Cavitational Osteonecrosis in Jawbone - Dr. Dr. (PhD-UCN) Johann Lechner

CAVITATIONAL

OSTEONECROSIS

IN JAWBONE

Abridged ONLINE Version

by

Dr. Johann Lechner

This presentation is a brief overview of the latest Jawbone Detox book. Experienced

authors create enlightening insights into the jawbone and the immunological

derailments of the jawbone marrow for you.

Cavitational Osteonecrosis in Jawbone –

from neglected local inflammation to endangering systemic diseases

Ultrasonography CaviTAU ® for radiation-freeimaging in

Maxillo-Mandibular Osteoimmunology –

A Guide to Jawbone Detox

Interested in this exciting topic?

Then order this book at www.icosim.de/en/literature

or become a member at “International College of Maxillo-

Mandibular Osteoimmunology” www.icosim.de

How many pages? 398

How many pictures and figures? 392

How many scientific references? ca. 670

ISBN 978-3-931351-45-8

Price

€ 68.00 (incl. VAT)

All pictures are © by Dr. Johann Lechner 1

Introduction

There are so many reasons why this book is necessary: Why does this book aim to focus

scientific attention on the bone marrow of the human jaw (Maxilla & Mandible) and the

possible inflammatory interface with systemic diseases?

• We have a classic problem of so many dentists nowadays, only looking at the

trees and forgetting about the forest.

• Books like this truly will dramatically change the way things are done and can

literally change and save the lives of both doctors and patients alike.

• We need to see more synergies between dental surgeons and physicians.

• And by all means, they should have every single source of inflammation from the

jawbone removed, and this is what we like to call Jawbone Detox.

• This book covers the use of a worldwide patented technology that uses

ultrasound called CaviTAU ® .

We need to ensure that every single patient that has a systemic illness that has its

origins uncertain, that more dentists or physicians are looking for inflammation in the

human jaw that can then be confirmed via ultrasound.


1. What are “Bone marrow defects in jawbone”?

• Below the surface: This book tries to elucidate the conversion of acute infection

(AI) into chronic inflammation (CI) in the jawbone (maxilla & mandible) during

common dental procedures like simple extractions, wisdom tooth surgery, root

canal treatment and implant surgery.

• Chronic inflammation following bad wound healing shows up as fatty degeneration

of jawbone marrow (FDOJ)

Morphology of Fatty-Degenerative Osteolysis / Osteonecrosis in Jawbone:

FDOJ is more similar to "silent inflammation" or "subclinical inflammation" with

typical signs of subliminal inflammation and – often - painlessness.

Figure 1: Left panel: Fatty and osteolytic spongy bone samples of medullary jawbone. Right

panel: The corresponding radiograph of an apparently unaltered area of the upper left jawbone

(28/29). The softening in FDOJ is so distinct, that the marrow space can actually be sucked and

spooned out. Hollow cavitations with fatty degenerated adipocytes have undergone dystrophic

changes, accompanied by demyelination of the bony sheath of the infra-alveolar nerve. J. Bouquot

describes FDOJ induced necrotic, softened cancellous bone as follows: Hollow cavitations with soft

tissue that had undergone fatty dystrophic changes and delamination of the bony sheath of the

inferior alveolar nerve.

Cross reference in book: see section 1.2 and 1.3.


2. Pathogenetic aspects of FDOJ: Approach to a

mediator-based hypothesis of causal systemic

relations

Our studies in the following sections support an expanded immunological signaling network

primarily by the proinflammatory chemokine RANTES/CCL5 as the unique interface of

FDOJ with overall health.

2.1 Cytokine profile measurement in jawbone osteolysis

Which science-based facts make Jowbone Detox necessary?

Figure 2: Distribution of seven cytokines in the FDOJ samples obtained from five disease groups:

Atypical Facial and Trigeminal pain (n=9); Neurodegenerative disorders (Multiple Sclerosis and

Amyotrophic Lateral Sclerosis) (n=5); Tumors (Breast Cancer and Prostate Cancer) (n=5);

Rheumatism (Fibromyalgia and Lyme Disease) (n=8); and Chronic Fatigue Syndrome (n=8).

