(Note: Some of the following material was written by Dr. Karen Shrimpken and others)
A cavitation is a hole in the bone that cannot be detected through visual inspection and is poorly detected by radiographs. The term "cavitation" was coined to describe the result of a disease process in which the lack of blood supply to an area of bone resulted in a hole or "hollowed out" portion of the jawbone or other bones in the body. Dr. G.V. Black described this process as early as 1915. He investigated how this disease produces extensive jawbone destruction without causing redness, swelling or increasing the patient's body temperature. This disease progressively impairs the blood supply to the bone marrow in the jawbone resulting in osteonecrosis (bone death). The cause might be a biofilm form of bacteria that is antibiotic resistant and adheres to blood vessels. The released toxins and by-products from these bacteria, combined with cellular material, might be responsible for the lesions. Dr. Black recommended surgical removal of this dead necrotic tissue to promote healing of the jawbone.
Biopsy specimen Schematic representation
The term "cavitation" is generally used to describe lesions appearing as empty holes in the jawbone. They are usually ischemic (no oxygen supply), necrotic (dead), osteomyelitic (infected bone), and they usually release toxins. These lesions are often found in old extraction sites, under or near the roots of root canal teeth, avital (dead) teeth, and/or wisdom teeth. The lesion may spread throughout the jawbone, penetrate the sinuses or totally encompass the inferior alveolar (jaw) nerve.
Recent research by Dr. Boyd Haley, of the University of Kentucky, shows that ALL cavitation tissue samples tested contain toxins that significantly inhibit one or more of the enzymes used in the energy production cycle. These chemical toxins (most likely from anaerobic bacteria) can produce significant systemic effects, i.e. stopping the Krebs cycle at any one of a number of parts of the cycle. The Krebs cycle is responsible for energy production. This energy is what powers us in our day-to-day lives. Thus if you have no to poor energy production you will exhibit Chronic fatigue. And negatively affect the local blood supply in the jawbone enhancing the disease process.
Research has shown these toxins combine with chemicals or heavy metals, such as mercury, forming even more potent toxins. Research from German toxicologists indicates the jawbone may be a biological reservoir for chemicals and heavy metals (especially wisdom teeth sites). Clinically, it is easier to successfully detoxify the body of mercury after cavitations and mercury fillings are removed.
The term NICO (neuralgia-inducing cavitational osteonecrosis) has been used when severe facial pain, neuralgia, headache, or a phantom toothache accompanies this disease. Although the presence of cavitations is a common occurrence, only a small percentage of the individuals with cavitations suffer from this pain component. Even in the absence of pain or localized jawbone symptoms systemic symptoms can be extensive. Researchers and physicians as early as 1918 expressed concern about the systemic effects of cavitations. A growing number of contemporary dentists, physicians, and researchers are even more alarmed by the latest research.
There are many possible initiating, predisposing, and risk factors associated with cavitations. A single or combination of factors can influence the occurrence, type, size, progression, growth pattern or symptoms resulting from a NICO lesion. Each individual is unique and each NICO lesion is uniquely located in a particular jawbone area making diagnosis and treatment complex. One of the major initiating factors is likely dental trauma, which includes physical, bacterial and toxic components.
Initiating Factors: Physical Trauma:
As you will see, almost anything that can disrupt the tissue we call bone can act as an initiator.
Extractions; dental injections; periodontal surgery; root canal procedures; grinding – bruxism; electrical trauma; metallic restorations; high speed drilling; bacterial Trauma; periodontal disease; cysts; abscesses root canal bacteria;
avital teeth; improper debridement after extractions; infected wisdom teeth or tooth buds
Initiating Factors: Toxic Trauma:
dental materials; root canal toxins; anesthetic by-products; vasoconstrictors in anesthetics; chemical toxins; bacterial toxins; other toxins
A number of factors predispose people to cavitational type lesions. Clotting disorders such as thrombophilia, hypofibrinolysis and others (which may be undiagnosed) may lead to oxygen-depleted areas of bone. Age - research suggests up to 11% of older individuals may have major or complete blockage of arteries to the jaws. Radiation or chemotherapy for cancer; systemic disease such as rheumatoid arthritis, lymphoma or bone dysplasia, osteoporosis, lupus, sickle cell disease, homocystinemia, Gaucher's disease, hyperlipidemia, hemodialysis, gout or antiphospholipid antibody syndrome. Inactivity (bedridden, paraplegic); deficiency of thyroid or growth hormone, occupational hazards such as variable atmospheric pressures can all be predisposing factors.
Risk factors :
Many different factors put an individual at risk for ischemic osteonecrosis/(NICO) including corticosteroid use, pregnancy, estrogen use, alcoholism, cigarette smoking, and pancreatitis.
For a sufferers viewpoint see this book, available in the office. Beyond Amalgam by Susan Stockton.
