Troubled Bones: Normal Histology A Part of the Hyperlinked Atlas 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 Normal Main Index of Normal 3,150,000 hits annually The Author The Author Dedication Directions The Tissue The Tissue Copyright Module 1 Quick Review of Pathology for Comparison Quick Review of Pathology for Comparison 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 Normal Index of Normal Modules: 1)Normal 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 changesIschemic 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 ischemic bone diseasesClassification of ischemic bone diseases 12)Classification of osteomyelitisClassification of osteomyelitis 13)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 Normal Index of Normal 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 Normal Index of Normal

© 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 Normal Index of Normal

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 Normal Index of Normal 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 The most popular oral pathology website, worldwide; 1,694,000 hits in 2012; webmaster: Dr. J.E. Bouquot 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. Index of Normal Index of Normal

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 Normal Index of Normal

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 Normal Index of Normal

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 Normal Index of Normal

Normal Jawbone Histology New Bone Formation New Bone Formation Normal Nerves Normal Nerves Normal Marrow Normal Marrow Normal Bone Normal Bone Module 1 Review of Ischemic/Inflamed Bone Changes Review of Ischemic/Inflamed Bone Changes

Normal Fatty Marrow of Jaws Basic Facts, Part 1  Almost ALL adult marrow is fatty (yellow) marrow  A small residuum of hematopoietic marrow may be seen in third molar sites in <5% of adults  Fat cells are like tomatoes in a basket, all support arises from the surrounding cortex -- No stroma is needed for support between cells -- No or almost no fibrous stroma is present -- Therefore, fibrous tissue in marrow is ALWAYS ABNORMAL  Adipocytes are somewhat irregular in size -- Some may be 3x or 4x larger than others, normally  Fat cell membranes are intact -- Some are artifactually broken by lab slicing  Fat cell nuclei are attached to cell membrane  Fat cells are clear (all fat is removed by lab processing Adipocyte nuclei Page 1 of 6 Index of Normal Index of Normal

Normal Fatty Marrow of Jaws Basic Facts, Part 2  Capillaries are collapsed, almost invisible -- Largest normal = 3-4 RBC diameters  No fibers around vessels, except arteries  Two veins follow every artery  No nerve fibers -- Almost invisible reticulum fibers can act as “communication wires”  No visible sinusoids in adults -- Remaining ones along bone are collapsed  No visible fluid between adipocytes  No marrow hemorrhage with hand curettage  No inflammatory cells between fat cells  No oil cysts (bubbles of liquid fat released by adjacent dead fat cells)  Adjacent bony trabecula are inactive Normal capillary, slightly dilated Normal capillary, inactive (collapsed) Inactive, thin trabeculum Page 2 of 6 Normal capillary, slightly dilated Index of Normal Index of Normal

The Mildest Ischemic Change in Fatty Marrow Page 3 of 6 Wispy fibrosis around vessel Dilated capillary (marrow congestion) Trabeculum Index of Normal Index of Normal

 Immature RBC & leukocyte precursors  Megakaryocytes (platelet precursors) -- Large, multinucleated cells  Most of childhood marrow is this type -- Called “red marrow’  When present in adult: admixed with fat cells  When present in adult: in third molar area of mandible  When in adult jaw: may be focal osteoporotic marrow defect (hematopoietic marrow defect)  Sinusoids are common and scattered -- Normally <5-7 RBC diameters -- Contain leukocytes/precursor cells, RBCs  Aggregates of lymphoid cells may be seen -- Sometimes called “follicles”  Layer of fat cells lines bone, usually  Adjacent bone is typically inactive Normal Hematopoietic Marrow Basic Facts Adipocyte nuclei Page 4 of 6 Dilated sinusoid Megakaryocyte Index of Normal Index of Normal

Normal Hematopoietic/Fatty Marrow Megakaryocyte Sinusoid Adipocyte Below: Normal hematopoietic in an adult is typically scattered with variable numbers of mature fat cells. White spaces around bony trabecula (arrow) represent open sinusoids (some may represent artifactual shrinking of tissues during processing. Above: Higher power view of normal marrow shows a slightly dilated capillary or sinusoid (yellow arrow). Sinusoids are minimally present in fatty marrow, usually remaining only directly around the bony trabecula. Page 5 of 6 Index of Normal Index of Normal

