Neuralgia Inducing Cavitational Osteonecrosis (NICO

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Neuralgia Inducing Cavitational Osteonecrosis (NICO)

A small minority of dentists, who commonly refer to themselves as "biologic dentists,' claim that most facial pains and even pains and diseases located far from the mouth are caused by cavities (cavitations) within the jaw bones. This concept was first proposed in 1976 and called "cavitational osteopathosis" ("CO"). Proponents of this concept alleged that many patients had infected cavities within their jaws and that these cavities were not treatable with antibiotics or detectable on x-rays.

Dentists are able to diagnose abscesses, cysts, and bone infections with x-rays and treat many of them with antibiotic therapy. Because the theory of CO contradicted so much of what was known about bone infections, it was not widely accepted. In addition, the treatment advocated for CO was highly invasive and consisted of drilling into the supposed “cavitations,” scraping the bone and rinsing the wound with antibiotics. Some dentists even rinsed the cavity with colloidal silver and administered intravenous vitamin C. The scientific evidence for both the diagnosis and treatment of CO was extremely weak.

During the the 1980s, CO was renamed "neuralgia inducing cavitational osteonecrosis (NICO)" and a new theory of its origin was proposed. NICO’s prime promoter is J.E. Bouquot, D.D.S., M.S.D., an oral pathologist who coined the term. Bouquot was associated with the West Virginia University School of Dentistry, but in 1994 he began operating the Maxillofacial Center for Diagnostics and Research (later called the Maxillofacial Center for Education and Research), a private laboratory and consultation service in Morgantown, West Virginia.  The center’s mail-in biopsy service is called Head & Neck Diagnostics of America. In 2004, Bouquot became a professor at the University of Texas Health Science Center in Houston, Texas.

The alleged cause of NICO is not localized jaw infections but avascular osteonecrosis (AO). AO is a real condition that is most often associated with the head of the femur (hip bone) and is common among athletes who play contact sports such as football. It occurs because repeated trauma can damage the blood supply to areas such as the hip where there is not a lot of collateral circulation (the presence of many blood vessels that deliver to the same area). Because the jaw has abundant collateral circulation, most experts do not think that AO can occur there. The treatment of NICO is the same as for CO; invasive and irreversible surgeries and extractions.

The research on NICO is very limited. No randomized controlled studies related to "NICO" diagnosis and treatment have been published. Bouquot is the main person diagnosing NICO in the tissue specimens obtained by dentists who claim that the condition exists. Several other pathologists who reviewed some of the same specimens have judged the tissue to be entirely normal. Some proponents locate their alleged problem areas with an unapproved ultrasound device called the Cavitat.

The concepts of cavitational osteopathosis and NICO have been promoted by the American Academy of Biological Dentistry. Postgraduate seminars held by this organization have persuaded a number of dentists and some physicians to claim they can cure such conditions as arthritis, heart disease, and pain throughout the body by removing infected cavities within the patient's jawbones.

Believers in "biological dentistry" have taken the treatment one step further. They claim that root-canal-treated teeth cause NICO as well as a host of other chronic systemic diseases. They recommend removing all root-canal-treated teeth and most of the other teeth close to the area where they say an infection exists. According to a 1994 article in Milwaukee Magazine, a group of local patients filed suit against several practitioners of this bizarre and dangerous therapy. These patients had many perfectly healthy teeth removed without any improvement in their diseases. (I don't know the outcome of the suits.)

Legal Actions

Many people who have been falsely diagnosed with NICO have grounds to sue for malpractice and fraud. There may also be issues of practicing without a license and violation of the Racketeer Influenced and Corrupt Organizations (RICO) Act. For example, a doctor in one state who is not licensed to diagnose patients in another state and does so could be prosecuted for practicing medicine without a license. In such a case, a malpractice suit could secure punitive as well as actual damages. The RICO statute might apply when two or more individuals engage in an interstate activity to defraud. Even though the parties may not be officially in business together, their combined activity functions as if they were.

