Neuralgia-inducing cavitational osteonecrosis: a possible diagnosis for an orofacial pain complaint?

JADA 142(6) http://jada.ada.org June 2011 651 A45-year-old woman visited her general dentist because of severe pain in the right mandibular posterior region. Her first molar contained a large mesialocclusal-distal amalgam restoration, and the patient experienced symptoms consistent with irreversible pulpitis. In addition, radiographs showed changes associated with the mesial root. The second molar contained a conservative occlusal amalgam restoration, and the premolars contained no restorations. The clinician performed endodontic therapy in the patient’s first molar; the pain remitted for a few weeks after treatment but then returned. The dentist performed endodontic treatment again in the first molar, which resulted in no change in the patient’s pain. He referred her to an endodontist, who also treated the tooth endodontically, then performed an apicoectomy and a retrograde sealing of the tooth. Again, the patient experienced short-term pain relief, but owing to pain recurrence, the patient’s general dentist extracted the tooth. The patient continued to experience pain, and her general dentist performed endodontic treatment in the second molar. However, the pain persisted. The dentist referred her again to the endodontist, who concluded that the second premolar was the source of the pain and performed endodontic therapy in that tooth. Subsequently, the patient’s general dentist extracted the second premolar and second molar, but the pain continued. The patient later sought care from her general dentist for persistent severe pain in the edentulous right side of the posterior mandible. Did this patient experience the phenomenon known as neuralgia-inducing cavitational osteonecrosis (NICO), or did her pain complaint represent another orofacial pain condition?