There was significant overexpression of RANTES/CCL5 in all groups in the jawbone; there

were no statistically significant differences between the individual groups (Kruskal-Wallis).

2.2 Expression of seven cytokines in the apical area of root-filled teeth in

jawbone

Figure 3: Comparison of the seven cytokines in the FDOJ underneath RFT #46 with the cytokines

in the healthy jawbone (n=19). Legend: The left X-ray shows the apical area of RFT #46 in a red

circle on a two-dimensional orthopantomogram (2D-OPG); the right X-ray shows the same area

on the sagittal plane in three-dimensional cone beam (3D-CBCT).

Cross reference in book: see section 1.4. and 2.1.1.5


2.3 FDOJ areas – a systemic pathogenic relevant phenomenon

Presented data and submitted contexts suggest that existing FDOJ areas in jawbone

could act as a significant pathogenic potential to the overall immune system:

2.3.1 Hyperactivated Signaling Pathways of Chemokine RANTES/CCL5 in

Osteopathies of Jawbone in Breast Cancer Patients

Figure 4: Distribution of individual RANTES values in FDOJ MaCa cases compared to normal

jawbone in green base line (n= 23 & 19 respectively) (pg/ml). The mean value of RANTES in

serum from 13 MaCa patients was 56,4 (ng/ml) with a SD of ± 36,1.

Figure 5: Clinical case breast cancer patient – Comparison of X-ray diagnostics and RANTES/CCL5

expression: Left panel: 2D X-ray diagnostics of area 38. Right panel: Documentation of the expanse

of FDOJ in retromolar area 38/39 using a contrast agent after FDOJ surgery.

Cross reference in book: see section 2.1.1.6/2.1.3


2.3.2 Peripheral Neuropathic Facial/Trigeminal Pain and RANTES/CCL5 in Jawbone

Cavitation – Patient cohort: 15 patients with atypical facial pain/trigeminal

neuralgia

Figure 6: Analysis of seven cytokines in the FDOJ - AFP/TRN cohort (n = 15) compared to healthy

jawbones.

• FDOJ, as a contributing factor to AFP/TRN is a widely neglected form of “silent

inflammation” characterized by the overexpressed chemokine RANTES/CCL5.

• The presence of FDOJ is often not entirely obvious from examination of a panoramic

or other 2D x-rays and should always involve a 3D CBCT as well as a trans alveolar

ultrasonography by CaviTAU ® .

Cross reference in book: see section 2.1.5

2.3.3 The Impact of RANTES from Jawbone on Chronic Fatigue Syndrome

Figure 7: Distribution of 7 cytokines in healthy jawbone (blue columns/ n = 19) versus in

FDOJ specimens of the Chronic Fatigue Syndrome cohort (red columns/n = 21) in pg/ml.



3. Salutogenetic aspects of FDOJ treatment in complementary

medical practice

3.1 Case study linking RANTES/CCL5 overexpression in jawbone

with chemokine receptors in the central nervous system.

Figure 8: Unremarkable 2D-OPG from December 2009, with no findings in the areas of the

extracted wisdom teeth 38 and 48. CaviTAU ® measurement displays reduced mineralisation in

lower edentulous wisdom tooth areas. It is proposed that this case study should guide the

implementation of a standardised clinical procedure in which appropriately selected patients can be

evaluated for FDOJ preferably by CaviTAU ® ultrasound sonography.


3.2 Chronic fatigue syndrome and “silent inflammation” of the jaw –

Case study on supplementing diagnostic dental X-rays with

ultrasound

Figure 9: Comparison of X-ray image (2D-OPG) and CAVITAU measurement which shows specific

via green dense, inconspicuous structures) and red (low-density, conspicuous structures) resolution.

Notes: In contrast to the 2D-OPG and 3D-DVT/CBCT images, the CAVITAU measurements with

respect to the edentulous retromolar area 38/39 clearly indicated the suspicion of osteolysis of the

jaw This finding was a result of increased attenuation of the ultrasound beam due to fatty

degeneration of the dense medullary cancellous bone. This may be compared to the finding for the

area at healthy tooth 37 which showed a solid bone structure and bone density in green.


Figure 10: Aspergilloma removed from the cancellous medullary cavity in edentulous jaw area

38/39. Notes: Within the cancellous medullary cavity in the edentulous jaw area 38/39, an

aspergilloma (“fungal ball”) formed a large, spherical colony of mold together with a fungal network

that also contained a mixture of inflammatory cells (see the “Histological findings” section).


3.3 Osteoimmunology of Tumor Necrosis Factor-alpha, Interleukin-6, and

RANTES/CCL5 – A Review of Known and Poorly Understood Inflammatory

Patterns in Osteonecrosis

Figure 11: Summary of the cytokine profiles and statistical comparison of TNF-a, IL-6, and

RANTES/CCL5 expression from FDOJ samples into different disease groups; marked downregulation

of TNF-a and IL-6 was observed, as was excessive upregulation of RANTES/CCL5. We

identify the chemokine RANTES/CCL5 as a neglected key factor; however, at the same time, it is

the dominant carrier of a chronic, low-grade inflammation within a “Maxillo-mandibular

Osteoimmunology”. For the benefit of systemically ill patients, it is necessary that medicine and

dentistry devote further attention to the concept of “Maxillo–mandibular Osteoimmunology” and the

associated personalized signal patterns.



4. Diagnostic problems of BMDJ / FDOJ lesions in jawbone

Why is a panoramic X-ray (2D-OPG) not enough for the diagnosis of a “bone

marrow defect”?

Figure 12: Fatty-degenerative osteolysis / osteonecrosis with typical fatty-degenerative changes

• The authors also concluded that the grey values of CBCT/DVT images are

influenced by device and scan settings.

• Interpretation bias of the measurement results cannot be excluded and detracts

from the objective assertion of the HU scale.

• However, it is possible to objectively close this diagnostic gap using CaviTAU®

for measuring mineralisation density.

Cross reference in book: see section 3.1 – 3.2.6


5. Ultrasound in Slow Dentistry for measuring bone quality –

Assessment of mechanical bone quality

Figure 13: The CaviTAU ® system has three main functional parts: The handpiece of the

measuring unit for use on the patient is at the front here with the actual processing unit of the

CaviTAU ® system and computer and screen for storing the measured data in the background. In

addition, a foot switch is used to control the measuring pulses (not shown here).

Figure 14: CaviTAU ® measurement of jawbone density. Notes: Individual adjustments of the

measuring unit are made in response to different jaw conditions by means of specially designed

gel cushions.

Figure 15: CaviTAU ® dashboard display: Example of the 2D colour scheme in CaviTAU ® in region

38: Several measurements (tooth 37, region 38 and 39) are displayed in the upper part of the figure.

Unremarkable area 37 in green; suspicious area at 38 and 39 with partial red colouration. In the right

part of the figure, the individual visualisation of area 38 shows the different mineralisation density

through different colouration of 91 individual sensor fields. The blue and white colouration of area 38

shows an even more precise differentiation of the levels of density.


• CaviTAU ® closes the diagnostic gap for degenerative bone changes as these

issues cannot be visualised with standard radiological diagnosis. This diagnostic

technique has many possible useful applications, e.g., immunological,

oncological, etc.

• CaviTAU ® also closes an application gap in implantology. The use of implants

can be improved by measuring the bone properties of patients, thus minimising

the risks of an unsuccessful implant.



6. Why is CaviTAU ® necessary in dentistry?

6.1 CaviTAU ® displays jawbone areas with reduced mineralisation density

Note: CaviTAU ® does not provide absolute measurement values or a direct

diagnosis. The clinical safety and performance of CaviTAU ® has been clinically

evaluated. This demonstrates that CaviTAU ® complies with the essential requirements

set out in Medical Device Directive 93/42/EEC and MEDDEV 2.7/1 Rev.4.

6.1.1 Case #1: Atypical facial pain – Determination of bone density in the jaw and

localisation of bone marrow defects / FDOJ with CaviTAU ®

Male patient, 36 years old: Facial pain with neuralgiform attacks at slightest of

touches or masticatory strain in the right mandible for 8 months following removal

of titanium implant at #46 tooth location.

Figure 16: Following the previous implant situation, the patient’s clinical presentation was as follows:

after insertion of the implant the neuralgiform facial pain developed to the extent that the implant

had to be removed again.



6.1.2 Case #2: Atypical facial pain/trigeminal neuralgia: Area with reduced

mineralisation density in CaviTAU ® : 48-49

Figure 17: CaviTAU ® shows reduced mineralisation density in areas 48-49; X-ray revealing no

abnormalities. Suspected diagnosis: fatty degenerative osteolysis/osteonecrosis in medullary cavity

of the jawbone = FDOJ/bone marrow defects with high RANTES/CCL5 over expression in Area 48-

49 = 1.750 pg/ml (Norm = 150 pg/ml).

Cross reference in book: see section 6.1.

6.2 Slow Implant with CaviTAU® - Implant surgery, bone marrow defects in

the jaw and TAU

• Slow Implant starts before implant insertion with the question: Is the level of

mineralisation in the jawbone suitable to ossify an implant without any issues and

to keep it secure in a stable bone bed for a long time?

• Slow Implant finishes implant insertion with the questions: Have further

inflammatory signal cascades – primarily based on RANTES/CCL5 messenger

substances – been provoked by the insertion of the implant and the directly

associated wound healing? Is it possible that the pathogenesis of systemic

diseases – associated with RANTES/CCL5 overexpression – has been indirectly

strengthened?


6.2.1 Implant success with CaviTAU ® - Quest for routine implant practice

Figure 18: Question: Is implant insertion successful in these jaw areas and do implants last for a

long time? The figure shows a good example of a perfect state of mineralisation in a lower jawbone,

which is characterised by widespread green colouration in CaviTAU ® and is suitable for a

prospectively unproblematic insertion of implants. This finding is consistent with good conditions for

a long implant lifetime as indicated in the literature.

Cross reference in book: see section 6.2

6.2.2 CaviTAU ® detects focal inflammation areas around implants that

cannot be identified by X-rays.

Figure 19: Left image shows two ceramic implants in area 46 and 47 in an unremarkable 2D OPG.

Right image shows CaviTAU ® measurement in four vertical comparison steps (see chapter 4.03):

Bottom right measurement #1 shows caudal visualisation of the lower cortical margin of the lower

jaw, as well as the less dense areas of the infra-alveolar nerve canal in red and dark blue colouring.

Scan #2 shows the dense implant structure in green or light blue and white with a clearly straight

delimitation to the distally located red or dark blue colouration as a sign of a reduced mineralisation

density with suspected osteolysis. In a cranial and vertical direction, scan #3 shows only dense

structures in green or white and light blue with suspected minor osteolysis/periimplantitis. Image #4

shows dense structures in green or light blue with the oral cavity shown in white.

• Due to the insufficient imaging of the mineralisation levels in the bony implant

environment in 2D-OPGs and the unavoidable hardening artefacts in CBCT/DVTs, a

part of the bone marrow in the jaw cannot be correctly immunologically assessed.

• These systemic assessment criteria in implantology – beyond local asymptomatic

symptoms – are only offered by CaviTAU ® measurement.

Cross reference in book: see section 6.2.9.3


6.2.3 Case #3: Female patient, 57 years old. Medical history: Medical history: Patient

suffers from muscle tenseness on the entire right side of the body with chronic

pain in the lower right jaw.

Figure 20: Left image shows unremarkable 2D-OPG of implants 46 and 47 with unproblematic

healing following insertion 11 years ago. Right image shows implant environment in 3D-DVT with a

bone structure that cannot be assessed. Lower images show a comparison of X-ray findings with

CaviTAU ® bone density measurements at 46 and 47 due to atypical facial pain in the right lower

jaw.

6.3 Endodontics and CaviTAU ®

Case #1: CaviTAU ® shows osteolytic intra radicular septa

Figure 21: While the OPG shows osteolysis/brightening of the intra-radicular septum in the case

of inadequate root fillings on tooth 46, a definitive reliable diagnosis cannot be made. However, the

CaviTAU ® image in 2D and 3D show the hard roots in green and in white respectively. The alveolar

parts in between both roots are shown in red in every CaviTAU ® image, thus indicating osteolysis.

Removing such a tooth without clearing the intraradicular septum does not achieve the goal of

getting rid of the chronic intraradicular inflammation. In the following case reports, we have

revisualised the existing ultrasound measurements with corresponding CaviTAU ® models.

Cross reference in book: see section 6.3 – 6.3.2.9


7. Why is CaviTAU ® important for systemic diseases?

As the fatty degenerative osteolysis in the jawbone (FDOJ) are completely or partially

invisible in X-rays as “silent inflammation”, they can be diagnosed much more accurately

with CaviTAU ® .

7.1 Case report of trigeminal neuralgia/ atypical facial pain and CaviTAU ®

Figure 22: The 2D-OPG of this patient shows a typical unremarkable finding, from which no dental

diagnosis is made - despite the patient's severe facial pain in this area - for more than a year.

Just a simple radiation-free measurement of the mineralisation density levels of the jaw in areas

38/39 shows the reduced bone formation via the red colouration of the CaviTAU ® image. Below

the 2D-OPG, the overview bar control image of tooth 37 shows a continuous green colouration

and clearly shows dense bone structures, proving that only the 38/39 area is affected by osteolysis

and not the underlying alveolar tissue of healthy tooth 37. Right image: Upper CaviTAU ® image

shows the dissolution of the cancellous bone in the dotted red area. At the same time, the green

area at the upper edge of the picture shows the harder cortical bone of the linea obliqua. Lower

part of right picture: 3D CaviTAU ® view of area 38. Again, the red area shows dissolved

cancellous bone; yellow area picks up the canalis infraalveolaris; white area corresponds to the

green dots in the upper right image and represents the harder cortical bone structure of the linea

obliqua.

Figure 23: Follow-up image with CaviTAU ® shows complete healing of the retromolar medullary

jawbone areas 18 months after the surgery with complete remission of neuralgic pain.



7.2 Neurodegenerative diseases and CaviTAU ®

RANTES/CCL5 Signaling from Jawbone Cavitations to Epistemology of Multiple

Sclerosis – Research and Case Studies:

Figure 24: Comparison of 7 cytokines from FDOJ in ALS patients (n = 5) with normal bone marrow (n =

19). Note: Sample of FDOJ displays the characteristic fatty-degenerative morphology of these bone

marrow effects.



8. Published papers on CaviTAU ®

Unabridged versions and references on CaviTAU® validation research:

1. Lechner J, Zimmermann B, Schmidt M, von Baehr V. Ultrasound Sonography to Detect

Focal Osteoporotic Jawbone Marrow Defects: Clinical Comparative Study with

Corresponding Hounsfield Units and RANTES/CCL5 Expression. Clin Cosmet Investig

Dent. 2020; 12: 205-216 https://doi.org/10.2147/CCIDE.S247345.

Access in journal https://www.dovepress.com/articles.php?article_id=54222.

Link on PubMed: https://pubmed.ncbi.nlm.nih.gov/32801922/.

2. Lechner J, Zimmermann B, Schmidt M. Focal Bone-Marrow Defects in the Jawbone

Determined by Ultrasonography – Validation of New Trans-Alveolar Ultrasound Technique

for Measuring Jawbone Density in 210 Participants. Ultrasound in Medicine & Biology.

Elsevier Published: Agust 12, 2021. https://doi.org/10.1016/j.ultrasmedbio.2021.07.012.

Link to paper in Journal: https://authors.elsevier.com/sd/article/S0301-5629(21)00309-4.

Link to paper on PubMed: 34392995.

Interested in this exciting topic?

Then order this book at www.icosim.de/en/literature

or become a member at “International College of Maxillo-

Mandibular Osteoimmunology” www.icosim.de


Cavitational Osteonecrosis in Jawbone - Dr. Dr. (PhD-UCN) Johann Lechner

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