Frequently Asked Questions About Cavitations

1. What are cavitations?

As recently as 1979, a newly described pain syndrome was reported by two separate oral surgeons, Ratner and Roberts. This disorder wasn’t really new, for as early as 1915, Dr. G.V. Black, the father of modern dentistry, described these lesions in his pathology textbook, calling the condition chronic osteitis. Futher, this bony problem has been discussed in the medical literature since the 1600s.

Dr. Black felt this bony inflammatory process had the unique ability to produce extensive bone destruction without producing redness or swelling of the overlying tissues, without causing an increase in the patient’s body temperature, and often producing no pain. He used the word cavity to describe these lesions within the bone marrow cavities. He recommended surgical curettage as the only effective treatment. Later, this condition became known as osteonecrosis of the bone, often a direct result of osteomyelitis (chronic osteitis), or bone inflammation.

2. Are cavitations known by other names?

Yes. The real term for cavitations is osteocavitation lesions. These bony lesions are also known as NICO lesions (Neuralgia Inducing Cavitational Osteonecrosis).

3. What causes these cavities in the bone to develop?

Basically, some pathological problem or disorder causes a small blood clot (termed a thrombus) to form, stopping the flow of blood and therefore, starving the bone of oxygen past the thrombus. A similar problem occurs in the heart with a heart attack or in the brain with a stroke.

In bones, oxygen starvation produces ischemia (loss of oxygen), actually causing osteonecrosis, or dead bone.

4. Do cavitations occur in other bones in the body?

Yes. In fact, jawbone cavitations occur at approximately the same frequency as do those in the hip. Any bone in the body is susceptible, but because of common tooth infections, dead and dying teeth, periodontal disease, and now the implication of mercury containing fillings (called amalgams), the jawbones seem more suseptible than other bones.

5. What causes thrombi or decreased blood flow in the jaws, thus producing cavitations?

There are many factors and conditions, which can reduce or stop the flow of blood in either the upper or lower jaw.

First, it seems as if chronic tooth infections, especially those that kill teeth, are most often the cause of jawbone cavitations. Usually, the story goes like this: a patient has a sensitive tooth or the dentist feels a filling should be replaced. The tooth becomes very sensitive, requiring another filling, but the sensitivity continues or gets worse. The patient requires a root canal, which may help for a short time, but the bone blood flow seems to already have been damaged. A second or even third root canal is done, maybe a surgical procedure termed an apicoectomy is performed, but ultimately, due to intense pain, the tooth is removed. Unfortunately, the pain often continues or returns after a short time.

Second, it seems that hormonal changes may cause a narrowing of the jawbone blood vessels, reducing the oxygen content. Couple this with a tooth infection and a cavitation may develop. This is true in some women who take or have taken birth control pills or who have had other forms of hormonal therapy.

There also appears to be a direct connection between cortisone use and osteocavitations. We often receive cortisone injections or pills because of infections, poison ivy, bee stings, or chronic illnesses. Cortisone use is a known cause of osteonecrosis in other areas of the bone (especially the hip), and so it is with the jawbones, too.

Trauma in the form of a direct blow to the jaw or even trauma from oral surgery (especially, wisdom tooth removal) are recognized causes of cavitations. Any form of trauma can cause blood vessel injury, thus slowing the blood flow in the jaws.

A fourth general cause of jaw bone cavitations may be blood clotting disorders (hyperfibrinolysis, sickle cell anemia, antiphospholipid syndrome), or perhaps, an elevated homocysteine blood level.

A fifth and common cause of cavitations is the use of local anesthetics, which contain a vasoconstrictor. Dentists are taught and generally use local anesthetics that contain various types of chemicals, which purposely decrease the size of blood vessels in order to prevent bleeding during surgery or to prolong the anesthetic’s effects. As you can appreciate, any reduction in blood flow through the jaws, especially when there are other predisposing factors, can certainly produce osteocavitations.

These are not the only causes of cavitations. In fact, to date, we know of at least 74 separate causes!

6. Where do most cavitations occur?

The third molar regions (wisdom tooth areas) are most often the sites of cavitations. First molar areas (six-year molar areas) are the second most frequent sites of cavitation development. However, cavitations form in any tooth area and any jawbone region, but posterior or back areas are more susceptible than areas closer to the front of the mouth.

