The Toxic Tooth: APPENDIX B Seeing is Believing: Photos Tell the Story

 

APPENDIX B

Seeing is Believing: Photos Tell the Story

Figure B-1: Tissue mass removed from the posterior mandible (lower jaw).

Panoramic X-ray of this area showed similar appearance as seen in the X-ray on page 300. Although sometimes an empty hole, cavitations can also contain fibrous and inflammatory tissue. This patient presented with facial pain for 9 years and was told by her dentist that there was “nothing wrong with her jaw.” After surgical debridement this patient was pain free. Photo: Robert Kulacz, DDS

Figure B-2: This photo depicts cavitations in the posterior mandible with black, tarry tissue (A) instead of healthy, healed bone. Photo of a sagittal section cadaver mandible on page 294 illustrates how this pathology can extend throughout the jawbone. Photo: Robert Kulacz, DDS

Figure B-3: This photo depicts cavitations in the posterior mandible with black, tarry tissue (A) instead of healthy, healed bone. Photo of a sagittal section cadaver mandible on page 294 illustrates how this pathology can extend throughout the jawbone. Photo: Robert Kulacz, DDS

Figure B-4: This is a perfectly normal appearing X-ray of the mandible. As discussed, 2D X- rays can appear perfectly normal even though there is significant pathology in the medullary bone. This is because it takes approximately 50 percent decalcification of the medullary bone to become visible on 2D X-ray. Photo: J.E. Bouquot, DDS, MSD

Figure B-5: This is a sagittal section of the same mandible shown in the 2D X-ray (Figure B- 4). Notice the prevalence of osteonecrotic bone (A) is completely invisible on the X-ray in figure B-4 on page 292. (B) points to the neurovascular bundle. Photo: J.E. Bouquot, DDS, MSD

Figure B-6: This is a photo of a cadaver mandible (lower jaw) that is split in sagittal section (front to back). This person had severe facial pain due to ischemic osteonecrosis/chronic osteomyelitis that involved a large part of the lower jaw (A) including the neurovascular bundle (B). Any infection or toxin release would have an easy pathway to the rest of the body via the large blood vessels that pass through this diseased bone. Photo: J.E. Bouquot, DDS, MSD

Figure B-7: Photo of a cavitation in the lower wisdom tooth area. There was no solid bone at this site, and the inferior alveolar neurovascular bundle (main nerve and blood vessels) can be seen at the base of the cavitation. Photo: J.E. Bouquot, DDS, MSD

Figure B-8: Tooth on the left is a healthy premolar tooth extracted for orthodontic reasons. Note the healthy color and lack of inflammatory tissue around the root. Photos: Robert Kulacz, DDS

Figure B9: Tooth on the right is a root canal-treated tooth that is blackened at the root apex. The jawbone around the apex of this tooth was also black and mushy with a diagnosis of chronic osteomyelitis and a positive microbiology culture of two anaerobic bacteria species. Photo: Robert Kulacz, DDS

Figure B-10: These are three root canal-treated teeth. Notice the discoloration and inflammatory tissue attached to the root. These roots are in the jawbone where bacteria and exotoxins can readily migrate into the body. Compare these to the non-infected tooth in Figure B-8 on page 296 that was extracted for orthodontic purposes. Photos: Robert Kulacz, DDS

Figure B-11: Tooth on the left was the worst smelling root canal-treated tooth that I ever extracted. Note the severe dark discoloration of the entire root and the ball of infection around the end of the root. Photo: Robert Kulacz, DDS

Figure B-12: Two root canal-treated teeth. Note the large amount of red inflammatory tissue around these roots and the silver point filling material protruding out from the broken root. Silver point root canal fillings cannot conform to the shape of the root canal space and are inferior to gutta-percha root canal filling. Although not routinely used, we wonder how many root canal-treated teeth have this type of root canal filling. These teeth were extremely toxic. Photo: Robert Kulacz, DDS

Figure B-13: Bone marrow edema in NICO lesion. The most diagnostic feature is a diffuse, pink, thick “serous ooze” (also called plasmostasis) with loose, embedded fat cells (large oval white/clear spaces in the photo); this is a protein-rich fluid pushed out of the marrow vessels by increased pressures. Clustered free or extravasated erythrocytes represent hemorrhage from focal microinfarcts. More than 72% of NICO patients have one or more inherited hypercoagulation states with increased risk of throwing small clots. Photo: J.E. Bouquot, DDS, MSD

Figure B-14: White dots outline a completely void or empty region of bone, i.e. ischemic bone cavitation, in a patient with idiopathic pain of the left mandible. The arrow points to the mental foramen, above which is an inverted triangle-shaped residual socket. The crestal bone above the socket was missing, replaced by a thick fibrous scar tissue; the overlying mucosa was normal in appearance. Photo: J.E. Bouquot, DDS, MSD

Figure B-15: X depicts a void in the bone (cavitation) and arrows point to residual tooth socket (laminar rain) that failed to resorb. Normal healing occurs with resorption of the tooth socket and deposition of new bone in the extraction space. Photo: J.E. Bouquot, DDS, MSD

Figure B-16: Several rounded and partially remodeled residual sockets remain years after extraction in a patient with severe local pain of 3 years duration. The crestal bone was missing in the premolar area, replaced by a thin, partially perforated fibrous tissue. Beneath the fibrous tissue was a bony void, i.e. ischemic bone cavitation. A curette has been placed into the void prior to taking the radiograph. Photo: J.E. Bouquot, DDS, MSD

Figure B-17: Multiple residual sockets are visible in the right mandibular molar region; one shows so little remodeling that even the Jacob’s ladder pattern remains between the first molar roots (on right). The second molar site was covered not with bone but with discolored fibrous tissue. The surgeon pushed a needle through the fibrous tissue and it literally fell into a void or ischemic bone cavitation beneath. The teeth had been removed decades earlier and the patient had suffered from local “idiopathic” pain for almost the entire time. Photo: J.E. Bouquot, DDS, MSD

Figure B-18: Intramedullary fibrous scar. A large, bilobed, slightly radiolucent lesion of the right mandibular third molar and ramus region has a sclerotic rim surrounding much of it. At surgery the area was found to be filled with very dense, avascular collagen, i.e. fibrous scar tissue. Such scar tissue is almost unheard of outside of the jaws and when in the jaws may be associated with considerable pain; it usually doesn’t show sclerosis of the borders. Arrows point to the sclerotic borders of the cavitation (X) Photo: J.E. Bouquot, DDS, MSD

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