Heart rate change following NICO and Cavitation removal in a 42 year old Chinese male

Dr Samintharaj Kumar
6 days ago
4 min read

When the Mouth Becomes the Missing Link:

Chronic Dental Infections, NICO, Cavitations, and Systemic Symptoms

As clinicians, we are trained to think in silos—cardiology here, dermatology there, dentistry somewhere else. Yet, every so often, a case forces us to step back and re-examine the interfaces between systems. This was one such case.

The Patient Story

A 42-year-old Chinese Malaysian male presented to Singapore with a four- to five-year history of unexplained systemic symptoms, including:

Recurrent flare-ups involving his hands
Persistent urticaria
A chronically elevated resting heart rate, typically in the 90 beats per minute range

He had been thoroughly investigated by multiple medical practitioners. Infectious, autoimmune, and systemic causes were explored and excluded. In an effort to eliminate potential contributors, he had even removed his dental amalgams. Despite this, his symptoms persisted.

What remained unresolved was his dental history: multiple root canal–treated teeth and wisdom teeth extractions performed approximately 10 years earlier. This prompted him to seek a comprehensive dental and maxillofacial assessment.

Dental Findings: More Than Just “Old Dentistry”

Advanced imaging and clinical evaluation revealed:

Cavitations associated with root canal–treated teeth, particularly:
- Upper left central incisor
- Upper right central incisor
Severe apical pathology affecting several endodontically treated teeth
Poor to hopeless prognosis of adjacent teeth due to compromised root structure
Significant bone loss associated with a lower second molar
External root resorption of the lower left first molar

Taken together, the diagnosis was chronic odontogenic infection with cavitations and long-standing apical pathology, representing a persistent low-grade inflammatory and infective burden.

What Is a Cavitation?

In dentistry, a jaw cavitation refers to an area of bone that has failed to heal normally following trauma—most commonly tooth extraction or endodontic infection.

Unlike healthy bone, cavitated bone may be:

Poorly vascularised
Necrotic or fatty-degenerated
Biologically inactive
Colonised by low-virulence anaerobic bacteria

Importantly, these areas often:

Do not present with pain
Do not show classic signs of infection
May be missed on standard 2D radiographs

Yet biologically, they can act as a chronic inflammatory nidus, quietly persisting for years.

What Is NICO?

NICO (Neuralgia-Inducing Cavitational Osteonecrosis) is a term used to describe a specific subset of jaw cavitations characterised by:

Chronic ischaemia (poor blood supply)
Osteonecrosis (non-vital bone)
Minimal acute inflammatory signs
Abnormal bone remodelling

Although originally described in association with facial pain or neuralgia, it is now increasingly discussed in the context of chronic inflammatory burden rather than pain alone.

Crucially, NICO is not acute osteomyelitis. It is low-grade, indolent, and often silent—yet biologically active.

Why Can Cavitations and NICO Occur After Wisdom Tooth Removal?

This is a key question patients often ask.

Wisdom teeth extractions, particularly lower third molars, involve:

Significant bone removal
Disruption of blood supply
High local bacterial load

If healing is incomplete—due to:

Reduced vascularity
Infection
Systemic stress
Smoking
Surgical trauma

The extraction socket may never fully re-ossify. Instead, it can leave behind:

Necrotic bone
Fatty marrow spaces
Areas of chronic inflammation

These changes may remain clinically silent for years, only becoming relevant when viewed in the context of systemic symptoms.

In this patient’s case, his wisdom teeth had been removed nearly a decade earlier, yet imaging and surgical exploration confirmed persistent cavitational pathology.

Treatment: Reducing the Infective Burden

The patient was counselled carefully.

While there is increasing evidence of association between chronic dental infection and systemic inflammatory responses, this does not equate to direct causation. Nonetheless, given the extent of pathology and poor dental prognosis, definitive treatment was advised.

The following procedures were performed:

Surgical removal of all identified cavitations
Extraction of teeth with hopeless prognosis
Thorough mechanical debridement of affected bone
Ozone disinfection of bone surfaces
Placement of platelet-rich fibrin (PRF) to support healing
Placement of ceramic dental implants at selected sites

The objective was not only local disease control, but reduction of chronic infective and inflammatory load.

The Outcome: An Unexpected but Measurable Change

At four days post-surgery, the patient reported feeling significantly better overall. Of particular interest:

His resting heart rate had fallen from the 90s to the low 60s
This was corroborated by his Apple Watch data, which he had been tracking consistently for years
His IV sedation records showed a preoperative heart rate of 92 bpm, supporting that the elevated heart rate was not merely situational anxiety

While one could argue perioperative stress or placebo effect, the magnitude and rapidity of change were notable.

Correlation, Not Causation — But Still Worth Noting

This case does not prove that cavitations or NICO caused the patient’s systemic symptoms. Medicine rarely offers such clean answers.

However, it does highlight an important clinical reality:

Chronic odontogenic infections can exist silently for years and may contribute to systemic inflammatory stress in susceptible individuals.

Removing that burden may, in some patients, lead to measurable systemic improvement.

Final Thoughts

Dentistry does not exist in isolation from the rest of the body. The jaw is a living bone, richly innervated and vascularised, and chronically diseased bone should not be dismissed simply because it is painless.

Cases like this remind us to: