Intended learning outcomes The periodontal pocket
What makes the Periodontal probe
• Classification/Clinical features stop in healthy gingival tissues?
• Pathogenesis/Histopathology
Periodontal disease activity
THE PERIODONTAL POCKET • ➢In healthy gingiva, the tip of the probe
remains within the junctional epithelium.
• Relationship of attachment/bone loss to pocket depth
➢The dense network of collagen fibres under
• Periodontal abscess &Lateral periodontal cyst the epithelium gives resistance to probing.
[Link] BDS,MDS
➢There is no BOP , the gingiva is pushed by
ASSOCIATE PROFESSOR side
DIVISION OF PERIODONTICS REFERENCE
Chapter 23, Carranza’s Clinical Periodontology
13th Edition
The periodontal pocket Periodontal pocket Clinical Attachment loss(CAL)
• Defined as a pathologically deepened gingival sulcus
What makes the bleeding on • Deepening of the gingival sulcus may occur as a result of coronal movement of the with region
probing in gingivitis ? gingival margin, apical displacement of the gingival attachment, or a combination →
of the two process.
Periodontal Pocket depth ? → coronal movement
Measured from gingival crest (gingival
➢In gingivitis, the tip of the probe pushes margin) to base of the pocket
through the junctional epithelium and
penetrates the underlying inflamed
connective tissue. Clinical attachment loss ?
➢The probe’s advance is stopped by the Measured from CEJ to sulcus or base of
dense collagen fibres apical to the the pocket.
inflamed region. og
➢There is bleeding during & after probing Jessica Pocket depth
time £ ,
Periodontal pocket vs attachment loss *
Attachment loss versus pocket formation Attachment loss versus pocket formation
Same pocket depth with different amounts of attachment loss. Different pocket depths with the same amount of attachment loss.
A: Gingival pocket with no recession. • The distance between the bottom of the sulcus (arrow) and the CEJ remains the same despite
different pocket depths.
t
B: Periodontal pocket of similar depth as in A, but with some degree of attachment loss
i
C: Pocket depth same as in A and B, but with still more attachment loss.
Gingival recession Classification of pockets
Classification of pockets
• Exposure of the radicular surface of the tooth due to destruction of the marginal Gingival pocket is formed by gingival enlargement without destruction of the
gingiva and the reestablishment of epithelial attachment at a more apical underlying periodontal tissues.
position
Depending on morphology
a. Gingival pocket
b. Periodontal pocket
c. Combined pocket
Depending on relationship to crestal bone
a. Suprabony pocket
b. Infrabony pocket
Classification of pockets
Periodontal pocket produces destruction of the supporting periodontal tissues,
thereby leading to the loosening and exfoliation of the teeth.
Suprabony & infrabony pockets
Ada Difference between suprabony and infrabony pocket
Suprabony (supracrestal or supra alveolar) Suprabony pockets Infrabony pockets
• occurs when the bottom of the pocket is coronal
to the underlying alveolar bone The base of the pocket is coronal to the crest of The base of the pocket is apical to the crest
alveolar bone of alveolar bone
Intrabony (infrabony/subcrestal/intraalveolar) Horizontal bone destruction Vertical or angular bone destruction
occurs when the bottom of the pocket is apical to
the level of the adjacent alveolar bone. Interproximally,the transeptal fibers are arranged Interproximally,the ,the transeptal fibers are
horizontally arranged in oblique pattern
The lateral pocket wall lies between the tooth
surface and the alveolar bone
On the facial and lingual surfaces, the Pdl fibers On the facial and lingual surfaces, the Pdl
follow horizontal-oblique pattern fibers follow the angular pattern
Classification-Periodontal pockets Classification of periodontal pocket Pathogenesis
Gingival pocket
Depending upon the surface involved Depending upon the nature of pocket wall
a. simple pocket-one tooth surface a. edematous pocket The cellular & inflammatory exudate causes degeneration of the
b. compound pocket-two or more tooth surface b. fibrotic pocket surrounding connective tissue & gingival fibers.
c. complex pocket-base of the pocket not in communication with the gingival margin
Collagen fibers are destroyed apical to the JE
Depending upon the disease activity Fibroblasts phagocytise collagen fibers degrading the inserted collagen
fibrils and the fibrils of the cementum matrix.