Attorney David Wilzig of Los Angeles, who has a special interest in dental malpractice cases, has filed suits on behalf of at least eleven victims of NICO-related misconduct. The suits indicate that the dentist(s) diagnosed nonexistent “cavitations,” removed healthy jaw tissues alleged to contain them, and sent specimens to Bouquot who confirmed the alleged NICO diagnosis. Some of the plaintiffs also had teeth and/or amalgam fillings removed unnecessarily, and some required extensive medical and surgical treatment to repair jaw damage and disfigurement caused by the NICO surgery. Many of the cases involved activities by the dentists that constituted the unlicensed practice of medicine (rather than dentistry). These included diagnosis via autonomic response testing (ART, a quacky muscle-test procedure); phony diagnosis of mercury poisoning; and neural therapy injections into breasts, stomach, shoulders, and/or other body parts. Some of the suits included Bouquot as a defendant. Nine of the victims settled with payment of undisclosed amounts.

One of the remaining cases was filed against Alireza Panahpour, D.DS., Cavitat Medical Technologies, and its president Robert Jones. The suit complaint states:

  • The patient consulted Panahpour because one of his teeth was loose and another was painful and tender. During a series of visits, Panahpour did inappropriate dental work that included removal of teeth and part of the patient's jawbone for an alleged "infection" diagnosed with the help of a Cavitat device.
  • In addition to dental care, Panapour did repeated ART testing, prescribed worthless dietary supplements for the patient's diabetes, and gave inappropriate injections (neural therapy) at various points in the body.
  • As a result of improper treatment, the patient was left with (a) numbness of the right side of his mouth, lower lip, chin, and right cheek, (b) improperly fitting dental appliances that will have to be replaced, and (c) possible loss of his remaining teeth through additional dental surgery and reconstructive work.

The other remaining case was filed against Panahpour, Bouquot, the University of Texas, Leigh Erin Connealy, M.D., and the South Coast Medical Center for New Medicine (now called the Center for New Medicine). The complaint states:

  • The patient visited Connealy's center in 2007 for a consultation about bio-identical hormones and was introduced to Panahpour by the medical staff. After conducting a dental examination, Panahpour falsely advised the woman that she had mercury poisoning and required (a) removal of two teeth and all of her amalgam fillings, (b) repair of previous root-canal treated teeth that were badly infected, and (c) surgery to remove bone fragments from two sites where wisdom teeth had been extracted 45 years earlier.
  • After removing 16 amalgam fillings, Panahpour restored four with composite material and shaved down the rest and fitted them with expensive porcelain inlays and onlays.
  • After falsely telling the woman she had "osteomyelitis," Panahpour removed significant amounts of bone tissue from two areas of her jaw. He also treated her with (a) intravenous solutions containing various vitamins and minerals and (b) procaine injections into her chest and upper breast.
  • Panahpour's treatment resulted in (a) infections that required medical treatment and additional surgery, (b) pain in the mouth and teeth, and (c) difficulty chewing and misalignment of the jaws because the crowns and other restorations did were too large.
  • After Panahpour had completed his treatment, he sent specimens of bone and other tissue to Bouquot who made invalid and inaccurate diagnoses in his laboratory at the University of Texas.

Disciplinary Actions

At least ten dentists in Arizona, California, Connecticut, Florida, Iowa, Minnesota, Ohio, New York, Pennsylvania, and Washington who treated "cavitations" have been disciplined by their state licensing boards for insurance fraud or other dental act violations, most of which were related to this alleged diagnosis.

In 2005, for example, James Shen, D.D.S.and his wife Riley Young, D.D.S. were charged of unprofessional conduct by the California Board of Dentistry. Young retired for health reasons and died shortly afterward. In 2006, Shen was further accused of inappropriately administering injections of hydrogen peroxide, vitamin C, and/or echinacea to patients who had complained of nondental problems. The [stipulation_2007.pdf stipulated settlement] included surrender of his dental license.

