Neuralgia and Atypical Facial Pain Related to Aseptic Osteonecrosis (FDOJ)

Introduction: The concept of perineural inflammation in the mandible is old and well described in the literature, but it may be associated with bone morphological changes such as FDOJ (Fatty degenerative osteonecrosis in jawbone). FDOJ is a cavitational osteonecrosis, bone mineralization disorder, occurs in the medullary trabecular bone with aseptic, ischemic, sometimes asymptomatic nature, an immunologically altered chronic bone condition with expression of pro-inflammatory chemokines RANTES. Overexpression of this chemokine activates signaling pathways in the immune system, a fact that may contribute to neuralgias or atypical facial pain. Case report: This case study shows the need for a diagnosis of atypical pain associated with cavitational osteonecrosis and its surgical resolution. Female patient 31a, diagnosis of atypical facial pain, inconclusive neuralgia, without involvement of V cranial nerve. Shocking, limiting, radiating pain for 3 years.
Materials and methods: After analysis of bone density using CBCT images, the patient underwent cortical osteotomy and curettage of the altered alveolar bone in regions 18, 28, 38 and 48. The material removed was subjected to histopathological analysis to confirm the FDOJ.
Results: After surgically removing the cavitations in dental regions 18, 28, 38 and 48, the patient presented complete regression of the pain related to neuralgia. No new pain episodes at 1-year follow-up.
Discussion: RANTES/CCL5 inhibit opioid receptors (they play an important role in modulating pain in peripheral neurons and CNS), amplifying pain signals and increasing the pro-inflammatory response in microglia, generating neuroinflammation . In this context, it makes sense to reduce facial pain and trigeminal neuralgia by surgically cleaning the FDOJ in RANTES signaling areas. A significant limitation refers to the detection of this pathology. The lack of local inflammatory signs and radiographic image impairs the diagnosis of osteonecrosis. The lack of knowledge of the relationships of the chemokine RANTES by dentistry can be a challenge in solving these cases.
Conclusion: With the correct diagnosis of Cavitational Osteonecrosis and surgical FDOJ removal, it is possible to bring a consistent improvement in the patient's pain condition related to FDOJ. Bone density analysis of edentulous regions with tomography and transalveolar ultrasound can be a decisive diagnostic complement in the resolution of neuralgias and atypical facial pain.