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Review of NICO Follow-up Studies

Several follow-up studies are published (Table 1) relative to patients who
have had surgical curettage of bone marrow damaged by ischemia, infarction
or low-grade inflammation.  These were almost all informal surveys with the
surgeon asking the patients how they were doing.  The investigations by
Roberts et al. were conducted by mailed survey, a step in the right
direction.  The 1995 study by Bouquot & Christian (Table 2) was the only one
to not use the patients' surgeons to ask the questions, it was a mailed
survey which was returned to a researcher who was unknown to them.  It was
further unique in that it guaranteed anonymity, used a standard pain
assessment instrument (the McGill Pain Survey), incorporated multiple
questions designed to identify patients providing inconsistent data, and had
follow-up as long as 18 years.

Comparison of NICO follow-up studies with those for trigeminal neuralgia
The "gold standard" for facial pain follow-up studies, excluding those
relating to the temporomandibular joint disorders, is the collective body of
clinical studies of patients with trigeminal neuralgia, a pain disorder
which is more precisely defined than most others and one which has been
studied much longer and more extensively than others.  This gold standard is
considerably flawed.  Of the 85+ trigeminal neuralgia studies published up
to 1998, many had such brief sections on methods & materials that it is now
impossible to say how the study was performed...some had no methods section
at all. Almost all studies were simple searches of the medical records of
affected patients, a technique with obvious biases relative to the patient
telling the doctor what the doctor wants to hear, the doctor hearing only
what he or she wants to hear, etc. These are all honest mistakes but
undoubtedly give a more positive outcome that anonymous surveys which
guarantee anonymity.   In fact, only two studies used mailed surveys and
only one used an established pain questionnaire/instrument.  The best
studies were those which compared two different treatment modalities, but
these are different types of studies and excluded from the present
discussion.   References will eventually be posted here.

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Table 1: Listing of all published follow-up studies of NICO patients.
References can be found at end of this page.

     Author(s)  Year  Country  Number
     Patients  Median Post-Operative
     Pain Reduction
     Ratner et al. 1976 USA 26 * 100%
     Ratner et al. 1979 USA 61 * 93
     Roberts et al. 1979 USA 42 * 100
     Shaber et al. 1980 USA 8 100
     Mathis et al. 1981 USA 8 100
     Wang et al.  1982 China 103 100
     Demerath,Sist 1982 USA 29 50
     Roberts et al. 1984 USA 208 * 95
     Grecko,Puzin 1984 Russia 65 100
     Ratner et al. 1986 USA 1300 * 85
     McMahan et al. 1991 USA 48 80
     Bouquot, Christian 1995 USA 103 72

   * overlapping patient pools, i.e. some patients probably reported in
multiple papers.

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Table 2: Results of surgical curettage of jawbone NICO (Neuralgia-Induced
Cavitational Osteonecrosis) lesions, an average of 4.5 years after last
surgery, in 103 patients with "idiopathic" chronic facial pain for an
average of 6 years (range: 2-18 years) prior to NICO surgery.

Reference: Bouquot JE, Christian J. Long-term effects of jawbone curettage
on the pain of facial neuralgia. J Oral Maxillofac Surg 1995; 53:387-397.

     Follow-up Rating Reduction % Pain Reduction Status of Pain % of Total
Cases
     0 0-10 % No improvement 8.8
     1 11-33 Minimal improvement 2.9
     2 34-75 Moderate improvement 15.5
     3 76-99 Considerable improvement ** 13.6
     4 100 No pain 59.2
     Total:
    100.0 %

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References

Ratner EJ, Person P, Kleinman DJ: Oral pathology and trigeminal neuralgia.
I. Clinical experiences. J Dent Res 1976; 55:299 (abst).

Ratner EJ, Person P, Kleinman DJ, et al: Jawbone cavities and trigeminal and
atypical facial neuralgias. Oral Surg 19794; 48:3-20.

Roberts AM, Person P: Etiology and treatment of idiopathic trigeminal and
atypical facial neuralgias. Oral Surg 1979; 48:298-308.

Shaber EP, Krol AJ: Trigeminal neuralgia -- a new treatment concept. Oral
Surg 1980; 49:286-293.

Mathis BJ, Oatis GW, Grisius RJ: Jaw bone cavities associated with facial
pain syndromes: case reports. Milit Med 1981; 146:719-723.

Wang M, Xiwei J, Qingrong I, Sanyou Z: [A study of the relation between the
various trigger zones of idiopathic trigeminal neuralgia and jaw bone
cavities]. Acta Acad Med Sichuan 1982; 13:233-238.

Demerath RR, Sist T: Treatment of osteocavitation lesions in facial pain
patients: preliminary results. J Dent Res1982; 61:218.

Grecko VE, Puzin MN: [Odontogenic trigeminal neuralgia] Zh Nevropathol
Psikhiatr 1984; 84(11):1655-1658.

Roberts AM, Person P, Chandran NB, Hori JM: Further observations on dental
parameters of trigeminal and atypical facial neuralgias. Oral Surg 1984; 58:
121-129.

Ratner EJ, Langer B, Evins ML: Alveolar cavitational osteopathosis --  
manifestations of an infectious process and its implication in the causation
of chronic pain. J Periodontol 1986; 57:593-603.

McMahon RE, Griep J, Marfurt C: Local anesthetic effects in the presence of
chronic osteomyelitis (necrosis) of the mandible: implications for
localizing the etiologic site(s) of referred trigeminal pain. Anesth
Prog1991; 38:189.

Bouquot JE, Christian J. Long-term effects of jawbone curettage on the pain
of facial neuralgia. J Oral Maxillofac Surg 1995; 53:387-397.