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<body link="#800000" vlink="#800000" alink="#800000"><table border="0" cellpadding="0" cellspacing="0" width="100%"><tr><td> <p align="center"> </p> </td></tr></table><table border="0" cellpadding="0" cellspacing="0" width="100%"><tr><td valign="top"> <p align="center"><font face="Arial" size="2" color="#000080"><b>Important notice: This page uses frames. Your browser doesn't support them, <br> but you can get a great deal of information through these non-frames pages.</b></font></p> <table CELLPADDING="2" width="100%" height="1" bordercolor="#808080" border="4" bordercolorlight="#C0C0C0" bordercolordark="#000000" style="border-collapse: collapse" cellspacing="0"> <tr> <b> <td WIDTH="741" VALIGN="Top" colspan="3" height="1"> <h1 ALIGN="Center"><font color="Maroon" face="Arial" size="5"><a NAME="ToC">Maxillofacial </a>Osteonecrosis & NICO</font></h1> </td> </b> </tr> <tr> <td bgcolor="#800000" WIDTH="741" VALIGN="middle" height="4" colspan="3" bordercolor="#800000" bordercolorlight="#C0C0C0" align="center"> <b> <font color="#FFFFFF" face="Arial Narrow" size="2">©The Maxillofacial Center for Diagnostics & Research</font> </b> </td> </tr> <tr> <td WIDTH="204" VALIGN="top" bordercolor="#000080" bordercolorlight="#C0C0C0" bordercolordark="#808080" height="181" align="center"> <p align="center"><br> <b><font face="Arial Narrow"><font color="#000000" size="3">Photo Albums:</font><a href="NICOimaging/NICOimagealbum.html"><font color="#800000"><br> </font> <font color="#800000" size="2"> Scans<br> </font> </a> <font size="2"> <font color="#800000"> <a href="NICOcad/NICOcadalbum.html">Cadaver<br> </a><a href="NICOcavit/NICOcavalbum.html">Clinical<br> </a> Clots & Infarcts <a href="NICOcavit/NICOcavalbum.html"><br> </a> <a href="NICOhisto/NICOmicalbum.html"> Microscopic<br> </a> </font><a href="JOPM99/JOPM99album.html">Microscopic #2<br> </a><font color="#800000"><a href="NICOxray/NICOxrayalbum.html"> Radiographs<br> </a> <a href="NICOsonic/NICOsonicalbum.html">Sonography</a> </font></font></font></b> </td> <td VALIGN="Top" width="295" align="center" height="160"> <img border="0" src="autopsy94a.jpg" width="320" height="228"> </td> <td VALIGN="middle" width="228" height="160" align="center"> <b> <p ALIGN="center"><font face="Arial Narrow" size="2"><strong><a HREF="#Definition">Definition & Disclaimer<br> </a><a href="#note">A Note to Patients<br> </a></strong><a href="NICOsummary.html" target="_top">Brief Review for Patient</a><a href="NICOsummary.html"><br> </a><strong><font COLOR="Purple"><a HREF="NICOclinical/NICOclinical.html" target="_blank">Clinical Features</a><a HREF="NICOclinical.html"><br> </a></font></strong><a href="NICOpain.html">NICO & Pain<br> </a><a href="NICOfollow.html">Follow-up Studies<br> </a><strong><a HREF="NICOmicro.html"> Microscopic Features<br> </a><a HREF="NICOcause.html">Causes/Coagulation<br> </a></strong><a href="NICOhistory.html">Historical Review<br> </a><strong><a HREF="NICOref.html"> Published Literature<br> </a><a HREF="NICOboko.html">Dr. Bouquot's Work<br> </a></strong><font color="#000080"><a HREF="index.html"> Home Page</a></font> </font> </b> </td> </tr> <tr> <td WIDTH="741" VALIGN="middle" bordercolor="#000080" bordercolorlight="#C0C0C0" bordercolordark="#808080" height="11" align="right" colspan="3" bgcolor="#C0C0C0"> <p align="center"><b><font color="#800000" face="Arial Narrow" size="2">Large hollow space (cavitation) in a severely ischemic mandible, with a generalized brown discoloration <br> (degenerated fat and fibrosis) and large area of osteosclerosis (irregular white "bone island").</font></b> </td> </tr> </table> <p align="center"><strong><font color="#800000" face="Arial" size="3">The Maxillofacial Center, 165 Scott Avenue, Suite 100, Morgantown, WV 26508 USA<br> Phone: 304-292-4429   Fax: 304-291-5149    <a href="mailto:MFCenter@aol.com">Email: MFC@aol.com</a></font></strong></p> <hr size="4" color="#800000"> <p align="center"> </p> <p align="center"> </p> <p align="center"><b><font color="#800000" face="Arial" size="4"><a NAME="Definition">Definition </a>of NICO/General Disclaimer</font></b></p> <p ALIGN="Justify"><font color="Black" face="Arial" size="2"><a NAME="Quick">NICO </a>(Neuralgia-Inducing Cavitational Osteonecrosis) is one of the jawbone versions of ischemic osteonecrosis, a common disease affecting any bone but with special affinity for those of the hips, knees and face. By definition, NICO is associated with pain.  