Troubled Bones: Low Bone Density A Part of the Hyperlinked Atlas of Ischemic & Inflammatory Jawbone Disease With more than 1,000 Copyright-Free Photos Version The Maxillofacial Center for Education & Research Dr. J. E. Bouquot, Director Main Index of Disease Changes Main Index of Disease Changes 3,150,000 hits annually The Author The Author Dedication Directions The Tissue The Tissue Copyright Module 6 Additional Resources Additional Resources Index of All Modules Index of All Modules

Troubled Bones Index of Modules (Topic-Related Sections) ©Photo(s): Dr. J.E. Bouquot, MFCenter for Education & Research Typical lesion: a pseudo-biker Index of Bone Changes Index of Bone Changes Modules: 1)Normal bone and marrowNormal bone and marrow 2)Ischemic marrow, Part I: vascular changesIschemic marrow, Part I: vascular changes 3)Ischemic marrow, Part II: nonvascular changesIschemic marrow, Part II: nonvascular changes 4)Ischemic bone, Part I: cavitated boneIschemic bone, Part I: cavitated bone 5)Ischemic bone, Part II: noncavitated bone changesIschemic bone, Part II: noncavitated bone changes 6)Ischemic bone, Part III: osteopenic changes 7)Ischemic bone, Part IV: imaging and clinical featuresIschemic bone, Part IV: imaging and clinical features 8)Osteomyelitis, acute & chronicOsteomyelitis, acute & chronic 9)Tori and exostosesTori and exostoses 10)Pulp diseasePulp disease 11)Classification of bone disordersClassification of bone disorders 12)References & definitionsReferences & definitions

About the Tissue Samples All tissue in these photomicrographs was hand-curetted from the marrow spaces, placed immediately in 10% buffered formalin and shipped by mail or FedEx to the laboratory. In the lab, the tissue was gently decalcified with a formic acid/formalin solution and cut at 7-8 microns in order to prevent destruction of osteocytes as well as to preserve tissue architecture. All non-tumor bone in this lab is treated in a manor designed to provide optimal assessment of viability and minimal artifactual change. Since most cases had a varied microscopic appearance, the photomicrographs are representative only and do not reflect all the different changes seen microscopically. The representative regions, however, are considered to be the most diagnostic regions. Index of Bone Changes Index of Bone Changes Views from Bouquot’s new office: front porch of his home in West Virginia

Troubled Bones Presentation created by Dr. J.E. Bouquot ©Photo(s): Dr. J.E. Bouquot, The MFCenter; Morgantown, West Virginia Directions:   This is a self-learning module designed to provide very basic information about ischemic and inflammatory bone disorders, bone hyperplasias and pulpal diseases   Purpose: to familiarize the student with enough knowledge to recognize basic jawbone and pulpal ischemic and inflammatory diseases and their distinction from other bone diseases   To use a hyperlink handout: click on buttons to jump between topics, or the buttons in the lower right corner to go backwards or forwards. Use the button to return to the last slide viewed. Use the button to go to the first slide.   Features for each disease appearance are briefly reviewed, primarily microscopic, but some clinical and radiographic features are also presented   One module is dedicated to references and definitions, while another to classification Please note: This is not a routine Power Point presentation. It is a reference atlas with hyperlinks. This atlas does not function like a scrolling presentation, rather, it works like a web site with hyperlinks allowing you to navigate to various topics within the document. This was created with Power Point Index of Bone Changes Index of Bone Changes

© The Maxillofacial Center for Education & Research This presentation is intended for students and colleagues of the author, but is available for general distribution to the health professions. Designated owners of the photographic images retain the copyrights for those images but have agreed to allow their photos to be used for teaching and learning.* You are welcome to use this presentation or portions thereof for your own teaching without permission from the Maxillofacial Center or its contributors, but permission is not given for the publication of these photos in electronic or other formats except for classroom teaching (including online) and handouts of various forms for that teaching. You are welcome to give this presentation free to other health professionals. This presentation is intended for students and colleagues of the author, but is available for general distribution to the health professions. Designated owners of the photographic images retain the copyrights for those images but have agreed to allow their photos to be used for teaching and learning.* You are welcome to use this presentation or portions thereof for your own teaching without permission from the Maxillofacial Center or its contributors, but permission is not given for the publication of these photos in electronic or other formats except for classroom teaching (including online) and handouts of various forms for that teaching. You are welcome to give this presentation free to other health professionals. Troubled Bones This presentation created by Dr. J. E. Bouquot Disclaimer: The author is an adjunct faculty member of the University of Texas School of Dentistry at Houston and the West Virginia University School of Dentistry. The information and opinions provided herein are, however, his own and do not represent official opinion or policy of either university. * Special thanks to photo and idea contributors Index of Bone Changes Index of Bone Changes

