Improving diagnostic clarity in fibro-osseous lesions using modified Gallego's, alizarin red, and von kossa stains: A pilot comparative study.

BACKGROUND: Distinguishing bone, cementum, and immature osteoid in maxillofacial fibro-osseous lesions (FOLs) can be challenging using routine haematoxylin and eosin (H&E) staining alone. OBJECTIVE: To quantitatively evaluate the comparative diagnostic utility of H&E, Alizarin Red, Von Kossa, and Modified Gallego's stains (MGS) in identifying mineralized components across FOL subtypes. MATERIALS AND METHODS: In this pilot study, archival specimens of fibrous dysplasia (n = 2), cemento-osseous dysplasia (n = 2), cemento-ossifying fibroma (n = 2), and juvenile ossifying fibromas (n = 2) were stained. Independent pathologists scored structural feature visibility utilizing a semi-quantitative 0-3 scale. Visibility scores, inter-observer, and intra-observer reliability were analysed using Friedman, Wilcoxon signed-rank, and Gwet's AC1 tests. RESULTS: Qualitatively, MGS provided consistent bone (green) versus cementum (red) differentiation, Alizarin Red isolated immature osteoid, and Von Kossa mapped mature, phosphate-rich calcifications. Quantitatively, inter-observer reliability demonstrated strong to perfect consensus, while intra-observer stability was moderate-to-perfect for MGS, slight-to-substantial for Alizarin Red, and poor-to-moderate for Von Kossa. Descriptively, MGS achieved the highest mean clarity score (2.93 ± 0.25), followed closely by Alizarin Red (2.80 ± 0.40) and Von Kossa (1.80 ± 1.17). Global Friedman and post-hoc pairwise comparisons confirmed that these differences were statistically significant (P = 0.0003), with both MGS (P = 0.0069) and Alizarin Red (P = 0.0057) yielding significantly superior diagnostic clarity over Von Kossa (P < 0.01). CONCLUSION: Integrating a targeted special stain selection protocol significantly overcomes the descriptive limitations of routine H&E, reducing diagnostic ambiguity in maxillofacial FOL configurations.