Normal Hematopoietic/Fatty Marrow In Osteoporotic Bone Page 6 of 6 Index of Normal Index of Normal

Normal Hematopoietic/Fatty Marrow In Osteoporotic Bone Above: Higher power Sinusoid Adipocyte Page 6 of 6 Index of Normal Index of Normal Trichrome stain shows fibers as blue

End of this Subunit Next: Normal Bone Index of Normal Index of Normal

Normal Bone of Jaws Basic Facts Osteocyte with tight lacuna tight lacuna Inactive osteoblasts osteoblasts  Unless bone is properly processed, viability cannot be assessed via routine staining  Each lacuna is filled with an osteocyte -- Occasional scattered empty lacunae are normal -- Cluster of empty lacunae is abnormal -- Up to 1/2 of lacunae are empty if bone is improperly decalcified by strong acids  Almost all lacunae remain small -- Large lacunae are abnormal  Very few cement lines -- More than 2/trabeculum is abnormal  May show mildly active osteoblasts  Almost no osteoclasts are present (in adults)  Trabeculae are not thin or widely spaced  Bone is lamellar (mature) Page 1 of 8 Index of Normal Index of Normal Normal cadaver, anterior mandible Normal dried skull, posterior mandible

Normal Lamellar Bone of Mandibular Cortex Properly Processed Cortical space, with fibrovascular tissue (normal) Osteocyte in tight lacuna Below: Empty lacunae are a sign of nonviable bone. When bone is properly processed, as seen below, very few missing osteocytes are seen. With improper decalcification, many, sometimes all osteocytes are destroyed, leaving empty lacunae. Above: Healthy lamellar bone has lacunae just a bit larger than their enclosed bone cells (osteocytes). An enlarged lacunae around an osteocyte usually indicates poor nutrition, chronic ischemia or an increased systemic need for calcium. Page 2 of 8 Index of Normal Index of Normal

Normal Lamellar Bone of Mandibular Cortex Properly Processed Osteocyte in tight lacuna Below: When properly processed, few, if any, osteocytes are missing from healthy bone. Additionally, few prominent cement lines are present (no more than 1 or 2). Above: Healthy bone cells completely or almost completely fill their surrounding small lacunae. Enlarged lacunae are a sign of diseased or dysfunctional osteocyte activity. Page 3 of 8 Index of Normal Index of Normal

Normal Trabecular (Lamellar) Bone Separated by normal hematopoietic/fatty marrow Osteocyte in tight lacuna Hematopoietic/fatty marrow Page 4 of 8 Index of Normal Index of Normal

Normal Bone Density Moderate sized marrow spaces are filled with fatty marrow Photo: Dr. Ben Crawford, University of Texas, Houston Page 5 of 8 Index of Normal Index of Normal

Viable (Normal) Bone Note the Typical Bone Density Page 6 of 8 Normal cortex cut longitudinally Index of Normal Index of Normal

Bundle Bone Osteocyte in tight lacuna Below: White streaks in cortical bone represent Sharpey’s fiber attachment sites for the periodontal ligament or, in other bones, for tendons. Above: Scattered between the white streaks, osteocytes are surrounding by small lacunae, indicating bone health. Page 7 of 8 Index of Normal Index of Normal

Bundle Bone Osteocyte in tight lacuna Below: White streaks in cortical bone represent Sharpey’s fiber attachment sites for the periodontal ligament or, in other bones, for tendons. Above: Osteocyte lacunae are somewhat enlarged, indicating a lack of full health for the bone, i.e. dysfunctional brush borders. Page 8 of 8 Index of Normal Index of Normal