Wisdom Teeth Extraction Sites
One source of data indicates that 45% of all jawbone cavitations are located in the third molar area where wisdom teeth have been previously extracted. These areas are particularly susceptible because they contain small terminal blood vessels (microvasculature) and osteonecrosis is a disease of such vessels. Injections for dental procedures are often given near these areas. When local anesthetic with vasoconstrictor (i.e. epinephrine) is used, the blood and thus oxygen supply to the bone in these areas is reduced. We recommend and use non-vasoconstricting anesthetics.
Prevention of Cavitations
Prevention involves the elimination or appropriate modification of initiating, predisposing, and risk factors. New technology, instruments, products and technological applications, may improve prevention and treatment and enhance the bone regeneration process. More research will improve the prevention, diagnosis and treatment of cavitations. Today, individuals can receive relief from local and systemic symptoms, diseases and pain by the surgical treatment of cavitations.
Treatment of cavitations is to surgically debride (scrape clean) the area, removing all unhealthy bone and all pathology such as abscesses, cysts, etc. Draining the lesion and injecting homeopathic remedies or other substances into the lesion may increase the severity of the lesion. After removing the unhealthy bone, the goal is bone regeneration. Successful bone regeneration relies on an individual's healing capacity and the elimination and treatment of predisposing/risk factors. This is not always possible. Failure to heal or reoccurrence of a lesion and the need for retreatment is always a possibility, no matter how well the surgery is performed. There are very few dentists who are trained to effectively diagnose and treat these lesions. Those who are not so trained are not qualified to diagnose this condition or confidently assure patients that they do not have cavitations.
Diagnosis of Cavitations
Diagnosis - the first step in successfully treating cavitations (NICO). Currently, a diagnosis is made using a panoramic x-ray. This large x-ray produces an image of the upper jaw, lower jaw, teeth and sinuses. A panoramic x-ray does not always detect early stages of osteonecrosis in the bone, but many lesions can be seen on this type of x-ray. A new tool we have is the Cavitat Through Transmission Sonography (TTS) diagnostic system. The Cavitat is a unique diagnostic instrument employing advanced sonar engineering. By using pulsed ultrasound through the bone, an image is obtained that gives information the user can use to determine the amount of bone present in an area as well as the relative health of the bone present. The following images show various depictions of bone health and vitality. The best area is where green is in great abundance and the worst to have is where you have only a red looking floor present.
A relatively simple technique used to locate and confirm the presence of a NICO lesion. Here a few drops of non-vasoconstrictive anesthetic is injected into the gum tissue over a suspected site. Several minutes are allowed to pass and the pain pattern is evaluated for change. By doing this slowly and sequentially one can gain a greater awareness of the condition and location of the source lesion.
Occurrence of Cavitations/NICO - the CAVITAT (tm)
Bob Jones, the inventor of the CAVITAT(tm) (an ultrasound instrument designed to detect and image cavitations) has scanned several thousand sites where wisdom teeth had been previously extracted. He reported finding cavitations of various sizes and severity in approximately 94% of these sites. He reported finding cavitations under or located near 100% of root canal filled teeth scanned in both males and females of various ages from several geographic areas of the United States.
Preparation - Oral
Once the diagnosis is made and the need for surgical treatment determined the patients need to be prepared. Naturally, the oral cavity is the most germ-laden area of the body. Plaque, calculus, or periodontal disease only increases the severity of the problem. Prior to surgery the patient's mouth, including the teeth, gums and tongue need to be as clean as possible. This may require a professional hygiene appointment at a dental office and diligent home care including brushing, flossing, rinsing, irrigating, and tongue scraping. Oral care products containing fluoride, alcohol, and sodium lauryl sulfate should be avoided.
Preparation - Systemic
There are several products, including enzymes, homeopathic lymphatic drainerage remedies, natural antimicrobials, and healing nutrients that may provide nutritional and systemic support prior to and after the surgery. In some cases, limited antibiotics may be needed. It is important that all body detoxification pathways are open and functioning well; bowels, kidneys, skin, lungs, and especially the lymphatics. Electrolyte balance is important for detoxification, healing, and ease in administering IV sedation.
Oral sedation or Intravenous (IV) sedation, can be important in the surgical procedure, especially in the removal of a large or extensive cavitation/ (NICO) lesions, involving the alveolar nerve or the sinuses. Through oral or IV administration, patients receive medication to help them relax. This conscious sedation allows the patient to respond to the surgeon's requests or instructions. This is not the same as general anesthesia. Conscious sedation helps the procedure pass more quickly and painlessly. The surgical procedure is more comfortable for the patients and easier for the surgeon. Blood pressure, heart rate and oxygen saturation are continually monitored. Oxygen and EKG monitoring should be available. The surgeon's instructions must be followed and a responsible adult who can transport them following the procedure must accompany the patient.