a. active pocket(exacerbation)
b. inactive pocket(quiescence)
The coronal portion of the junctional epithelium detaches from the
root and the apical portion migrates resulting in its apical shift
Periodontal pocket
Taichman N: Potential mechanisms of tissue destruction in periodontal disease. J Dent Res. 47:928 1968
Pathogenesis
& Clinical Features
The gingival wall of the pocket presents bluish-red
Histopathologic Features
Discoloration caused by circulatory stagnation
Bacterial invasion
• Filaments, rods, and coccoid organisms with predominant gram-negative bacteria
• Bacteria may invade the intercellular space, traverse the basement lamina and invade the
sub epithelial connective tissue
discoloration,a smooth, shiny surface; and pitting smooth, shiny surface by atrophy of the epithelium
on pressure. pitting on pressure by oedema and degeneration.
• Porphyromonas gingivalis
Less frequently, the gingival wall may be pink and Fibrotic changes predominate over exudation and
firm. degeneration. • Prevotella intermedia
• Tannerella forsythia
. Increased vascularity, thinning and degeneration of • Aggregati bacter actinomycetum comitans
Bleeding on gently probing the soft-tissue wall of the epithelium, and the proximity of engorged
pocket. vessels to the inner surface.
When explored with a probe, the inner aspect of
the pocket is generally painful. Ulceration of the inner aspect of the pocket wall.
Pus may be expressed with the application of Saglie FR et al: J Periodontol. 59:259 1988
digital pressure. Due to suppurative inflammation of the inner wall. Frank RM: J Periodontal Res. 15:563 1980
Microtopography of the Gingival Wall Periodontal Disease Activity Site specificity
SEM shows several areas in the soft-tissue (gingival) wall of the periodontal pocket
(50 to 200 µm)in which different types of activity take place • Periodontal destruction does not occur in all parts of the mouth
Period of exacerbation characterized by: Periods of quiescence characterized by:
• Presence of gram-ve/anaerobic bacteria • Reduced inflammatory response at the same time.
• Bleeding on probing • Little to no bone loss & CT loss
➢ Areas of relative quiescence • Deep pockets with bone loss • Accumulation of gram positive bacteria
➢ Areas of bacterial accumulation
• Severity of periodontitis increases with the development of new diseases
➢ Areas of emergence of leukocytes sites and with increased breakdown of existing sites.
➢ Areas of leukocyte–bacteria interaction
➢ Areas of intense epithelial desquamation
➢ Areas of ulceration
➢ Areas of hemorrhage
Davenport RH Jr et al: Histometric comparison of active and inactive lesions of advanced periodontitis. JPeriodontol. 53:285 1982
Saglie FR et al.: Scanning electron microscopy of the gingival wall of deep periodontal pockets in humans. J Periodontal Res. 17:284 1984
Area between Base of Pocket and Alveolar Bone
Changes in Root surface wall Surface morphology - tooth wall of periodontal pocket
The distance between the apical extent of calculus and the alveolar crest in
human periodontal pockets is most constant, having a mean length of 1.97 mm
➢Structural changes (±33.16%)
➢ Cementum covered by calculus
-presence of pathologic granules
➢ Attached plaque
-areas of increased mineralization
➢ Zone of unattached plaque
-areas of demineralization/root caries
➢ Zone where junctional epithelium is
attached
➢Chemical changes ➢ Zone of semi destroyed connective tissue
➢Cytotoxic changes
Selvig KA, Hals E: Periodontally diseased cementum studied by correlated microradiography, electron probe analysis and electron microscopy. Saglie FR et al: Plaque-free zones on human teeth in periodontitis. J Clin Periodontol. 2:190 1975
J Periodontal Res.12:419 1977 Waerhaug J: The gingival pocket. Odont Tidsk. 60:1952
Periodontal abscess & lateral periodontal cyst
Bone Destruction in Periodontal disease
slight crestal bone loss (~ 1mm).
Mild Bone Loss
bone loss (~1/3). >50% bone loss with vertical defects.
Newman MG, Sims TN: The predominant cultivable microbiota of the periodontal abscess. J Periodontol. 50:350 1979
