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NICO And Cavitations |
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History and Overview
Symptoms of Cavitations |
| Location of Cavitations |
| Current Research |
| Systemic Problems Associated With NICO Lesions |
| Initiating, Predisposing, and Risk Factors for NICO |
The Appearance of NICO Lesions
Diagnosis of Cavitations |
| Recommended Treatment of Cavitational Lesions of the Jaws |
| What Can A Patient Do? |
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| History and Overview |
Cavitations or NICO lesions are hollow places in jaw bones. These hollow areas may never cause pain or a problem. However, cavitations can produce trigeminal pain, headaches, and facial pain. Cavitations are common in all bones that have bone marrow. Many cavitations linger for years without producing facial pain.
Most people know what we mean when we say cavity, but the word cavitation is confusing. Both of these words come from the same root word meaning hole. A cavity is a hole in the tooth, whereas a cavitation is a hole in bone. Unlike most tooth cavities, bone cavitations can't be detected by simply looking at the bone, and even using x-rays, many cavitations are missed. The termed cavitation was coined in 1930 by an orthopedic researcher to describe a disease process in which a lack of blood flow into the area produced a hole in the jawbone and other bones in the body. Dr. G.V. Black, the father of modern dentistry, described this cavitation process as early as 1915 where he described a progressive disease process in the jawbone, which killed bone cells and produced a large cavitation area or areas within the jawbones. He was intrigued by the unique ability of this disease to produce extensive jawbone destruction without causing redness in the gingiva (gums), jaw swelling, or an elevation in the patient's body temperature. Essentially, this disease process, which produces osteonecrosis (dead bone) is actually a progressive impairment which produces small blockages (infarctions) of the tiny blood vessels in the jawbones, thus resulting in osteonecrosis, or areas of dead bone. These dead, cavitational areas, which produce pain, are now called NICO (Neuralgia Inducing Osteonecrosis) lesions (Figure 1). In his book on oral pathology, Dr. Black suggested surgical removal of these dead bone areas.
Figure 1: Diagram of cavitation lesions in the mandible.
Symptoms of Cavitations
Cavitational lesions may produce no symptoms at all, especially if we find no redness over the area or signs of drainage. However, these lesions may also produce intense, trigeminal neuralgia-like symptoms, which cause suffering to such an extent that it’s a wonder patients can stand the pain and suffering.
There are established, characteristic referred pain patterns (Figure 1), which we find very consistent in most symptomatic cavitation cases. Patients with pain usually have an underlying, constant dull aching. Along with this gnawing, deep pain, often there’s a sharp, shooting pain, which, understandably, convinces doctors that the diagnosis is trigeminal neuralgia.
A very common symptom we find is a sour, persistent drainage from the cavitation directly into the mouth. This foul taste makes many patients and doctors alike consider a diagnosis of sinusitis. Unfortunately, all the sinus surgery in the world will not correct the problem if the sour fluid is draining from areas of dead bone, namely, a jawbone cavitation.
Some of the more common symptoms of cavitations are:
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Deep bone pain and pressure, which may be constant but vary in intensity
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A sour, bitter taste, which often causes gagging and bad breath
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Sharp, shooting pain from the jaws, which eludes doctor’s diagnostic attempts
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Chronic maxillary sinusitis, congestion and pain
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A history of large dental fillings followed by pain, root canal therapy, and ultimately, removal of the tooth
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Multiple root canals
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Endodontic surgery (apicoectomy)
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Difficult tooth extraction, including wisdom teeth, several years earlier
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Post-operative complications, especially the development of a dry socket
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Failed attempts to treat trigeminal neuralgia
To confuse matters more, many patients report systemic symptoms like arm or leg pain and generalized fatigue. We’ve seen these systemic symptoms improve, or completely resolve, once the cavitation (or cavitations) is removed. The same has been seen in some chronic fatigue cases.
The most common scenario we see usually starts with a simple dental restoration. The family dentist replaces an old restoration (filling) and the tooth becomes sensitive, especially to cold temperatures. The doctor may replace the filling again or several more times, but the sensitivity never decreases. Then, in most cases, the tooth is treated with root canal therapy. But guess what? The pain continues. Another doctor is consulted, only to have the tooth re-treated with root canal therapy, but the pain persists . . . generally worse than in the beginning. Finally, out of sheer desperation (of both patient and doctor), the tooth is extracted, only to have the pain continue and intensify.