After the patient is sedated, local anesthetic is administered. A local anesthetic without vasoconstrictor is preferred, because it is the least toxic and least damaging. Additionally, homeopathic antibiotics and pain interrupters are administered. An incision in the gum and bone is performed. Once access is gained then specimens are removed for biopsy and/or ALT toxicity testing.
At times it is necessary to remove an avital or root canal tooth. The instruments and procedures are used to help prevent contamination of the open bone area and to remove the necrotic (dead), osteomyelitic (infected) and toxic bone. This can be a slow and tedious process, especially when the necrotic bone surrounds the alveolar nerve or extends into the sinuses.
After the necrotic bone is removed, the surgical site is irrigated with various solutions to aid in the removal of bacteria and toxins. To assist with bone regeneration, an enamel matrix protein (EMDOGAIN) may be used or other bone regenerative material can be placed in the surgical site. The area is closed with special sutures that help prevent bacterial growth. If there is extensive bone damage, a bone replacement material and/or resorbable membrane to guide new bone growth may be placed.
During and following surgery, intravenous vitamin C (IV-C) can assist with healing, cleaning up toxic materials and bacteria released into the bloodstream and detoxifying local anesthetics and IV medications. We coordinate this service with a nearby holistic physician. Tenderness and soreness generally occur in the area of the surgery and can be controlled with pain medication. Some swelling and bruising may occur. The area may ache during the healing process. We recommend liquid diet the first day and soft foods the first week. Salt water and/or antimicrobial rinses, and continued oral hygiene are important. Sutures are removed 7-10 days after the surgery. If any indication of infection (swelling, fever, increasing pain) occurs, the surgeon should be contacted immediately. The number of areas treated during one surgery depends on the number of lesions to be treated and the individual.
Other adjunctive therapies post surgically are: the use of low level infrared laser therapy(Anodyne) and hyperbaric oxygen. This is applied immediately post operatively and can be dispensed for continued daily home care for the next month. The frequency of light (860nm) emitted by the diodes was specially picked for the healing effects on the tissues. Tremendous amounts of research have been carried out on this particular system, which is why we have chosen to use it.
Low-Level Laser Therapy: We use an Anodyne (R) unit. Here we place the pads on the affected area. The science behind this technology is complex but in simple terms we have:
- Increased circulation to the area being energized
- Production of Nitric Oxide (NO). A very body friendly molecule. It is small molecule composed of single atoms of nitrogen and oxygen. It is a biological mediator that communicates physiologic and pathophysiologic messages. It is synthesized from the amino acid L-arginine by a family of enzymes. This reaction occurs within the vascular endothelium and is responsible for vascular tone that is essential for the regulation of blood pressure. Thus the benefits of Nitric Oxide (NO) are:
- Relaxes smooth muscle tissue.
- Increases vasodilation to increase circulation
- Causes lymphatic dilation
- Is necessary for the formulation of new capillaries and cell migration in a wound site.
- Increases collagen synthesis and proper collagen fibril alignment.
- Increases the viability of cutaneous flaps
- Reduces swelling
- Is anti-viral
- Is anti-inflammatory
- Is an anti-bacterial agent
- Is important for new bone growth
- Is the direct mediator of the analgesic effects of morphine.
This unit has recently become certified by the FDA for the treatment of Diabetic Neuropathy.
Hyperbaric Oxygen (HBO): is most readily known to treat the “Bends” from a scuba diver who ascends too rapidly from the depths of the ocean and develops small gas bubbles of nitrogen in their blood. This treatment modality is co-ordinated with your physician. Here however we use it to treat osteomyelitic bone. The possible mechanisms of action in the treatment of osteomyelitis are:
- HBO can raise the tissue oxygen tension in partially ischemic, hypoxic tissues.
- HBO, by providing adequate oxygen, enhances the leukocyte killing mechanisms that are oxygen-dependent through hydrogen peroxide and superoxide production. HBO, by itself, has been shown to be as effective as cephalosporins in controlling staphylococcal osteomyelitis in the animal model.
- Optimal wound pO2 can enhance osteogenesis or neovascularization to fill the dead space with vascular or structurally sound bony tissue. Improved vascularity facilitates entry of leukocytes, antibodies, and antibiotics to the infective focus.
- HBO enhances osteoclastic activity to remove bony debris.
- The effectiveness of HBO in osteomyelitis may be due to the enhancement of host factors rather than to a direct effect on microorganisms causing the disease. Oxygen tensions in the infected tissues cannot always be raised enough to be directly toxic to the microorganism.
Fees for the on biopsy specimens and for ALT toxicity tests (Affinity Labeling Technology) will be arranged before the surgical appointment. The results of both reports are sent to the patient after they are received from the labs.
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