Osteonecrosis itself may or may not be painful. It may or may not affect multiple sites. It is a problem of poor blood flow through the marrow and 4/5 of affected patients have underlying coagulation problems. This website provides information relative to this disease as it affects the jaws and facial bones. Every attempt has been made to assure that the information included herein is accurate and not overstated, but the Maxillofacial Center cannot be responsible for misrepresentations. It is your responsibility to use this information in an honorable and responsible fashion.</font></p> <font SIZE="3"> <b> <div align="center"> <center> <table border="4" cellpadding="3" width="170" cellspacing="4" bordercolor="#FFFFFF" bordercolorlight="#C0C0C0" bordercolordark="#808080" bgcolor="#000080"> <tr> <td bordercolor="#FFFFFF" valign="middle" align="center" bgcolor="#000080" height="8" bordercolorlight="#C0C0C0" bordercolordark="#808080"><a HREF="#Top"><b><font face="Arial" size="2" color="#FFFFFF">Top of This Page</font></b></a></td> </tr> </table> </center> </div> <hr noshade size="4" color="#000080"> </b> </font> <b><font SIZE="5"> <p align="center"> </p> </font> <p align="center"><font color="#800000" face="Arial" size="4">A <a name="note">Note</a> to Patients with Jawbone Osteonecrosis (NICO)</font></b></p> <p><font face="Arial" size="2">You have microscopic evidence of ischemic osteonecrosis (literally, "dead bone from poor blood flow"), a bone marrow disease with either dead bone or bone marrow that has been slowly strangulated or nutrient-starved. There are a number of local and systemic problems capable of producing this bone disease <a name="t1short" href="#Table 1">(Table 1)</a>, but more than 4 of every 5 patients with osteonecrosis have a problem, usually inherited, of excessive production of blood clots in their blood vessels <a name="t2short" href="#Table 2">(Table 2)</a>. These are not normally picked up with routine blood studies. Bone is particularly susceptible to this problem and develops greatly dilated blood vessels, increased, often painful, internal pressures, stagnation of blood, even infarctions (completely blocked vessels). This hypercoagulation problem might be suggested by a family history of stroke and heart attacks at an early age (less than 55 years), hip replacement or "arthritis" (especially at an early age), and deep vein thrombosis. Chronic fatigue syndrome and fibromyalgia are also associated with excess coagulation and are frequently found in patients with osteonecrosis, but the significance of this association is not yet known. The jaws have a special problem with this disease because, once damaged, the diseased bone is poorly able to withstand low-grade infections from tooth and gum bacteria.  Also, when a dentist works on a tooth he or she uses strong chemicals (vasoconstrictors, e.g., epinephrine) designed to make local blood vessels smaller and thus keep the local anesthetic in place longer.  For someone who already has a problem with poor blood flow through the jaws, this may be disastrous. </font></p> <p><font face="Arial" size="2">Regardless of the underlying cause, the bone develops either a fibrous marrow (fibers can live in nutrient starved areas), a greasy, dead fatty marrow ("wet rot"), a very dry, sometimes leathery marrow ("dry rot"), or a completely hollow marrow space ("cavitation"). Any bone can be affected, but the hips, knees and jaws are most often involved. Pain is often severe but about 1/3 of patients do not experience pain. The body has trouble healing itself from this disease, but about 1/3 of cases do indeed heal themselves. For the others, experience has shown that surgically removing the damaged marrow, usually by scraping with curettes, will eliminate the problem (and the pain) in almost 3/4 of patients with jaw involvement. Repeat surgeries, usually smaller procedures than the first, may be required, and almost a third of jawbone patients will need surgery in one or more other parts of the jaws because the disease so frequently has "skip" lesions, i.e. multiple sites in the same or similar bones, with normal marrow between. In the hip, at least half of all patients will get the disease in the opposite hip over time; this phenomenon occurs in the jaws as well. Recently, it has been found that some osteonecrosis patients respond to anticoagulation therapies.