Periodontal Disease

Cavitations are persistent holes found at the extracion sites of permanent teeth after apparent healing has taken place. Current dental literature considers this common phenomenon to be rare.

OBJECTIVES:

Our specific aim in 49 patients (42 women, 7 men) with osteonecrosis of the jaw was to determine whether thrombophilia (increased tendency to intravascular thrombosis) or hypofibrinolysis (reduced ability to lyse thrombi) were associated with this regional avascular necrosis.

STUDY DESIGN:

Determinants of thrombosis and fibrinolysis were compared in healthy controls and in 42 women and 7 men who had biopsy-proven idiopathic osteonecrosis of the jaw with severe chronic jaw or facial pain syndromes and failure to respond to conventional medical and dental treatments.

RESULTS:

Of the 49 patients, 35 (71%) had thrombophilia or hypofibrinolysis and only 14 were normal. Thrombophilia as a sole coagulation defect was found in 10 patients, 7 with resistance to activated protein C and 3 with low protein C (deficiency of an antithrombotic protein). Hypofibrinolysis with low stimulated tissue plasminogen activator activity and high lipoprotein (a) (an atherogenic, hypofibrinolytic lipoprotein) were found as sole coagulation defects in seven and eight patients, respectively. Ten patients had mixed defects; 7 of these 10 had thrombophilia with resistance to activated protein C. Sinusoidal dilatation was a constant feature in maxillary and mandibular bone biopsies, suggesting venous occlusion with intramedullary hypertension. Marrow fibrosis and occasional fibrin plugs were additional microscopic features believed to impair venous drainage and to contribute to ischemic necrosis of the alveolar bone.

CONCLUSIONS:

Primary thrombophilia and hypofibrinolysis appear to be common, heritable, pathophysiologic risk factors for idiopathic osteonecrosis of the jaws. These coagulation defects may also contribute to alveolar neuralgia, atypical odontalgia and facial neuralgia, idiopathic trigeminal neuralgia, and to treatment failures so often encountered in patients with alveolar osteonecrosis and disabling chronic facial and jawbone pain syndromes.

In 1915, Dr. G.V. Black described a condition of bone degeneration which he termed chronic osteitis. He further described the clinical entity as localized, softened, hollowed out bone, producing various types of symptoms. Since that time, much has been learned about what is now known as NICO – Necrotizing Ischemic Chronic Osteitis – a condition also known by other names, including neuralgia-inducing cavitational osteonecrosis, Ratner bone cavity, and Robert’s bone cavity.

The aims of this study were: (1) to demonstrate how reproducible variations in incomplete anesthesia of the inferior alveolar nerve can be used as a guide to locate the etiologic sites of referred trigeminal pain emanating from the mandible; (2) to describe the salient histopathologic features of a lowgrade, nonsuppurative osteomyelitis seen in this patient population. Forty-six patients with idiopathic facial pain were subjected to a specific protocol of local anesthetic injections to sequentially block branches of the mandibular nerve to determine the effects on his/her pain. If this significantly reduced or altered the pain on three separate appointments, then exploratory surgery was conducted near identified zones of unanesthetized gingiva. Blocking (92%), bridging (4%), and divergence (4%) were observed patterns of anesthetic resistance of the mucogingival tissues used to categorize the incomplete anesthesia. A 100% correlation was found between the identified zones of unanesthetized gingiva and the discovery of intramedullary pathology. Medullary fibrosis with ischemic and degenerative changes in the cancellous bone were common findings, along with chronic inflammatory cell infiltrates and clusters of lymphocytes. It is concluded that Ratner’s method of diagnostic anesthesia be implemented when searching for occult pain producing pathology of the jaws.

Osteomyelitis is described as an inflammation of bone and bone marrow that may develop in the jaws following a chronic odontogenic infection or for a variety of other reasons. This situation may be acute, sub-acute or chronic, resulting in a totally different clinical picture.

A consistent zone of ipsilateral tenderness adjacent to the maxillary molar root apices often is present in patients with atypical facial pain. The author performed bilateral palpation and recorded the temperature of this area on 18 consecutive patients with facial pain. He found tenderness and increased temperature on the involved side of the face in 15 and 17 patients, respectively. In two control groups of 10 patients without pain and 10 TMD patients, he observed no significant association between maxillary tenderness and increased temperature.

Hemophilic pseudotumor of bone is a rare condition that occurs in patients with hemophilia. To date only 10 cases have been reported in the mandible, and none has been reported in the maxilla. The clinical, radiographic, and histologic features and treatment approaches of two cases of hemophilic pseudotumor occurring in the jaws are presented. One of them is probably the first one reported in the maxilla. Both patients had a history of trauma to the area.

Sodium lauryl sulfate (SLS), a synthetic detergent commonly used in dentifrices, is an effective denaturant. The aim of the present study was to investigate the effect of SLS in patients with recurrent aphthous ulcers (RAU). Ten patients with multiple minor RAU participated in the study. The mean incidence of RAU was 17.8 during a 3-month period before the study. The patients used a dentifrice containing 1.2% SLS for a test period of 3 months followed by a dentifrice without SLS for the same time period. The results showed a statistically significant decrease in the number of aphthous ulcers from 14.3 after using the SLS-containing dentifrice to 5.1 ulcers after brushing with the SLS-free dentifrice (p < 0.05). It is suggested that the denaturing effect of SLS on the oral mucin layer, with exposure of the underlying epithelium, induces an increased incidence of RAU.

Literature reviews of oral lesions frequently lack an appropriate historic perspective, presuming that the mid- to late-twentieth century reports are the first valid reports available. The mid-nineteenth century dental journals, however, are replete with clinical, surgical, and microscopic descriptions of oral tumors and cysts. Most of these have never been referenced during the present century. The purpose of this article is to report the earliest dental journal references for a variety of odontogenic tumors and cysts. These references are derived from a canvass of all dental journals published from the first journal (American Journal of Dental Science) in 1839 to the appearance of Dental Cosmos and the organization of the American Dental Association in 1860.

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!