7. What are the symptoms of jawbone cavitations?

Many, but not all, cavitations produce some type of jaw or facial pain. These pains may only be dull and infrequent, but many people suffer from constant, deep aching pain, which at times produces sharp, shooting and electrical-type pains. That’s why so many of those suffering from cavitations are mis-diagnosed with trigeminal neuralgia, undergo various types of neurosurgery, and still have pain.

Another common complaint we’ve found with cavitation patients is a sour or bitter taste or smell coming from an unknown area in the mouth. Periodontal disease can also cause these symptoms, but many of our patients have excellent oral hygiene and still have a sour taste and/or smell.

Cavitation patients also seem to suffer with chronic maxillary sinusitis if the cavitation lesion is in the upper jaw. Some have had multiple sinus surgeries with little or no success.

Unfortunately, a high percentage of cavitation patients have had one or more root canals, endodontic surgery, and one or multiple oral surgical procedures. In an attempt to help the patient, we dentists can actually cause cavitations to develop. This in no way implies that dentists are negligent, but we were all taught certain dental procedures in order to help patients. Yet, in our best attempts, we can produce cavitations.

8. How are cavitations diagnosed?

As with any disease or disorder, there is no one way or method to diagnose cavitations. However, there are four (4) known successful methods of diagnosis:

A) History. An accurate and complete history is very important. The best thing a patient can do to help the doctor is to have his or her complete history written down in chronological order, listing all symptoms, doctors and/or therapists seen, past diagnoses and treatments, results of those treatments, lists of trauma or dental treatment, and lists of hormones and/or cortisone taken (if any).

B) X-rays. A panoramic x-ray is most often used to look for jawbone cavitations. All dentists receive extensive training in radiology, but unfortunately, we now know that what appears normal on x-rays often isn’t. Dentist and radiologists must be re-trained to read these valuable x-rays.

For example, look at the first x-ray. Most dentists and radiologist would claim this x-ray is normal.

(Pictures not available.)

Compare the same x-ray once the cavitations are indicated. If you look closely, you too, will see the cavitations.

Not to be shocking, but look at the cavitation, shown in the x-rays above, after only making an incision and reflecting the tissues to expose the bony lesion. Nothing else was done. This is exactly what we found at the beginning of surgery!

C) Diagnostic anesthetic injections. A good way to isolate where pain might be originating is using anesthetic injections. Just like throwing a circuit breaker in your home to turn-off the dishwasher for repair (for example), numbing an area in the jaw can also “turn-off” pain generation from that region, thus indicating a source of pain.

D) Cavitat examination. By far and away, the best method to “view” jawbone cavitations is by using a new ultrasonic device termed the Cavitat. This unique and very accurate ultrasound allows us to not only visualize the size and extent of cavitations, but we can also see areas of bone being robbed of oxygen, allowing us to treat areas that haven’t become painful or don’t show up on a panoramic x-ray. The Cavitat is, in my opinion, the most accurate method of evaluating jawbones for cavitations and I personally would not practice without it. I’m not proud to say that I have missed many lesions, both size and extent, in my career, but the Cavitat has never been wrong since we’ve been using it in our office. Early in August 2001, the U.S. FDA gave provisional approval for its use in the evaluation of jawbone cavitations and areas of ischemia.

9. How are cavitations treated?

There is only one way to treat osteocavitations of the jaw: surgery. Injections of homeopathic remedies, medicines, or any oral medications can only provide temporary relief at best. Dead is dead! Period. Dead bone must be removed and a good blood flow must be re-established. If not, there’s great danger that a cavitation will slowly expand, endangering more jawbone and vital teeth.

Don’t allow anyone to operate without first proving where your pain originates, if you’re experiencing pain.

10. Do teeth always have to be lost in areas of cavitations?

If the bone, seen on an x-ray or in a Cavitat scan shows a lack of oxygen, the tooth or teeth should be removed. If not, they will ultimately die, probably producing themselves another cavitation.

11. Does one surgery usually cure the cavitation problem?

In about 60 to 70% (estimated at this time), yes. However, about 30% require an additional surgery or even further multiple surgeries. This should not be surprising as orthopedic surgeons have similar healing problems when they surgically treat osteonecrosis of leg or hip bones.

12. If only one surgery is needed, is it always successful?

That depends upon what you consider successful. If you’re in intense, constant pain, then most likely, 75% relief most of the time would be considered successful. Many people receive total relief of their pain, but others receive a great reduction most of the time of pain, but not totally. This is just the nature of this horrible disease. It is very hard to re-establish good blood flow.

13. What about blood tests?

Today, blood tests to screen patients concerning possible clotting problems are very expensive ($1,500 to $2,000). We usually order blood tests if the patient requires more than two or three surgical procedures.