In this scenario, the finest dentistry was performed, but something went wrong. It wasn’t neglect by the dentist but damage to the tiny vessels in the jaw around and beneath the injured tooth. Due to the constant inflammation and swelling, an infarction occurs in one or more of the tiny vessels, producing ischemia and, ultimately, bone death and cavitation formation (Figure 2).
Remember, cavitations may be completely painless. This is not unique to the jawbones. In other bones, such as the femur, often there is no pain even when the bone destruction is extreme.
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| Location of Cavitations |
| Table 1: Common locations of NICO lesions. |
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Figure 2: Referred pain patterns of NICO lesions. |
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In the last several years, the term cavitation has been used to describe various bone lesions which appear both as empty holes in the jawbones and holes filled with dead bone and bone marrow. In Table 1, common locations of NICO lesions are listed. Note that the most common locations overall are areas of wisdom teeth (third molars). |
Often, these NICO lesions take years to develop, usually producing few if any symptoms . . . for a while. Then, generally for unknown reasons, pain in the jaws, face, head and neck may develop. There are characteristic referred pain patterns, which generally confuse patients and doctors alike (Figure 2). |
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| Current Research |
The results of recent research of Dr. Boyd Haley (former Chairman, Department of Chemistry, University of Kentucky) show that ALL cavitation tissue samples he's tested contain toxins, which significantly inhibit one or more of the five basic body enzyme systems necessary in the production of energy. These toxins, which are most likely metabolic waste products of anaerobic bacteria (bacteria which don't live in oxygen), may produce significant systemic effects, as well as play an important role in localized disease processes, which negatively affect the blood supply in the jawbone. There are indications that when these toxins combine with certain chemicals or heavy metals (for example, mercury), much more potent toxins may form. |
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| Systemic Problems Associated With NICO Lesions |
Researchers early in the 20th century and now recently have been concerned with systemic diseases caused by a primary problem (a focus of infection). The focal theory of infection fell out of favor with medical and dental doctors after the advent of antibiotics, but may researchers today believe that in spite of antibiotics, the focal theory of infection is alive and well. Ask and veterinarian doctor, and he or she will immediately agree that the focal theory of infection is a great concern of theirs.
Many researchers today believe that NICO lesions are the focus of various infections which may spread throughout the body. In the last few years, some of the most surprising medical news has been the discovery that bacteria from the mouth appear to be very influential in causing various heart, liver and kidney problems. If you have a joint implant or mitral valve prolapse, your dentist must prescribe an antibiotic before any dental treatment. Why? Because bacteria from the mouth can spread through the blood to cause serious problems elsewhere in the body. Could the toxins from NICO lesions do the same? |
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| Initiating, Predisposing, and Risk Factors for NICO |
There are many initiating, predisposing, and risk factors associated with cavitational lesions. It's likely that a combination of these factors present in a someone may influence the occurrence, type, size, progression and growth patterns of a cavitational bone lesion.
Initiating Factors: Probably the major initiating factors are dental trauma, which produce physical, bacterial, and toxic components, as described below.
Table 2: Dental traumas (initiating factors) associated with cavitational bone lesion development. |
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| Physical Trauma |
Bacterial Trauma |
Toxic Trauma |
Tooth Extractions |
Periodontal Disease |
Dental Materials |
Dental Injections |
Cysts |
Root Canal Toxins |
Periodontal Surgery |
Abscesses |
Anesthetic by-Products |
Root Canal Procedures |
Root Canal Bacteria |
Anesthetic Vasoconstrictors |
Grinding and Clenching |
Non-vital (dead) Teeth |
Chemical Toxins |
Electrical Trauma from Dissimilar Metallic Restorations |
Improper Removal of Periodontal Ligament after Tooth Extraction? |
Bacterial Toxins |
Heat from High Speed Drilling |
Infected Wisdom Teeth |
Other Toxins |
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Predisposing Factors: There are many predisposing factors and no doubt, many more will be discovered. Most of the known predisposing factors include: blood clotting disorders such as thromophilia, hypofibrinolysis, or others; age -- evidence suggests that as many as 11% of older persons may have major or complete blockage of arteries feeding the jaws or of the smaller arterioles within the jaws themselves; radiation or chemotherapy for cancer; rheumatoid arthritis; lymphoma or bone dysplasia; changes in atmospheric pressures in occupations; osteoporosis; systemic lupus erythematosis; sickle cell anemia; homcystinemia; Gaucher's disease; hyperlipidemia; hemodialysis; gout; antiphospholipid antibody syndrome; physical inactivity (bedridden); and deficiencies of thyroid or growth hormones.