End of this Subunit Next: Nerves Index of Normal Index of Normal

Normal Alveolar Nerves Basic Facts  Approximately 85% of all nerve fibers in an alveolar nerve are myelinated, i.e. covered with an insulation of myelin sheathing  Myelin stains blue/green with luxol fast blue  Chronic ischemia damages the myelin sheath much more readily than the nerve fibers, resulting in demyelination rather than nerve death  Damaged myelin presents as patchy regions of very thin or completely missing myelin  With continued, more severe ischemia the nerve fibers themselves disappear Page 1 of 3 Luxol fast blue staining of myelin Index of Normal Index of Normal

Normal Alveolar Nerve Healthy inferior alveolar nerve, inside bony canal, shows a uniform density and streaming pattern, with visible nodes of Ranvier (arrows). Page 2 of 3 Index of Normal Index of Normal

Normal Alveolar Nerves are Myelinated Luxol Fast Blue Stain for Myelin Below: Healthy alveolar nerve below shows good, even demarcation from surrounding fatty marrow, with almost all fibers showing a myelin sheath (blue/green stain). Above: Inferior alveolar nerve with even staining with luxol fast blue (myelin = blue/green staining). There is no splaying of fibers and the nerve is very well demarcated from surrounding marrow. Page 3 of 3 Index of Normal Index of Normal

End of this Subunit Next: Newly Forming Bone Index of Normal Index of Normal

Newly Forming Bone Basic Facts  New bone formation does not refer to the remodeling of bone into full maturity, which takes place after bone formation  Newly forming bone is woven or immature lamellar bone with active osteoblastic rimming -- Lack of active osteoblasts is not normal  Background stroma is immature fibrous tissue -- Fat cells = abnormal -- Dense, avascular collagen = abnormal -- Stromal edema = abnormal  Capillaries of stroma are somewhat dilated -- Greatly dilated capillaries = abnormal  Inflammatory cells are not present Woven bone, starting to become lamellar Active osteoblasts Slightly dilated vessel Page 1 of 4 Index of Normal Index of Normal

Newly Forming Bone The Earliest Bone Formation Collagen becomes osteoid (pink, with embedded bone cells), then calcifies (turns violet/purple), moving from left to right, above Page 2 of 4 Index of Normal Index of Normal

Above: New bone is woven, without a lamellar pattern and with enlarged osteocytes. Active osteoblasts are plump and form a rim along the edge of the bone. Inflammatory cells are not seen. Newly Forming Bone New Bone Formation Below: New bone has a moderately dense, somewhat immature background stroma of fibrous tissue. Osteoblastic activity is typically moderate to pronounced. Scattered capillaries may be somewhat dilated. Page 3 of 4 Index of Normal Index of Normal

Above: New bone is woven, without a lamellar pattern and with enlarged osteocytes. Active osteoblasts are plump and form a rim along the edge of the bone. Inflammatory cells are not seen. Newly Forming Bone New Bone Formation Below: New, woven bone is seen to stream off of the lamina dura (to the left) in an extraction socket undergoing normal healing (about 3-4 weeks after extraction). Page 4 of 4 Index of Normal Index of Normal

Newly Forming Bone New Bone Formation Below: New bone is being formed by active osteoblasts, which become incorporated into the bone as osteocytes. Typically, new bone has a background stroma of moderately dense fibrous tissue. Page 4 of 4 Index of Normal Index of Normal

End of this Subunit Next: Ischemic & Inflamed Bone, for Comparison with Normal Index of Normal Index of Normal

Diagnostic Terms & Definitions Names & Definitions – Ischemic Bone Disease Names & Definitions – Ischemic Bone Disease Names & Definitions – Inflammatory Bone Disease Names & Definitions – Inflammatory Bone Disease Photomicrographic Examples – Ischemic Bone Disease * Photomicrographic Examples – Ischemic Bone Disease * Photomicrographic Examples – Inflammatory Bone Disease * Photomicrographic Examples – Inflammatory Bone Disease * * These are featured in more detail under topics on the Main Index Index of Normal Index of Normal

