 25 (OH) D measured in blood tests remains low. Lechner said that in such cases, vitamin D supplementation would not work and would even be counterproductive (10). Trying to get vitamin D from the sun and foods as much as possible is actually the ideal, but if this is not possible, I think it would be better to use vitamin D supplements in many cases. In addition, the use of vitamin D and K2 may also help to balance. In addition, if there is a suspicion of infections of the type I mentioned above, it may be important to investigate this before the cavitation operation, especially for those with serious chronic diseases.
In the book titled “Toxic Tooth” written by maxillofacial surgeon Robert Kulacz and cardiologist Thomas Levy, alcoholism, hypothyroidism, autoimmunity and hypersensitivity, systemic lupus erythematosus, antiphospholipid syndrome and maxillary sinus infection were shown among the systemic conditions that predispose to cavitations (9).
How can NICO – Cavitation – FDOJ’s be prevented?
As I mentioned above, since they are most commonly seen after tooth extractions, it is important what to do before, after and during tooth extraction.
Things to Consider Before Tooth Extraction
(Actually, our subject is cavitations, but we can take these factors into consideration for the success of all surgical procedures involving bone).
Since the systemic condition is closely related to bone metabolism, trying to correct chronic diseases, hormonal imbalances, vitamin mineral deficiencies as much as possible should be the first preparation for surgical procedures. Of course, if you have a chronic disease, I am not saying that you should not undergo surgery without correcting it. In most cases, this is not possible. But for example, there are methods such as paying more attention to your diet for a few months before surgery, exercising, etc. that change the course of many chronic diseases in a positive way and are in your hands. In the case of a non-urgent oral surgical procedure, I think it would be better to coincide the procedure with a period when your general health is more stable, perhaps when some corrections are made with a functional medicine doctor.
Apart from this, I can list the general recommendations we give as preparation for surgery as follows:
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- D3K2, magnesium, vitamin A, zinc and vitamin C supplements
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- Apart from these, a good quality multivitamin can be taken in the two months before the operation to meet other possible deficiencies. (I do not like iron and calcium in multivitamins. It is also important that the vitamins in it are selected from high bioavailability and non-toxic forms. I like the Goodday brand 2PD multivitamin in Turkey, which has these features – I have no agreement with them).
- Anti-inflammatory nutrition – Avoid packaged foods, processed foods, simple carbohydrates and foods that you know are bad for you as much as possible.
- Pay attention to adequate protein intake. Try to get at least 0.8g of protein per kg of body weight each day. The amount you need to take increases according to your level of physical activity. I believe that animal protein sources will be more beneficial (eggs, liver, red meat, fish, organic chicken, etc.).
- Eat healthy fats, limit omega 6 intake.
- Include practices to regulate your circadian rhythm in your life. This is very important for the correct functioning of your hormones. Remember that bone metabolism is affected by circadian rhythm.
- Exercise. You can choose any exercise that you can sustain. Our goal here is to increase microcirculation and lymph drainage.
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Things to Consider During Tooth Extraction
In many sources (internet articles, not scientific papers) on cavitations, the causes of cavitations during tooth extraction are the incomplete removal of the periodontal ligament around the tooth root and the use of local anaesthetics containing vasoconstrictors that constrict blood vessels. Let’s look at these substances:
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- It is said that the periodontal ligament surrounding the tooth root in a healthy tooth, which continues to be present when the tooth is extracted, disrupts bone formation. I have not heard Bouquot or Lechner mention this, but it is mentioned in “Toxic Tooth”. Nevertheless, after tooth extraction, I clean the area both with hand tools and with a device called a piezosurgery device, which works by vibration and does not damage soft tissues such as vessels and nerves. I do this in order to remove infected tissues, to create bleeding areas in the thick cortical bone with low blood supply and to eliminate the periodontal ligament.
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- It is recommended to use local anesthetics that do not contain “vasoconstrictors” (usually adrenaline) because they reduce the blood supply to the area. (Obviously, it is very difficult to work with these anesthetics because their effects are very short). However, the literature shows that epinephrine (adrenaline) actually reduces blood supply. In addition, when the vasoconstrictors are gone, oxyradicals are released into the area and this can lead to a very unhealthy jawbone (2).
After extracting the tooth and cleaning the extraction cavity, I apply ozone to the area within the framework of the biological dentistry extraction protocol. With this, we aim to clean the microorganisms that may be present in the area and increase blood supply (11).
Finally, we obtain PRFs from the blood taken from the patient just before the extraction with a special centrifuge device and place them in the extraction cavity. According to a systematic review and meta-analysis published in 2021, PRF applied after wisdom tooth surgery reduces the likelihood of postoperative pain and inflammation in the bone and promotes soft tissue healing (12). PRF does this with elements such as leukocytes, platelets and growth factors.
Things to Consider After Tooth Extraction
The two most vital items you should pay attention to after tooth extraction are not rinsing your mouth and not spitting. Depending on the time of the procedure, it is very important to follow this rule on the day of the procedure and the next day. In order for the wound healing to be healthy, the blood clot must hold on to the extraction cavity. Therefore, avoid doing things such as mouth rinsing, constant spitting, pulling and looking at the cheek if you have had an operation where the gum is cut. Avoid using straws that will create a vacuum effect and smoking (as you can guess, the vacuum effect is the most innocent part of smoking!) Do not consume granular foods that can escape into the extraction area for a few days. In summary, we need to take care of the blood clot formed here after the procedure because this clot will heal the area.
Rinsing the mouth alternately with saline and lugol water for 1 week after the procedure will help wound healing and help prevent the wound from becoming infected (you can only leave it for the first evening and pour it out of the mouth very gently because we said that there should be no rinsing and spitting, let’s remember. Or you can start the next day if you have not eaten).
Other rules to be followed after tooth extractions (applying ice, etc.) I do not write in order not to distract our subject too much.
In order to form healthy bone in the extraction cavity, you can continue to apply the list I recommended for the pre-procedure in the post-procedure period.
Take care to rest for 3-4 days after the procedure and avoid physical activity. However, exercising in the following period will be beneficial for the blood supply of the tissues.
Again, due to its positive effects on circulation, LLLT or red light application is a support that those who have the opportunity can benefit from (I recommend you to try to get plenty of daylight instead). In addition, I observe that my patients who take high doses of vitamin C (IV or liposomal, but especially IV) on the day of the procedure and the next day have a more comfortable post-procedure period.
Various supplements to increase blood supply and other methods to increase tissue oxygenation can also be considered in risky patients.
To Summerise
If the extraction cavity does not heal properly after tooth extraction, it can have systemic consequences or make it difficult for your existing chronic diseases to heal. The formation of fatty tissue instead of bone in the extraction cavity may be caused by systemic factors related to your general health and mistakes during and after extraction. Taking care of your general health before tooth extractions and bone surgeries and acting in accordance with the rules during the operation period can support bone healing and prevent this type of complication.
Resources
1 – https://www.researchgate.net/profile/Jerry-Bouquot
3 – https://pubmed.ncbi.nlm.nih.gov/30519117/
5 – https://pubmed.ncbi.nlm.nih.gov/17914389/
6 – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8044077/
8 –https://medscimonit.com/abstract/index/idArt/897044
11- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8092153/
12 – https://pubmed.ncbi.nlm.nih.gov/32950350/