Risk Factors: There are many risk factors which greatly increase the probability of the development of cavitational lesions, especially in the occlusion or blockage of tiny blood vessels within the jawbones. The most common risk factors are: heavy smoking; high and long-term cortisone usage; pregnancy; estrogen use; alcoholism; and pancreatitis. Undoubtedly, there are many other risk factors.
Wisdom Teeth Sites: Research findings indicate that 45% to 94% of all cavitational lesions are found at wisdom teeth extraction sites. These areas are anatomically predisposed to develop these bony lesions because they contain numerous tiny blood vessels which are apparently, easily damaged from trauma (oral surgery in these areas) and osteonecrosis can easily develop. Also, many local anesthetic injections are given in the wisdom tooth areas and many of the local anesthetic solutions contain vasoconstrictors (especially epinephrine) which is used to intentionally close or shut-down the blood supply to the bone, teeth and gingiva to prolong the effects of the anesthetic and reduce bleeding. The actions of closing down the blood supply to these wisdom tooth areas may be a major cause for NICO development. |
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| The Appearance of NICO Lesions |
Figure 3: Gross appearance of NICO lesions. Note that at least 4 lesions are visible. IAN: inferior alveolar nerve. |
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Cavitational lesions are difficult to discover. On most x-rays, unless the doctor is specifically trained, these bony lesions are usually missed.
Gross examination of NICO lesions are shown in Figure 2. Note the large nerve, the inferior alveolar, as it travels through and between NICO lesions.
Dental students and residents spend a lot of time learning to properly read x-rays of all types. A very useful x-ray view in dentistry is the panoramic radiograph. Unfortunately, all of us were trained to read certain irregularities as normal! We now know that these irregularities on panoramic x-rays are quite often cavitational lesions. |
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| Figure 4: A normal panoramic x-ray? |
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Figure 5: NICO lesions in left posterior mandible. |
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See the panoramic x-ray above (Figure 4)? Most dentists, oral surgeons, radiologists, and other doctors would read this x-ray as normal. |
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Now, look again at the same x-ray, but with lines drawn to the NICO lesions (Figure 5). This 44 year old lady had left lower jaw pain for a couple of years, after the last two molars were treated with large fillings, then root canals, and then removed. She also had a slow drainage into her mouth which produced a sore throat. Unfortunately, this lady saw at least 8 doctors (a dentist, 2 oral surgeons, a periodontist, an endondontist, 2 ENT physicians, and a family physician) and all could find nothing and even suggested she consult a psychologist!
