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The substantial intolerance exhibited by Dr. Donlon’s’ commentary on our article that dealt with the histopathology of jawbone osteomyelitis (neuralgiainducing cavitational osteonecrosis, NICO) in facialneuralgia patients is disappointing. It is enticing, I know, to blithely accept one’s own suppositions as science and the other chap’s as drivel. In this case we are accused of generating considerable drivel, excluding science from our research, creating facts from fantasy, and possessing no diagnostic skills worthy of mention. These charges are especially intriguing because
the political controversy that surrounds NICO led me to the unusual action of referring our paper to several international experts before it was submitted for publication. I truly thought I had addressed its major deficiencies!

A somewhat obscure etiologic theory for facial neuralgias presumes a low-grade osteomyelitis of the jaws that produces neural degeneration with subsequent production of inappropriate pain signals. Animal investigations and treatment successes with human patients based on this theory lend it credence. The present study examined 224 tissue samples removed from alveolar bone cavities in 135 patients with trigeminal neuralgia or atypical facial neuralgia. All tissue samples demonstrated clear evidence of chronic intraosseous inflammation. 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, nonresorbing necrotic bone flakes. Very little healing or new bone formation was visible. These lesions were able to burrow several centimeters to initiate distant cavities. The present preliminary investigation cannot prove etiology, but the presence of intraosseous inflammation in every single jawbone specimen in these patients and certain clinical and treatment aspects of these lesions (to be reported later) has led the authors to recommend the term neuralgia-inducing cavitational osteonecrosis or NICO for these lesions.

A patient with a history of trauma to the maxillary left anterior region presented with chronic pain of unknown etiology. Root canal therapy and periradicular surgery failed to resolve the persistent pain. A second surgical procedure revealed a bone cavity superior and distopalatally to the apex of the maxillary left lateral incisor. The suspected etiology was necrotic bone removed from the bone cavity.

A 32-yr-old white North American male resident of Norway presented with an asymptomatic radiolucency first identified 3 yr after the removal of an impacted mandibular right third molar in Southern California 16 yr previously. Surgical exploration revealed an intraosseous cavity filled with a black, homogeneous, gelatinous substance thought to be foreign material, but which was diagnosed histologically as containing black yeasts. Cultivation of a microbiologic sample for 6 wk grew black yeast-like colonies. The yeast isolate was identified as an Aureobasidium species different from the typical A. pullulans. A blood sample was negative with regard to antibodies both with double diffusion technique and ELISA. Also, examination with respect to dermatologic manifestations gave negative results. Flucytocin 10 g/d was administered systemically for 30 d. Six months postoperatively bone regeneration was satisfactory radiologically.