The BTG (Bouquot-To-Go) disk A resource with 3,000+ copyright free photos Examples of Power Point presentations on the disk:  The 53 Most Common Oral Lesions. Hyperlink handout; 500+ clinical photos; first version: 2004; updated 2011  The Must-Know Oral Lesions. Hyperlink handout 0f differential diagnosis; 1,150+ clinical photos; first version: 2009  The CD Johnson Collection – A potpourri of Oral Lesions from the Urgent Care Clinic. Hyperlink handout of various oral lesions, especially those related to drug use; 500+ clinical photos; first version: 2009  The Beginnings of Oral Pathology/Oral Medicine, PP presentation depicting the earliest books, articles, drawings of oral lesions; 90+ photos; first version: 2002  The Dreizen Collection – Oral Lesions from the University of Texas, Houston, One of the first popular collections of oral clinical lesions, from a previous University of Texas faculty member; 90+ clinical photos; first PP version: 2009  Troubled Bones: Ischemic Jawbone Disease. Hyperlink handout providing detailed information about ischemic and inflammatory jaw disorders; 1,000+ photomics and clinical photos; first version: 2006  Review of NICO. PP of a popular lecture; 150+ photos; first version: 2003  The Little Book of Lists. Hyperlink handout of important lists of oral lesions/ effects associated with drugs, syndromes, systemic disorders, etc.; first version: 2009 Order by contacting Dr. Bouquot at or $10 US for shipping and handling is requested but not required. Page 1 of 2 Index of Bone Changes Index of Bone Changes This disk is literally full of copyright-free clinical and microscopic photos relating to topics in oral pathology and oral medicine. Altogether, there are more than 3,000 photos In Power Point (PP) format, continuously updated and ready for you to use for study, diagnosis or in your own talks. These “hyperlink handouts” have become very popular, with many thousands in use worldwide.

oralpath.com the Oral Pathology Home Page Page 2 of 2 Web-based information pertaining to diseases of the oral & maxillofacial region is relatively sparse, scattered in small fragments throughout the internet and often lacking in real and evidence-based content. The oralpath.com portal is designed to be not only a reliable source for such information but also a guide to other sites with reliable information. Initiated in 1998, it improved for 6 years, at which time Dr. Bouquot, its webmaster, moved to Texas and was unable to continuously update it. Upon his retirement in 2012 the update began anew. The most popular oral pathology website, worldwide; 1,694,000 hits in 2012; webmaster: Dr. J.E. Bouquot Index of Bone Changes Index of Bone Changes

Jamie, Jerry Jerry (left) and James (right) * Director of Research, The Maxillofacial Center for Education & Research Adjunct Professor, West Virginia University & University of Texas at Houston Jerry Bouquot, DDS, MSD, DABOMP, FAAOMP, FICD, FACD, FADI, FRSM  Born & raised: St. Paul, Minnesota (just another Swede)  St. Olaf College, Minnesota (BA, psychology, biology)  University of Minnesota (DDS, MSD in oral pathology)  Bone Pathology Fellowship, Mayo Clinic  Oral Pathology Fellowship, Royal College of Dentistry, Copenhagen, Denmark  Chair (18 yrs), Oral & Maxillofacial Pathology, WVU -- Youngest oral path chair in U.S. history  Chair (8 yrs), Diagnostic & Biomedical Sciences, Univ. Texas  Senior Visiting Scientist, Mayo Clinic, Rochester, MN  Dental Director, West Virginia Bureau for Public Health  Consultant, Pittsburgh Children’s Hospital  Consultant, New York Eye and Ear Infirmary  Osteonecrosis Scientific Advisory Board, Novartis Pharm.  Board of Directors (national), American Cancer Society  Executive Council, Amer. Academy of Oral & Maxillofac. Path.  President, American Board of Oral & Maxillofacial. Pathology  President, Eastern Society of Teachers of Oral Pathology  President, Western Society of Teachers of Oral Pathology  President, Organization of Teachers of Oral Diagnosis  President (multiple times), American Cancer Society, WV Div.  President, 3 regional dental associations  Career Development Award, American Cancer Society  Outstanding Teacher Award, WVU (8 times)  Heebink Award for Service to Humanity, WVU  Scholar’s Walk (Two bronze plaques), WVU  St. George National Award, American Cancer Society  W. Robert Biddington Distinguished Lecturer, WV  Robert B. Bridgeman Distinguished Dentist Award, WVDA  Fleming & Davenport Award for Original Research, Univ. TX  Distinguished Alumnus Award, University of Minnesota Click to see Bouquot age Page 1 of 2 Index of Bone Changes Index of Bone Changes