  Chronic ischemic bone disease: a generic, less specific reference to marrow or bone changes resulting from ischemia   Bone marrow edema: ischemic myelofibrosis, dilated marrow vessels, scattered chronic inflammatory cells, usually viable bone; perhaps: oil cysts, focal hemorrhage, coalesced fat cells, mast cells, plasmostasis, granular necrosis of fat cells, calcific fat necrosis   Marrow congestion/edema: Dilated marrow capillaries & other vessels, with no other signs of damage   Ischemic myelofibrosis: Loose, streaming fibrosis flowing between adipocytes, perhaps with dilated capillaries, often with a few mast cells; no other changes   Idiopathic marrow fibrosis: Dense, usually multifocal, sometimes diffuse, fibrous replacement of fat cells in marrow; perhaps with a few chronic inflammatory cells   Intramedullary fibrous scar: Dense, rather avascular fibrous tissue, sometimes very large, in marrow spaces; may represent scar tissue in poorly healed socket Note: Photo examples follow this listing of diagnostic terms; almost all terms are taken from the orthopedic pathology literature Ischemic Bone Disease Diagnostic Terms and Criteria, Part I of IV Index of Normal Index of Normal

  Plasmostasis: Amorphous pink, perhaps slightly granular exudate between fat cells (may fill dead fat cells), perhaps with embedded (floating?) inflammatory cells, fat cells or oil cysts.   Focal marrow hemorrhage: Small (usually) blip of hemorrhage released from thrombosed marrow capillary as it dies; often multifocal; this is the first sign of infarcted marrow in animal studies and, presumably, in humans   Microinfarction of marrow: Focal area of granular residual cytoplasm in dead fat cells, oil cysts (local death of fat cells), dystrophic calcification; bone is usually viable (has a different blood supply)   Ischemic cavitation: Intramedullary void, greater than 5 mm. diameter, with little or no soft tissue lining; scraping walls may yield: fibrous tissue, viable trabecula, scattered chronic inflammatory cells, plasmostasis, focal hemorrhage, ischemic myelofibrosis; surgeon must indicated the presence of the void   Traumatic bone cyst: Intramedullary void, usually in a young person (less than 30 years of age); is most likely a variant of ischemic cavitation; surgeon must indicate the presence of the void Note: Photo examples follow this listing of diagnostic terms Ischemic Bone Disease Diagnostic Terms and Criteria, Part II of IV Index of Normal Index of Normal

  Regional ischemic osteoporosis: Low bone density with thin, widely spaced trabecula, a thin cortex, and diffuse or multifocal signs of ischemic marrow damage   Focal osteoporotic marrow defect: Low bone density with thin, widely spaced, inactive trabecula, a thin cortex, and minimal, if any, signs of ischemic damage   Avascular necrosis: Dead bone with focal or diffuse loss of osteocytes, perhaps with microcracks and enlarged lacunae; marrow necrosis may or may not be present   Partially nonviable bone: Focal loss of osteocytes (the focal nature is a hallmark of ischemic damage; osteocytes fed by a single capillary or capillary bed die together); most of bone is viable; may show enlarged lacunae or microcracks   Denuded cancellous bone (honeycombed bone): Inactive, almost always viable bony trabecula with no or almost no attached fatty marrow or hematopoietic marrow; may have small amounts of attached fibrous tissue; caution: this is only a valid feature if no rotary instrument touched the cancellous bone sample   Ghost erythrocytes: Pale-staining RBCs in vessel, indicates stagnation Note: Photo examples follow this listing of diagnostic terms Ischemic Bone Disease Diagnostic Terms and Criteria, Part III of IV Index of Normal Index of Normal

  Poorly forming new bone: Immature bone which is viable but has little or no residual osteoblastic activity and usually has fatty replacement of the normal fibrous stroma of new bone; may have a few chronic inflammatory cells   Granular fat necrosis: Dead fat cells keep their outlines but fill with a granular eosinophilic debris (mixture of serum and fibrin?)   Marrow thrombosis: Clots (partial or complete blockage) are seen in dilated capillaries of the marrow   Oil cysts: Large bubble of liquified fat (coalesced from fat cells which necrosed adjacent to one another). Caution: small fat bubbles may be created by a rotary instrument   Fatty microvesicles: Small fat bubbles from fat necrosis or rotary instrumentation   Microcracking: Smooth-walled, spindled spaces along cement lines is a hallmark of bone created under ischemic conditions   Residual socket: Hollow lamina dura socket remains as hollow space or partially remodeled bone surrounded by lamina dura, perhaps with periodontal ligament remaining (evidence of poor healing after extraction) Note: Photo examples follow this listing of diagnostic terms Ischemic Bone Disease Diagnostic Terms and Criteria, Part IV of IV Index of Normal Index of Normal