14. What can you do if you think you might have a cavitation problem?

Realize that most dentists today haven’t even heard of this problem. So, understanding that, talk with your family dentist. If he or she doesn’t treat facial pain problems (and most don’t), then ask to be referred to someone who does. You can also contact Cavitat Medical Technologies. Call (303) 755-2688. They have a list of many doctors who treat cavitations.

15. What can you do if you’ve been diagnosed with cavitations to prepare yourself for surgery?

First, if you’re not satisfied, get a second opinion. Second, you need to improve blood flow through the jawbones, so consider taking the following:

A) Vitamin C, 2,000 to 3,000 mg per day in divided doses;

B) Coenzyme Q10, 100 to 200 mg per day;

C) Vitamin B complex (make sure it contains vitamins B6, B12 and folic acid);

D) Vitamin E, 800 to 1,200 IU per day;

E) Zinc gluconate 50 to 100 mg per day;

F) Gingko baloba, 80 mg per day;

G) Odorless garlic, approximately 5 mg per day;

H) Selenium, 200 to 400 micrograms per day;

I) 1/2 to 1 aspirin per day; and,

J) Increase your water consumption each day.

Obviously, these are only suggestions and you should consult your surgeon before taking any of these. Also, discontinue the gingko baloba, garlic and vitamin B complex a couple days before surgery (to prevent bleeding during surgery) and DO NOT take vitamin C the day of surgery (it often decreases the effectiveness of local anesthetics).

16. Does insurance cover the expense of cavitation treatment?

Good question! Most medical insurance companies will give benefits for the examination and diagnosis of cavitations. They will term the disorder as ischemic osteonecrosis or osteomyelitis of the jaws. Check with your insurance company to see if they allow benefits for this type of treatment.

17. What about HMOs?

Do they provide benefits? Again, who knows? HMOs are supposed to pay for out-of-network doctors if no one in the HMO network treats a specific problem, and osteonecrosis of the jaws is no exception. Like insurance companies, they may require a referral from a network doctor to a dental surgeon before even considering paying benefits.

18. Are there possible complications with cavitation surgery?

As with any type of surgery, there are risks. Fortunately, cavitation surgery is relatively safe, but some of the post-operative risks are listed below. This is not an inclusive list:

A) Post-operative pain (although, it is surprising how many of our patients require little or no medication following surgery);

B) Normal bruising and swelling;

C) No improvement or only partial improvement;

D) Worsening of the pain condition (this is very rare);

E) Injury to the inferior alveolar nerve (the main nerve in the lower jaw), which may produce temporary or in some cases, permanent numbness throughout the lower jaw, lips, gums and teeth;

F) Entrance into the maxillary sinus;

G) Loss of teeth;

H) The need for additional surgeries; and

I) The need to consult other doctors.

19. What next?

If you’re concerned that you may have a cavitation problem, first, don’t panic. Many other orofacial pain disorders mimic cavitations. Don’t expect the worst. See a doctor knowledgeable about cavitations, but also one who understands orofacial and TMJ problems.

20. Does Dr. Shankland see patients from other states or countries?

Yes. We’ve treated patients from all over the United States, Canada, Mexico, the Caribbean, and every continent in the world except Antarctica. However, Dr. Shankland believes it’s best to see a doctor in your area. Unfortunately, there are only a few of these doctors world-wide.

21. What do I ask the doctor or receptionist when inquiring about the doctor’s ability to diagnose and treat cavitations?

Ask how long the doctor has been treating cavitations. There are many new doctors, so longevity doesn’t always mean the better, but experience is important.

Second, ask about success rates. If you’re told that a doctor has a 90 or 95% success rate, find someone else. That’s just not possible, regardless of the skill of the surgeon.

Third, ask if you might be able to talk with a former patient or two, just to hear about what you might expect in that specific office.

Lastly, ask if the doctor uses a Cavitat. There are a few good doctors who don’t yet use a Cavitat, but that is changing. The best radiologist can’t see all the damage or potential damage due to impaired blood flow. The Cavitat is the best method of determining the presence and extent of cavitations.

Please do not call our office asking about specific problems or expecting a phone consultation. Due to the large volume of phone calls which we receive every day (every hour!) from all over the world, we can’t and won’t provide specific information about pain disorders. Also, unless a physical examination is conducted, it wouldn’t be fair or proper for Dr. Shankland to comment on your particular problem(s). Thank you for your understanding.