2009, with Geritol High school grad, Caldwell, New Jersey College grad. Northfield, Minnesota With father ElmerWith sisters Jan, Marlene With mother MarionWith brother Dave With brothers Dave, Randy, Den With mother Marion, at Univ. Minnesota 1969 This is what 44 years in dentistry will do to you 2000 Director of Research, MFCenter, WV 2011 J.E. Bouquot, DDS, MSD, FAAOMP, Diplomate-ABOMP, FICD, FACD, FADI, FRSM JB Click x2 to see Bouquot age Page 2 of 2 Index of Bone Changes Index of Bone Changes

This Atlas is dedicated to Dr. Robert McMahon, oral surgeon in Merrilville, Indiana, for his constant questioning, skillful therapies and remarkable observational insights. Index of Bone Changes Index of Bone Changes

Ischemia-Induced Low Bone Density Focal Osteoporotic Marrow Defect Focal Osteoporotic Marrow Defect Regional Ischemic Osteoporosis Regional Ischemic Osteoporosis Imaging of Imaging of LBD Lesions LBD Lesions Module 6

 FOMD is a poorly defined jawbone disorder of unknown etiology characterized by a poorly- demarcated region of radiolucency showing relatively normal marrow on biopsy  Not related to generalized, i.e. “routine” osteoporosis  Similar long bone lesions: post-fracture regional osteoporosis, transient osteoporosis, regional osteoporosis  Might be from chronic ischemia of a region of marrow  Marrow can be fatty or hematopoietic; normal histology  Very low bone density -- Widely spaced, thin, inactive trabeculae -- Thinned cortex (optional)  May be tender or painful, but usually asymptomatic Focal Osteoporotic Marrow Defect Basic Facts Page 1 of 11 Index of Bone Changes Index of Bone Changes

Focal Osteoporotic Marrow Defect Below: Maxillary tuberosity has almost no remaining bony trabecula (none are visible below) and is completely filled with relatively normal fatty marrow. Cortex is extremely thin. Red at top of photo is surgical hemorrhage. Above: Higher power showing several clusters of coalesced, presumably nonviable fat cells (arrow) within an otherwise normal fatty marrow. Page 2 of 11 Index of Bone Changes Index of Bone Changes

Focal Osteoporotic Marrow Defect Below: Maxillary tuberosity is completely devoid of bony trabecula and shows small focal hemorrhage (arrow), i.e. microinfarction. The overlying cortex is viable but extremely thin; A perio probe was able to easily perforate it with minimal pressure. Above: Higher power shows viable but inactive cortex and unremarkable fatty marrow. Page 3 of 11 Index of Bone Changes Index of Bone Changes

Focal Osteoporotic Marrow Defect Below: Maxillary tuberosity with almost no bony trabecula and with a thin overlying cortex of viable, inactive bone. Above: Higher power shows normal fatty marrow with normal-sized, i.e. not ischemically dilated, capillaries (arrow). Page 4 of 11 Index of Bone Changes Index of Bone Changes

Focal Osteoporotic Marrow Defect Below: Cancellous bone adjacent to the lamina dura (arrow) has very few bony trabecula, i.e. is osteopenic. The adjacent tooth is viable but shows fibrosis of the pulp tissues (an ischemic change?). Above: Cancellous bone adjacent to a viable and inactive and thin lamina dura (arrow) shows thin, inactive and widely spaced bony trabecula, i.e. shows osteoporotic changes. Fatty marrow is only mildly ischemic. Tooth Tooth Page 5 of 11 Index of Bone Changes Index of Bone Changes

Focal Osteoporotic Marrow Defect Below: Region of very widely spaced, thin bony trabecula shows extensive hemorrhage in a central marrow region of the mandible, indicative of ischemic vessel damage rather than surgical hemorrhage. Arrow points to thin cortex. Above: Higher power view shows relatively normal fatty marrow with scattered erythrocytes (a sign of microinfarction). Page 6 of 11 Index of Bone Changes Index of Bone Changes

Focal Osteoporotic Marrow Defect Below: The cancellous bone between these mandibular teeth shows almost no bony trabecula, and a microcrack is seen in the lamina dura (arrow), indicating that the bone was formed under ischemic conditions. The cortex is extremely thin. Above: Higher power view shows relatively normal fatty marrow (on right), an inactive but viable lamina dura and greatly dilated periodontal veins (arrows), most likely secondary to chronic back-up pressures, i.e. intramedullary hypertension. Page 7 of 11 Index of Bone Changes Index of Bone Changes