  Acute/Subacute osteomyelitis: Pus (dead neutrophils & necrotic soft tissue) fills marrow spaces and coats nonviable bony sequestra, bacteria (usually filamentous, maybe coccal) are often in spaces and coat dead bone fragments   Chronic nonsuppurative osteomyelitis: Usually viable bone with chronic inflammatory cells between fat cells or, more often, infiltrated into fibrosis of marrow spaces   Chronic fibrosing osteomyelitis: Subset of chronic nonsuppurative osteomyelitis with chronically inflamed fibrous tissue filling marrow spaces   Focal chronic sclerosing osteomyelitis: Viable bone (perhaps with focal loss of osteocytes (ischemic damage?), usually lamellar, usually without inflammatory cells; also called condensing osteitis   Chronic granulomatous osteomyelitis: Viable bone, usually, with fibrosis of marrow, chronic inflammatory cells and focal collections of multinucleated giant cells; also called, variously: intraosseous foreign body reaction, tuberculosis osteomyelitis, syphilitic osteomyelitis, sarcoid osteomyelitis, hyalin angiopathy, etc. Note: Photo examples follow this listing of diagnostic terms Inflammatory Bone Disease Diagnostic Terms and Criteria, Part I of II Index of Normal Index of Normal

  Periapical granuloma: Variable amounts of granulation and fibrous tissue with chronic and acute inflammatory cells, with or without focal edema or necrosis; often has foreign material from endodontic therapy; a form of paradental osteomyelitis, but very small lesions (before the lamina dura is breached) are more properly considered to be a form of apical periodontitis; may be suppurative or fibrotic with only chronic inflammatory cells   Periapical scar: Intramedullary fibrous scar remaining at the apex of a tooth after resolution, via endodontics, of a periapical abscess or granuloma; will presumably remain indefinitely Note: Photo examples follow this listing of diagnostic terms Inflammatory Bone Disease Diagnostic Terms and Criteria, Part I of II Index of Normal Index of Normal

Plasmostasis Note: Word definition of diagnoses precede this photo collection Ischemic Bone Disease Photo Examples of Diagnostic Terms and Criteria, Part I of III Bone marrow edema Focal hemorrhage Osteosclerosis Regional ischemic osteoporosis Focal osteoporotic marrow defect Focal osteoporotic marrow defect Index of Normal Index of Normal

Marrow congestion/ edema Note: Word definition of diagnoses precede this photo collection Ischemic Bone Disease Photo Examples of Diagnostic Terms and Criteria, Part II of III Oil cysts Granular fat necrosis Marrow thrombosis Poorly forming new bone Microinfarction Index of Normal Index of Normal

Intramedullary fibrous scar Note: Word definition of diagnoses precede this photo collection Ischemic Bone Disease Photo Examples of Diagnostic Terms and Criteria, Part III of III Marrow fibrosis Residual socket Ghost erythrocytes Microcracks Partially nonviable bone Index of Normal Index of Normal

Note: Word definition of diagnoses precede this photo collection Inflammatory Bone Disease Photo Examples of Diagnostic Terms and Criteria, Part I of I Chronic fibrosing osteomyelitis Chronic nonsuppurative osteomyelitis Chronic nonsuppurative osteomyelitis Acute osteomyelitis Periapical granuloma Chronic granulomatous osteomyelitis Condensing osteitis Index of Normal Index of Normal

End of this Module Index of Normal Index of Normal Main campus of the Texas Medical Center in Houston, Texas; the world’s largest medical center