In 2007, Wesley R. Shankland, II, D.D.S., who operates the Central Ohio Center for Facial Pain in Columbus, Ohio, settled charges against him by entering into a consent agreement under which (a) his dental license will be suspended for six months; (b) he must complete 300 hours of continuing dental education that includes at least 40 hours in ethics, (c) he must not utilize any "alternative" dental or medical treatment without informing the patient that the procedure is nonstandard, (d) his ability to prescribe narcotics and psychiatric drugs will be restricted during 2008, and (e) his records must be available for review and monitoring by a physician or dentist who is experienced in the management of chronic pain. In addition to being one of NICO's leading proponents, Shankland improperly advises that amalgam fillings and root-canal-treated teeth are problematic. The dental board's complaint did not specify whether any of its concerns were related to these nonstandard theories and practices.

The Failed Attempt to Intimidate Aetna

Aetna Insurance Company does not pay for NICO diagnosis or treatment. After reviewing the scientific literature, it published a Clinical Policy Bulletin stating that NICO-related diagnoses are "experimental and investigational because the clinical significance of this syndrome is in question" and that the Cavitat Ultrasonograph (an imaging device used primarily to detect NICO) is experimental and investigational because "there is no adequate scientific evidence to support its clinical value.”

In 2004, Cavitat Medical Technologies and Jones filed a lawsuit suit accusing Aetna of publication of injurious falsehoods, unlawful restraint of trade, and racketeering. However, Aetna had done none of these things, and the plaintiffs did not allege a single instance of illegal conduct to support their false charges. After Aetna filed objections, the judge dismissed the racketeering charge and all but one of the others. In June 2005, Aetna filed a countersuit which stated:

  • The original lawsuit was generated and financed by Cavitat users and others who apparently hoped that it would intimidate Aetna and other insurance companies into paying for practices associated with use of the device.
  • Many of the organizers "conspired to accomplish their objectives through unlawful acts . . . . insurance fraud; illegal and unauthorized research activities; the unauthorized practice of medicine and dentistry; misrepresenting that the Cavitat device was exempt from FDA regulations; misrepresenting that the Cavitat device was approved by the FDA and, specifically, approved by the FDA for detecting diseased bone; obstruction of justice; witness tampering; and barratry."
  • To fund the suit, Cavitat solicited funds from third parties who had invested in the company, some of whom had a monetary stake in its survival, as well as others whose livelihoods derived from the use of the Cavitat device. In exchange, each of these individuals was promised a share of the anticipated recovery.
  • The alleged third parties included Darrel and Patricia Hershey of Parker, Colorado; Dr. Michael Margolis of Mesa, Arizona; Dr. William P. Glaros of Houston, Texas; Dr. William Medlock of West Palm Beach, Florida; and Drs. John Tate and Robert Jones of Spartanburg, South Carolina.
  • In addition, in exchange for unspecified information, a percentage of the anticipated recovery was promised to Tim Bolen, a publicist who has "engaged in a venal and systematic campaign to attack Aetna and persons whom Cavitat alleges are associated with Aetna, all for the purpose of his making money for himself and the others he has acted in concert with in advancing the baseless claims asserted against Aetna in this lawsuit."

The countersuit also described how the NICO concept has been promoted by Bouquot, Wesley Shankland, II, D.D.S., of Columbus, Ohio, and Boyd Haley, Ph.D., a chemist who operates a laboratory that performs "oral toxicity" tests that support what "biological dentists" claim.

In September 2005, Aetna filed an amended counterclaim which described how Cavitat Medical Technologies and members of its board of scientific advisors taught dentists how to miscode insurance claims in order to get paid for diagnosing and treating NICO. The amended counterclaim listed 22 dentists who allegedly filed a total of 427 fraudulent claims for which they got paid. The list included 185 from Bouquot, 53 from Shen, 50 from Shankland, 29 from Glaros, and 17 from Jones. Aetna sought recovery of its legal costs plus punitive damages that could have amounted amount to millions of dollars. In January 2006, the judge ruled on narrow legal grounds that Aetna did not have standing to file its counterclaim. This ruling was unfair and could have been appealed. However, in April 2006, apparently pressured by the judge, Aetna paid $2.1 million rather than facing the uncertainty of a trial by jury in front of a hostile judge. The settlement terms were supposed to be confidential, but subsequent events disclosed the payment amount.

