A Critical Look at Cavitational Osteopathosis,
NICO, and "Biological Dentistry"
Stephen Barrett, M.D.
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 Jerry 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.
In 2012, the American Association of Endodontists issued a position statement which concluded:
The American Association of Endodontists cannot condone surgical interventions intended to treat suspected NICO lesions. Even when a NICO lesion is suspected to be associated with an endodontically treated tooth, no surgical procedures should be performed until orofacial pain specialists confirm the diagnosis. . . . In addition, the practice of recommending the extraction of endodontically treated teeth for the prevention of NICO, or any other disease, is unethical and should be reported immediately to the appropriate state board of dentistry.
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.
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.)
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. Some of the patients wound up with chronic pain. 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. All of the victims settled with payment of undisclosed amounts.
Dental Board 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. For example:
- In 2004, 2012, and 2013, the Arizona Board of Dental Examiners disciplined Michael Margolis, D.D.S., for inappropriately diagnosing and treating patients for "NICO" and unnecessarily extracting teeth based on diagnoses made with a Cavitat device. In two of these cases, he had also performed invasive jawbone surgery that was unnecessary and had left the patients with persistent jaw discomfort. In the 2004 case, he was ordered to take 12 hours of board-approved continuing education. In the 2012 case, he was ordered to take 24 hours of continuing education. In the 2013 case, he was ordered to pay restitution of $11,986 to the patient.
- In 2005, 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 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.
- In 2018, the Washington Dental Quality Assurance Commission charged Alireza Panahpour, D.D.S. with unprofessional conduct in his treatment of a patient. The board's complaint noted that (a) he performed four "cavitation" operations on a patient's upper and lower left jaw even though a panoramic x-ray showed no infection or other abnormal findings, and (b) during one of the operations, Panahpour injured a nerve in the jaw that caused the patient to have long-term numbness. In 2019, the board concluded that Panahpour's care of this patient was substandard and revoked his license for a minimum of five years. It also ordered him to reimburse the patient for all fees and pay the State of Washington a $5,000 fine plus $18,000 for the cost of the disciplinary proceedings. In order to reinstate his license, he must pay these assessments and pass several competency tests.
In 2007, the Pennsylvania State Board of Dentistry dismissed a case against Stephen R. Evans, D.D.S., who was charged with unprofessional conduct for "treating a disease in which its existence has not conclusively been established, recommending supplements prior to and subsequent to surgery, and . . . recommending lymphatic exercises to patients." Evans's defense included testimony by Bouquot that the NICO concept had sufficient scientific support to be within the standard of care in the dental community. The hearing examiner ruled that board had failed to present sufficient evidence to rebut Bouquot's assertions and the case should therefore be dismissed. I believe that with better preparation, the board could have prevailed.
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 15, 2017) version of Aetna's policy states:
- 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.
- 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 did not pursue 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. 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." However, I have heard nothing further about that.
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:
For Additional Information
- Aetna's Clinical Policy Bulletin explaining why does not cover Cavitat ultrasonography for diagnosing "NICO"
- Aetna Rips the Lid off the Cavitat conspiracy
- Is this dental diagnosis real? A radical treatment prompts a lawsuit by Aetna—and raises questions for the FDA. Business Week, Jan 18, 2006.
- Unconventional dentistry: Part IV. Unconventional dental practices and products
- "Biological dentists" charged with unprofessional conduct in California.
- Aetna's counterclaim against Cavitat Medical Technologies and Robert J. Jones
- Aetna's amended counterclaim against Cavitat Medical Technologies and Robert J. Jones
- FDA warning letter to Robert Jones (2003)
- Brauer C. Export report on regulatory improprieties for Cavitat device
- Greer R. Expert report on NICO and Cavitat
- Marx RE. Expert report (NICO case reviews)
- BlueCross BlueShield of Illinois medical policy statement on NICO
- Anthony G. Roeder, D.D.S. charged with unprofessional conduct
- James Shen, D.D.S. surrenders dental license
- Wesley Shankland, D.D.S. placed on five-years' probation
- Offbeat dentists sued for negligence
This page was revised on May 18, 2019.