</font></p> <font SIZE="3"> <div align="center"> <center> <table BORDER="2" CELLSPACING="2" CELLPADDING="6" WIDTH="492" bordercolorlight="#C0C0C0" bordercolordark="#808080"> <tr> <td COLSPAN="2" bgcolor="#C0C0C0"> <p ALIGN="CENTER"><b><font face="Arial">Diseases/Phenomena Associated with <br> Ischemic Osteonecrosis</font></b></td> </tr> </font> <tr> <td WIDTH="49%" VALIGN="BOTTOM" HEIGHT="31" align="center"> <p ALIGN="CENTER"><b><font face="Arial" size="2">Coagulation disorders (hypercoagulation)</font></b></td> <td WIDTH="51%" VALIGN="BOTTOM" HEIGHT="31" align="center"> <p ALIGN="CENTER"><b><font face="Arial" size="2">Alcohol abuse (cirrhosis/pancreatitis)</font></b></td> </tr> <tr> <td WIDTH="49%" VALIGN="BOTTOM" align="center"> <p ALIGN="CENTER"><b><font face="Arial" size="2">Estrogen or cortisone/prednisone therapy</font></b></td> <td WIDTH="51%" VALIGN="BOTTOM" align="center"> <p ALIGN="CENTER"><b><font face="Arial" size="2">Cancer chemotherapy</font></b></td> </tr> <tr> <td WIDTH="49%" VALIGN="BOTTOM" align="center"> <p ALIGN="CENTER"><b><font face="Arial" size="2">Arteriosclerosis</font></b></td> <td WIDTH="51%" VALIGN="BOTTOM" align="center"> <p ALIGN="CENTER"><b><font face="Arial" size="2">Sickle cell anemia</font></b></td> </tr> <tr> <td WIDTH="49%" VALIGN="BOTTOM" align="center"> <p ALIGN="CENTER"><b><font face="Arial" size="2">Tobacco use</font></b></td> <td WIDTH="51%" VALIGN="BOTTOM" align="center"> <p ALIGN="CENTER"><b><font face="Arial" size="2">Deep sea diving</font></b></td> </tr> <tr> <td WIDTH="49%" VALIGN="BOTTOM" align="center"> <p ALIGN="CENTER"><b><font face="Arial" size="2">Lupus erythematosus</font></b></td> <td WIDTH="51%" VALIGN="BOTTOM" align="center"> <p ALIGN="CENTER"><b><font face="Arial" size="2">Starvation (e.g. anorexia nervosa)</font></b></td> </tr> <tr> <td WIDTH="49%" VALIGN="BOTTOM" align="center"> <p ALIGN="CENTER"><b><font face="Arial" size="2">Arthritis & osteoporosis</font></b></td> <td WIDTH="51%" VALIGN="BOTTOM" align="center"> <p ALIGN="CENTER"><b><font face="Arial" size="2">Shwartzman reaction (serum sickness)</font></b></td> </tr> <tr> <td WIDTH="49%" VALIGN="BOTTOM" align="center"> <p ALIGN="CENTER"><b><font face="Arial" size="2">Osteomyelitis (infection in bone marrow)</font></b></td> <td WIDTH="51%" VALIGN="BOTTOM" align="center"> <p ALIGN="CENTER"><b><font face="Arial" size="2">Chronic inactivity (e.g. leg in cast)</font></b></td> </tr> <tr> <td WIDTH="49%" VALIGN="BOTTOM" align="center"> <p ALIGN="CENTER"><b><font face="Arial" size="2">Hypertension (high blood pressure)</font></b></td> <td WIDTH="51%" VALIGN="BOTTOM" align="center"> <p ALIGN="CENTER"><b><font face="Arial" size="2">Congestive heart failure (weak heart beat)</font></b></td> </tr> <tr> <td WIDTH="49%" VALIGN="BOTTOM" align="center"> <p ALIGN="CENTER"><b><font face="Arial" size="2">Local anesthesia use</font></b></td> <td WIDTH="51%" VALIGN="BOTTOM" align="center"> <p ALIGN="CENTER"><b><font face="Arial" size="2">Raynaud phenomenon</font></b></td> </tr> </table> </center> </div> <p ALIGN="left"><font face="Arial" size="2">For more information about hypercoagulation, visit: <b><a href="http://blues.fd1.uc.edu" target="_blank">http://blues.fd1.uc.edu</a></b>, <b><a href="http://www.hemex.com" target="_blank">http://www.hemex.com</a></b>, or <b><a href="http://www.mdl-labs.com" target="_blank">http://www.mdl-labs.com</a></b>. For information about neurotoxicity in NICO lesions visit, <b><a href="http://www.altcorp.com" target="_blank">http://www.altcorp.com</a></b>. For a good NICO support group visit <b><a href="http://delphi.com/nicoandaps/" target="_blank">http://delphi.com/nicoandaps/</a></b>.</font></p> <b> <p><font face="Arial" color="#800000" size="2">Handy definitions:</font></b><font face="Arial" size="2"> <b>Avascular necrosis</b> (another name for ischemic osteonecrosis); <b>bone marrow edema</b> and <b>regional ischemic osteoporosis</b> (mild versions of osteonecrosis); <b>thrombophilia</b> (increased tendency to form blood clots); <b>hypofibrinolysis</b> (decreased ability to dissolve clots as they form); <b>NICO</b> ("neuralgia-inducing cavitational osteonecrosis;" painful osteonecrosis of the jaws – the pain is often like a facial neuralgia); <b>osteomyelitis</b> (infection of bone marrow)<font COLOR="#ff0000">.</font></font></p> <font SIZE="3"> <b> <div align="center"> <center> <table border="4" cellpadding="3" width="170" cellspacing="4" bordercolor="#FFFFFF" bordercolorlight="#C0C0C0" bordercolordark="#808080" bgcolor="#000080"> <tr> <td bordercolor="#FFFFFF" valign="middle" align="center" bgcolor="#000080" height="8" bordercolorlight="#C0C0C0" bordercolordark="#808080"><a HREF="#Top"><b><font face="Arial" size="2" color="#FFFFFF">Top of This Page</font></b></a></td> </tr> </table> </center> </div> </b> </font> </td></tr></table></body>