Cavitat's suit did not achieve its primary purposes. Its backers hoped that the prospect of facing racketeering charges would intimidate dental licensing boards as well as other insurance companies, but no such effect is apparent. Although Cavitat's name has been replaced by a more general statement in Aetna's Clinical Policy Bulletin, the Cavitat device and NICO-associated practices still remain ineligible for insurance coverage and are unlikely to be covered by other companies. The latest (November 17, 2009) version of Aetna's policy states:

  1. Aetna considers surgery (including scraping of “infected cavities” and removal of root-canal-treated teeth) and/or any other therapies (e.g., rinsing the “cavity” with colloidal silver and administering chelation therapy and intravenous vitamin C) and bone graft replacement for the treatment of neuralgia inducing cavitational osteonecrosis (NICO) related diagnoses to be experimental and investigational because the clinical significance of this syndrome is in question.
  2. Aetna considers the use of devices to image the jawbones to diagnose NICO or NICO-type conditions experimental and investigational because there is no adequate scientific evidence to support their clinical value.

Cavitat also got embroiled in a nasty battle over the disposition of the $2.1 million. In 2006, the attorney who filed the Aetna suit sued Cavitat for more than $500,000 in unpaid attorneys fees. Cavitat defaulted and then tried to block recovery of the money by filing for bankruptcy. Aetna, Cavitat, and the attorneys reached a settlement agreement under which Cavitat's original attorneys got most of what they asked for.

Aetna does not appear to be interested in seeking recovery of the money it paid in response to miscoded claims. However, other insurance companies have been alerted to look more closely at claims submitted for NICO-related procedures and more victims of NICO surgery have filed lawsuits against its practitioners. Cavitat Medical Technologies may also be facing other trouble. During a bankruptcy hearing, Cavitat President Bob Jones disclosed that in May 2006, his records had been seized by a "SWAT team raid from the FDA into our home and offices."

Advice to Consumers

If you find yourself in the office of a dentist who tells you that a systemic disease or pains far from the mouth are due to infected jaw-bone cavities, run fast, and find another dentist! If you have been a recent victim of NICO-related quackery and would like information on what to do about it, please contact me .

Spotting NICO-Related Insurance Fraud: A Note to Insurance Claims Examiners

Because most insurance companies do not cover procedures related to "cavitational osteonecrosis," many of the dentists who diagnose NICO try to hide their activities by "miscoding" or deliberately misstating facts of a case. Common ploys to "hide" NICO surgery are to state that the patient has osteomyelitis (bone infection), cysts, granulomas, or another pathology near the tip of the tooth root. These diagnoses would not normally stand out for scrutiny because periapical cysts and granulomas are fairly common. To detect miscoding, it would be necessary to compare a particular dentist's diagnostic patterns with what would be expected from a dentist who practices appropriately.

Osteomyelitis near tooth sockets is not common. Deceptive dentists typically list routine (and often unnecessary) extractions as "surgical extractions" (thus charging more) and then scrape out bone from the socket and tooth roots, claiming that an "infection" or osteomyelitis exists. NICO advocates may also remove every tooth with a root canal treatment, regardless of success or failure of the treatment. They claim that root canal treated teeth are "toxic" and cause "cavitations," without any valid biological basis or clinical data to support these assertions.

Insurance carriers would be wise to require a pre-extraction diagnosis for every extracted tooth, and periodically require pre-extraction x-ray films on a random basis. In cases of suspected fraud, pretreatment x-ray films should always be reviewed. Review of the diagnoses submitted would help uncover fraud cases. Other claim patterns that should trigger an examination for fraudulent treatment include:

Multiple extractions on the same day in the same quadrant, coupled with diagnoses of cavitations, osteomyelitis, or other bony pathology

  • Any diagnosis of "NICO"
  • Removal of root canal-treated teeth without cause
  • Multiple bone biopsies
  • Bone biopsies coupled with extractions
  • Osteomyelitis without months of documented antibiotic therapy
  • Multiple bone surgeries done by general dentists.

For Additional Information