Focal Osteoporotic Marrow Defect Below: Widely spaces trabecula in osteopenic region of the posterior mandible sometimes contains hematopoietic (arrows) as well as fatty marrow. Above: Higher power view shows normal hematopoietic/fatty marrow. Page 8 of 11 Index of Bone Changes Index of Bone Changes

Focal Osteoporotic Marrow Defect Below: Widely spaces trabecula in osteopenic region of the posterior mandible Above: Higher power view shows normal hematopoietic/fatty marrow. Page 9 of 11 Index of Bone Changes Index of Bone Changes

Focal Osteoporotic Marrow Defect Below: Widely spaces, thin trabecula with hematopoietic/fatty marrow between. The marrow has been artifactually pulled away from the bone during processing. Right: Normal alveolar bone (with teeth in place) with more thick, less widely spaced trabecula. Page 10 of 11 Index of Bone Changes Index of Bone Changes

Focal Osteoporotic Marrow Defect Below: Small regions of coalesced adipocytes (arrow) in the fatty marrow represent areas at which a cluster of fat cells died when their common capillary bed became infarcted. There is seldom an inflammatory response. Caution: this can be artifactually created by a dull microtome blade or cutting sections too thin (less than 6 microns). Above: Normal bone density with hematopoietic marrow. White spaces are shrinkage artifacts because of use of strong acids to decalcify the bone. Page 11 of 11 Index of Bone Changes Index of Bone Changes

End of this Subunit Next: Regional Ischemic Osteoporosis Index of Bone Changes Index of Bone Changes

Regional Ischemic Osteoporosis Basic Facts  Same as bone marrow edema, but associated with low bone density  Except: often the capillaries are not dilated  Bony trabeculae are osteoporotic -- Thin, inactive, widely spaced  Often has a more diffuse (less patchy) ischemic marrow change, compared to bone marrow edema  Intramedullary cavitations (voids) are frequently seen  If ischemic damage is minimal, a better diagnosis = focal osteoporotic marrow defect Page 1 of 5 Index of Bone Changes Index of Bone Changes

Regional Ischemic Osteoporosis A variant of Bone Marrow Edema? Below: In osteopenic bone the trabecula are thin and widely spaced. In RIO the ischemic myelofibrosis is typically diffuse, with scattered chronic inflammatory cells. Focal hemorrhage (arrow) are seen frequently. Above: Higher power view shows the wispy fibrosis streaming between fat cells. Small areas of hemorrhage (arrow) represent microinfarction with focal release of erythrocytes from the dead capillary. Extravasated erythrocytes are also seen. Page 2 of 5 Index of Bone Changes Index of Bone Changes

Regional Ischemic Osteoporosis A variant of Bone Marrow Edema? Below: The classic presentation: wispy ischemic myelofibrosis with dilated capillaries (yellow arrow) and very widely spaced, thin but viable bony trabeculae (white arrow). Without the osteopenia this is classic bone marrow edema. Above: Oil cyst (yellow arrow) is seen within a region of routine marrow necrosis, especially above the cyst in the photo. The lower portion of the marrow shows a viable marrow with myelofibrosis. The cracks in the bone (white arrow) is too irregular to be an ischemic microcrack. Page 3 of 5 Index of Bone Changes Index of Bone Changes

Regional Ischemic Osteoporosis Bone Marrow Edema Below: Ischemic myelofibrosis classically presents with streaming between residual adipocytes (arrow), with few chronic inflammatory cells. Adjacent fat cells show dramatic differences in size – a feature of chronic ischemia. Adjacent bone is viable. Above: Higher power view shows scattered lymphocytes in the streaming fibrosis. Extravasated erythrocytes on right (arrow) are indicative of microinfarction with release from a thrombosed capillary. The ruptures vessels is usually not in the plane of sectioning. Page 4 of 5 Index of Bone Changes Index of Bone Changes

Regional Ischemic Osteoporosis Bone Marrow Edema To Main Index To Main Index To Marrow Edema Index To Marrow Edema Index Below: Wispy ischemic myelofibrosis with a few residual fat cells, a few chronic inflammatory cells, and dilated capillaries. Bone is viable (different blood supply from marrow). Above: A vessel is completely plugged by aggregated fibrin (arrow). Page 5 of 5

End of this Subunit Next: Imaging of Osteoporosis Index of Bone Changes Index of Bone Changes