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Here's another interesting case. This is a 47 year-old business woman who has had extensive and good dental treatment. Her wisdom teeth were taken out when she was 14 years old and the surgery was difficult. When she was first married at age 18, she took birth control pills for only a few weeks because she developed phlebitis in the deep veins of her legs. When she was 45 or 46, she began experiencing deep aching pain in her lower right jaw. There was no swelling, but she complained of a terrible, sour taste. |
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Look at Figure 6. This is her panoramic x-ray. From the looks of this x-ray, there appears to be nothing wrong, yet she had continual deep aching pain in the right lower jaw, a sour taste and no teeth which seemed painful or sensitive. |
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| Figure 6: An apparently normal panoramic x-ray. |
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Figure 7 is a copy of this lady's Cavitat or ultrasonic scan of her lower right jaw. Tooth #28 was removed years earlier for othodontic reasons. |
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| Figure 7: Ultrasound (Cavitat) scan of lower right jaw. |
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Note the red, yellow and brown colors in the areas of teeth numbers 29 through 32. These colors indicate areas in the bone of reduced blood flow or dryness, or in other words, a cavitation or cavitations. When this lady's lower jaw was numbed with a local anesthetic, all her pain subsided, but her sour taste persisted. This, along with her symptoms and Cavitat scan, indicated that she had a cavitation in the areas of teeth numbers 29 through 32. |
Figure 8 is a picture during surgery of this area. Note the large, void area in the jaw bone. This cavitation area was present within the bone and not created by Dr. Shankland. The two last molars were removed, but the cavitation is lateral to the teeth. Her surgery was difficult and she had minor nerve damage for a few weeks. But today, more than four years after the surgery, she's pain-free and no longer has a sour taste in her mouth. |
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| Figure 8: Cavitation in lower right jaw at surgery. |
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Figure 9 is another case in which a lady in her early 40s, who was plagued with constant deep aching pain in the jaw. She'd seen several types of doctors, none of whom felt she had a physical problem. Yet, with a simple incision, without removing any bone, this cavitation was discovered. This patient required a second surgery to finally eliminate the cavitation and stop her pain. |
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| Figure 9: Cavitation in lower right jaw. |
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Not to belabor the point, look at Figure 10, which shows yet another case. Is there any doubt that there's a hole in this lady's upper jaw? At this point, only the gum tissue was lifted up; no bone was removed. This lady had constant upper jaw pain, pressure and a sour taste in her mouth. She was diagnosed with trigeminal neuralgia and scheduled for brain surgery. This bone lesion went clear through her jaw into her palate and up into the floor of her nose. |
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| Figure 10: Cavitation in upper jaw of 58 year-old woman. |
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In one last case, this lady had undiagnosed right facial pain for years. She complained of a sour taste at times and when the sour taste wasn't present, she'd have intense pressure in her right jaw. Figure 11 shows her ultrasound or Cavitat scan. Note the red area in the area of #31 and as it extends into the area of #30. Again, this shows an area of ischemia, or reduced blood flow, which is actually a jaw bone cavitation. |
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| Figure 11: Cavitat scan of lower right jaw. |
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Figure 12 shows a panoramic x-ray of this same patient. If you look closely at the x-ray, it will look normal and you'll not be able to see any abnormality. Yet, look at Figure 13, a picture taken after an incision was made and nothing else done at the surgical site. Look at the large cavitation at a former extraction site. |
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| Figure 12: Panoramic x-ray of the same patient shown in Figure 11. |
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| Figure 13: A cavitation visible after an incision and the gingival tissue is retracted. This is a former extraction site. |
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| Figure 14: The same cavitation with the bony roof removed. |
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Now, look at Figure 14, a picture of the same patient with the roof of the cavitation removed for access to surgically repair the area. Isn't that amazing? Several fine doctors couldn't diagnose this lady's problem and most thought she was crazy! Fortunately, she's doing fine with no further pain, sour taste and pressure and no nerve damage after the surgery. |
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| Diagnosis of Cavitations |
The diagnosis of cavitation lesions is complicated by the fact that x-ray examination of the jawbones often appears normal . . . to the untrained eye. Considerable diagnostic experience is required to detect disorders that mimic cavitations, including variations of normal anatomy. |
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Why is this so? Osteonecrosis is a disease of the marrow spaces of bone and 40% to 50% of such bone must be destroyed before changes can be seen on x-rays. So, if your dentist or oral surgeon takes an x-ray and pronounces the film normal in spite of your symptoms, don’t necessarily believe it. X-rays may be interpreted as normal unless (1) there’s a significant amount of bony destruction or (2) the doctor is experienced in reading x-rays specifically for cavitations. |
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Although MRI (magnetic resonance imaging) is the imaging technique of choice for long bones, flat bones of the face are not imaged well with regular MRI scans. CT scans are also ineffective in locating most cavitations in the jawbones. |
