Most biological dental patients know them as “cavitations,” but these lesions – associated with poor healing and chronic inflammation – have gone by many names over the years. Even among biological dentists, they’ve been known by a variety of clinical names, including
- Neuralgia-Inducing Cavitational Osteonecrosis (NICO).
- Fatty Degenerative Osteonecrosis of the Jawbone (FDOJ).
- Chronic Ischemic Medullary Disease of the Jawbone (CIMDJ).
- Chronic Ischemic Bone Marrow Disease.
But though the names differ, the underlying biology is similar. Each term just highlights different aspects of what biological dentists have observed.
“Osteonecrosis” quite literally refers to dead and decaying bone. “Fatty degeneration” describes what pathologists see under the microscope: marrow spaces filled with soft, fatty tissue instead of healthy, mineralized bone. “Ischemic medullary disease” emphasizes reduced blood flow within the marrow space itself. And “cavitation” captures what may be encountered surgically: a hollowed or structurally compromised area within the jawbone.
Most basically, these sites are areas – often where a tooth was previously extracted – where normal healing didn’t fully occur. Instead of regenerating strong, well-vascularized bone, the marrow space may remain filled with fatty tissue with reduced blood supply. The normal internal bone framework can become thin or break down. In some cases, areas of necrotic (dead) bone persist.
Importantly, the gum tissue over these areas usually looks completely healthy. There’s typically no redness, swelling, or visible sign that anything unusual is happening below. From the surface, everything can look perfectly fine – even when deeper structures are not.
This is why you also hear the pathology called “hidden infections.” While that phrase is hardly a formal diagnostic label, it does capture the reality that they have few obvious oral symptoms and evade detection on routine dental exams.
Regardless of the name, the condition is also nothing new. G.V. Black – often referred to as the Father of Modern Dentistry – described similar findings more than a century ago. What’s evolving now isn’t the existence of the phenomenon but our ability to describe, image, and treat it with greater precision.
In fact, some recent research has documented inflammatory signaling molecules, bacterial metabolites, and other toxic byproducts within these lesions. For some, that inflammatory activity doesn’t necessarily show up as sharp jaw pain. When symptoms do occur, they’re often not even local at all.
At the same time, not everyone who’s had teeth extracted will develop such a lesion at all. And not every systemic symptom traces back to one. Careful diagnosis matters. A lot.
And that brings us to a newly published review by a group of six notable researchers, including Dr. Shahram Ghanaati, Dr. Jerry Bouquot, and Dr. Johann Lechner – all highly regarded for their work on this aspect of pathology. Consolidating decades of histological research, it identifies consistent biological patterns across studies and calls for clearer, unified terminology moving forward. (“Histological research” is the study of body tissues as they appear under a microscope.)
The review shows how similar findings emerge again and again across the literature: fatty, degenerated marrow, reduced blood flow, changed bone density, chronic inflammatory signaling. It also argues for the need to move beyond all the fragmented terminology and have a single, precise term to describe the pathology.
The term that the authors propose is “Covered Socket Residuum” (CSR).
The name describes what is consistently observed. “Covered” acknowledges that the overlying gum tissue often looks totally healthy. “Socket” refers to the original extraction site. “Residuum” describes what remains when healing has not fully restored normal bone architecture within the marrow space.
By focusing on those physical attributes instead of symptoms or potential mechanisms, the strength of the new term is that it grounds the condition in what can be observed. It shifts the conversation from labels to careful evaluation of what’s actually there.
Historically, diagnosis of CSR has been the hardest part. Because the changes happen within the bone marrow compartment, they seldom show clearly on traditional dental x-rays. That’s one reason patients have been told all “looks fine.” From a 2D perspective, it often does.
But today we have 3D imaging, such as CBCT (cone beam computed tomography), which allows us to more effectively evaluate bone density and architecture. When combined with a thorough review of the patient’s medical history, dental history, and clinical findings, it helps us identify areas that warrant closer attention.
Here in our office, taking such a deep and careful look is the norm. Dr. Michael, who has had the honor of studying under Dr. Ghanaati, has followed and integrated this evolving body of research into the protocols we use for evaluating and addressing cavitations. That means careful imaging, detailed history, and thoughtful surgical technique for removing diseased tissue and encouraging good bone regeneration and improved circulation.
No assumptions. No dramatic claims. Just a recognition that bone is living tissue, and healing doesn’t always happen the way we expect.
For patients who’ve sensed that something hasn’t quite resolved after an extraction – even when the gums look healthy – this latest research offers reassurance. It’s possible for deeper structures to need attention. And when identified appropriately, these sites can be treated methodically and predictably.