Imaging: Focal Osteoporotic Marrow Defect Basic Facts  By definition, osteoporosis refers to low bone density great enough to be at risk for fracture or microfracture.  By definition, osteopenia refers to low bone density not severe enough to be at risk for fracture  Most FOMD cases are found in third molar sites, especially maxillary  Many cases are found in areas of old extraction and probably represent simple lack of healing after the extraction (because of ischemia/malnutrition/etc. at the time?)  Radiographically, FOMD is represented by a moderately well demarcated area of radiolucency without scalloped borders  Some lesions show a thin sclerotic rim  Some lesions are well demarcated Page 1 of 9 Index of Bone Changes Index of Bone Changes

Focal Osteoporotic Marrow Defect Moderately Demarcated Radiolucency Below: Two regions of FOMD are seen. One (white arrow) overlaps the apex of a viable tooth and is very well demarcated. The other (yellow area) is a very poorly demarcated region of radiolucency just beneath a very thin cortex. Above: Arrows surround a moderately well demarcated radiolucency of the maxillary tuberosity. The overlying cortex is extremely thin. Page 2 of 9 Index of Bone Changes Index of Bone Changes

Focal Osteoporotic Marrow Defect Moderately Demarcated Radiolucency Below: Poorly demarcated radiolucency of the mandibular third molar region (arrows) was tender to palpation. The crestal cortex is very thin and slightly convex. The molar had been extracted 12 years earlier without incident. Above: Moderately well demarcated radiolucency of the maxillary left tuberosity (arrows); the third molar is congenitally missing. The cortex was so thin that it was slightly compressible. Page 3 of 9 Index of Bone Changes Index of Bone Changes

Regional Ischemic Osteoporosis Radiolucencies Below: Poorly demarcated radiolucency of the posterior mandible (arrows) has ghost marrow (very pale ground glass appearance) and a thin, irregular sclerotic rim. There was no overlying cortical bone, only a tough, dense fibrous scar. The molar in the area was extracted more than 18 years ago. Above: Very well demarcated, very painful radiolucency of the left posterior mandible (arrow) is kidney shaped, with a small focus of diffuse sclerosis centrally located in the superior aspect. The cortex has honeycombed at surgery, with fibrous scar tissue filling numerous defects. Page 4 of 9 Index of Bone Changes Index of Bone Changes

Regional Ischemic Osteoporosis Poorly Demarcated Radioluceny Below: Circular region of poorly demarcated radiolucency (arrows) in the posterior of a chronically painful mandible. There was a positive anesthesia test and curettage of the lesion eliminated the pain, even though minimal ischemic disease was found microscopically. Above: A posterior mandibular region of intense pain shows a very poorly demarcated radiolucency (black arrows) with slight scalloping between the overlying roots (yellow arrows), like a traumatic bone cyst. Part of the lesion was cavitation. Page 5 of 9 Index of Bone Changes Index of Bone Changes

Focal Osteoporotic Marrow Defect Well Demarcated Radiolucency Below: Region of subpontic osseous hyperplasia is comprised predominantly of low bone density bone (arrows). Above: A maxillary tuberosity region of moderately well demarcated radiolucency (arrows) shows small scalloping of the anterior border. Page 6 of 9 Index of Bone Changes Index of Bone Changes

Focal Osteoporotic Marrow Defect Variable Radiolucencies Below: Region of poorly demarcated osteopenia (arrows) has a multilocular appearance. Above: A very well demarcated radiolucency (arrows) wraps around the distal root of an endodontically treated molar. The lesion was filled with normal fatty marrow. Page 7 of 9 Index of Bone Changes Index of Bone Changes

Focal Osteoporotic Marrow Defect Multilocular Radiolucency Below: Relatively well demarcated radiolucency has a slight multilocular appearance. The area was not painful but was very tender to palpation. Above: Entire tuberosity presents as a multilocular region of low bone density (arrows). Page 8 of 9 Index of Bone Changes Index of Bone Changes

Focal Osteoporotic Marrow Defect With Regional Ischemic Osteoporosis Below: Moderately well demarcated radiolucency in a mandibular subpontic area (arrows) shows a lower area of more intense bone loss and a superior half with less loss. The bridge has been in place for more than 8 years, during which time there was a constant, low-grade “ache.” Above: Triangulating the film. i.e. using 3 different beam angles, may provide additional information. Here a smaller region of intramedullary void or cavitation (arrows) is seen to extend posteriorly from the main lesion. The secondary lesion is somewhat scalloped and has an opaque rim. Page 9 of 9 Index of Bone Changes Index of Bone Changes

End of this Module Fall colors from front porch of Bouquot’s West Virginia home Index of Bone Changes Index of Bone Changes