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However, we've discovered that using the technique of MRI STIR imaging (Figure 15) is very effective and accurate in locating areas of bone marrow edema (swelling) and ischemia (areas of reduced oxygen). Both of these conditions can and do lead to the formation of cavitations. |
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| Figure 15: MRI STIR image. The cavitation is the larger white area on the right side of the picture. |
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Bone scans using a radioactive isotope are somewhat helpful in locating cavitations but very difficult to interpret. Also, radiologists, not expecting these lesions in jawbones, often note the lesions in their radiology reports but interpret the results as normal. |
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| Figure 16: Bone scan using tech 99 radioisotope. The cavitation is the darker area in the lower right front. |
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The best, most effective method to locate cavitations is the Cavitat bone scanning device (Figure 17). This computer-based sonar imaging system was designed to aid the medical community with a detailed profile of the interior of bones. The Cavitat computer generates digitized two and three dimensional images of the interior of the jawbones from sound waves passed through the bones. |
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| Figure 17: Cavitat scan. |
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Because liquid is a near perfect conductor of sound waves, when these waves enter into voids or porosities in bone (areas that have compromised bone flow; i.e., cavitations), the sound waves slow down considerably, which produces images of the interior of the bony area being scanned. We’ve found the Cavitat results to be very accurate, especially when compared with patients’ panoramic x-rays. Our diagnostic results have improved dramatically. Most importantly, our surgical successes have soared since we began using this revolutionary device. |
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Therefore, since both MRI STIR imaging and ultrasound imaging (Cavitat) are so effective and accurate (Figure 18), since November of 2003 we're been using both imaging techniques with most patients. Using both of these diagnostic tests have helped improve our diagnostic abilities and better yet, have improved our overall success rate in treating cavitations of the jaws. |
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| Figure 18: MRI STIR image and Cavitat scan of the same area, both demonstrating a cavitation in the same area. |
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For patients experiencing pain, diagnosis is further improved through anesthetic confirmation or anesthetic blocking. By giving a local anesthetic injection (similar to having your dentist numb the jaw before he or she performs a dental procedure), pain in the jaws can be selectively turned-off, meaning the sense or feeling of pain can be chemically and temporarily eliminated. If the pain goes away after the injection, then we can be reasonably certain that there’s a problem in the anesthetized area, generating pain. |
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| Recommended Treatment of Cavitational Lesions of the Jaws |
The only treatment available at this time to remove cavitational lesions is surgical removal. Some have attempted to inject homeopathic remedies or ozone into these areas of dead bone, but unfortunately, there's no blood circulation within cavitational lesions, so any medications, drugs, or remedies can't get into and permeate these lesions, let alone allow toxins and metabolic products to be removed. Homeopathic remedies certainly have their place in NICO treatment, especially in healing after surgical removal of the lesions themselves.
The surgery basically consists of making an incision, exposing the bony defects, and scraping them clean (termed debridement) to remove all unhealthy bone and other pathological problems like abscesses and cysts. It's not sufficient to simply punch a hole in the bone and rinse the area out, like some doctors recommend. In fact, treating these expanding bony lesions in such a conservative fashion often makes the lesion and subsequent pain much worse.
After removing the dead bone and other pathological products, the goal in healing is bone regeneration. But first, if possible, we remove all predisposing and risk factors. |
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What Can A Patient Do? |
If you think you might have a NICO lesion, what can you do? First, find a doctor who understands this disease process; one who is trained in effectively diagnosing and treating these bony problems. Unfortunately, there are precious few such doctors in the world and very few in North America at this time.
If you're experiencing pain, don't allow anyone to operate without first proving where your pain originates. This is done most effectively by closely evaluating x-rays and using diagnostic anesthetic injections to actually turn-off the suspected NICO areas to see if the pain is turned-off. There are characteristic referred pain patterns of NICO lesions and there are also characteristic responses to local anesthetic testing. Find a doctor who knows about these characteristic patterns and realize that most doctors who treat orofacial and TMJ pain know nothing about NICO lesions.
Be certain that the doctor obtains Cavitat scans, MRI STIR imaging, or both in the process of diagnosing your problem. Both of these imaging tests give us a view of the size and extent of cavitations and can also indicate if surgery is truly needed or not.
Keep watching this site as we have many new and exciting things soon to come out about NICO lesions. For more information about NICO lesions and other orofacial pain problems which are often misdiagnosed, see Dr. Shankland's latest book, Face The Pain.
Dr. Shankland consults and treats NICO, orofacial, and TMJ patients. If you have any questions, please call Dr. Shankland's office (614-794-0033) and ask for the NICO Information Packet to be sent to you free of charge. You can also consult with Dr. Shankland. If you'd like to know more about Dr. Shankland, click on Biography. |
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