Understanding NICO and Dental Cavitations

What They Are, Why They Matter, and How They Are Managed

Dental cavitations — often referred to as NICO (Neuralgia-Inducing Cavitational Osteonecrosis) — are a poorly understood and frequently overlooked phenomenon in dentistry. They can be deeply frustrating for patients, particularly those who experience persistent facial pain, unexplained systemic symptoms, or a sense that an extraction site “never quite healed properly.”

This article aims to explain what dental cavitations are, how they form, how they are diagnosed, and how they are managed in a careful, staged, and evidence-aware manner.

What Is a Dental Cavitation (NICO)?

A dental cavitation refers to an area of non-healing or poorly regenerated bone, most commonly found at the site of a previous tooth extraction, apical surgery, or traumatic dental procedure.

Although the gum tissue overlying the area may appear healed, the bone beneath can remain:

• Necrotic

• Hypovascular

• Structurally deficient

• Metabolically inactive

• 
  

In some cases, this area may harbour inflammatory mediators or degraded fatty marrow, which is why the term NICO is sometimes used in the context of chronic facial pain or neuralgia.

Importantly, cavitations do not behave like acute infections — there may be no swelling, pus, or fever — which is why they are often missed.

Why Do Cavitations Occur?

Cavitations are usually multifactorial. Common contributing factors include:

• Difficult or traumatic extractions

• Previous apical (root-end) surgery

• Dry socket or compromised clot formation

• Reduced blood supply to the jawbone

• Repeated antibiotic exposure

• Systemic conditions affecting healing

• Foreign material left within the socket

• High physiological or inflammatory stress at the time of healing

• 
  

Some patients also report long-standing sensitivity to dental materials or medications, which may further impair bone recovery.

Symptoms Patients May Experience

Cavitations can present very subtly. Symptoms may include:

• Atypical or persistent facial pain

• Pressure or discomfort without sharp tooth pain

• A sensation that the jawbone feels “thin” or abnormal

• Pain triggered by chewing or tapping

• Referred pain to the ear, temple, or neck

• Generalised fatigue or inflammatory symptoms (in selected cases)

• 
  

It is important to emphasise that not all cavitations cause symptoms, and not all systemic symptoms can be attributed to dental cavitations.

How Are Cavitations Diagnosed?

Clinical Examination

Clinically, the overlying gum may look normal. Occasionally, the ridge appears:

• Collapsed

• Thinner than expected

• Tender to deep palpation

• 
  

Imaging

Cavitations are often missed on standard 2D X-rays.

More useful imaging includes:

• CBCT (Cone Beam CT) – shows areas of radiolucency and reduced trabecular density

• Comparison with adjacent healthy bone is critical

• Nerve position must be carefully assessed

A cavitation typically appears as:

• A radiolucent defect

• Poor internal bone density

• Intact outer cortical plates with hollow internal structure

  
  

A Conservative, Staged Approach to Management

At our clinic, cavitation management is never rushed. Many patients presenting with suspected cavitations also have:

• Recent systemic illness

• Dental trauma

• High anxiety

• Poor wound healing history

• Upcoming travel or life commitments

  
  

Step 1: Observation and Stabilisation

If the patient is systemically unwell or anxious, we may:

• Monitor clinically and radiographically

• Avoid immediate surgery

• Focus on nutrition, rest, and recovery

• Address acute dental issues only

  
  

Step 2: Surgical Debridement (When Indicated)

If symptoms persist and imaging supports intervention, cavitation surgery may be considered.

This typically involves:

• Raising a mucoperiosteal flap

• Identifying necrotic or poorly vascularised bone

• Debriding the cavitation thoroughly

• Allowing the site to bleed to re-establish vascularity

• Applying adjunctive therapies such as ozone

• Placing platelet-rich fibrin (PRF) to support healing

• Tension-free closure

  
  

Photographic documentation is often taken for records and transparency.

Step 3: Healing and Review

Healing is reviewed clinically and symptomatically, typically at:

• 2 weeks

• Longer-term follow-up if required

Further restorative or implant planning is only considered once bone healing is satisfactory.

The Role of PRF in Cavitation Surgery

PRF (Platelet-Rich Fibrin) is derived from the patient’s own blood and contains:

• Growth factors

• Cytokines

• A fibrin scaffold to support healing

  
  

In cavitation surgery, PRF helps:

• Improve angiogenesis (new blood vessel formation)

• Support bone regeneration

• Reduce postoperative inflammation

• Improve patient comfort

  
  

What Cavitation Surgery Is Not

It is important to be clear:

• Cavitation surgery is not a guaranteed cure for systemic illness

• Not every radiolucency requires surgery

• Not every patient will benefit from intervention

• Over-treatment can be as harmful as under-treatment

This is why shared decision-making and pacing are essential.

Addressing the Bigger Picture

Many patients with cavitations also present with:

• Heavily restored dentition

• Root canal treated teeth

• Amalgam restorations

• Altered occlusion

• Airway or ENT-related concerns

  
  

A holistic dental plan may involve:

• Staged prosthetic rehabilitation

• Mercury-safe amalgam removal (if chosen)

• Conservative management of root-treated teeth

• ENT referral when indicated

• Collaboration with functional or medical practitioners if appropriate

  
  

Final Thoughts

Dental cavitations and NICO sit at the intersection of dentistry, bone biology, pain science, and systemic health. They require neither blind belief nor outright dismissal — but careful assessment, clinical judgement, and respect for the patient’s lived experience.

A thoughtful, conservative, and evidence-aware approach remains the cornerstone of ethical cavitation management.

If you’re experiencing unresolved symptoms after dental procedures or have concerns about a poorly healed extraction site, a proper clinical and radiographic assessment is the first step.