PERIODONTAL POCKET

PRESENTED BY –SRISHTI SRIVASTAVABDS

• When the sulcular depth is more then three millimeters, will allow food debris and microbes to accumulate. This poses a danger to the periodontal ligament (PDL) fibers that attach the gingiva to the tooth. If accumulated microbes remain undisturbed in a sulcus for an extended period of time, they will penetrate and ultimately destroy the delicate soft tissue and periodontal attachment fibers. If left untreated, this process may lead to a deepening of the sulcus.

Introduction

• Pocket can be defined as pathologically deepened of the gingival sulcus. (CARRANZA)

• Pocket occur with the destruction of the supporting periodontal tissues.

Definition

• The periodental pockets are caused by micro-organism and their products,which produce pathologic changes that lead to the deepening of the gingival sulcus.

Etiology

morphology

• Gingival •

periodontal

• combined

relationship to crestal bone

• suprabony • infrabony

The number of surface involved

• simple • compound • complex

The nature of the soft

tissue wall of the pocket

• edematous • fibrotic

Depending upon the disease

activity

•active •inactive

Classification -

• GINGIVAL POCKET (PSEUDO POCKET):

• This type of pocket is formed by gingival enlargement without destruction of the underlying periodontal tissues. The sulcus is deepened because of the increased bulk of the gingiva

• Periodontal pocket:

• This type of pocket occurs with destruction of the supporting periodontal tissues. Progressive pocket deepening leads to destruction of the supporting periodontal tissues and loosening and exfoliation of the teeth.

• Suprabony (supracrestal or supraalveolar), in which the base of the pocket is coronal to the underlying alveolar bone.

• Intrabony (infrabony, subcrestal or intraalveolar), in which the base of the pocket is apical to the level of the adjacent alveolar bone.

Different types of periodontal pockets

A, Gingival pocket-There is no destruction of the supporting periodontal tissues B, Suprabony pocket-The base of the pocket is coronal to the level of the underlying bone.

C, Intrabony pocket. The base of the pocket is apical to the level of the adjacent bone. Bone loss is vertical.

pockets-

• SIMPLE POCKET-involving one tooth surface

• COMPOUND POCKET- involving two or more tooth surface

• COMPLEX POCKET-base of the pocket is not in direct communication with the gingival margin, also c/a spiral pocket.

A-Simple pocket. B-Compound pocket.

C-Complex pocket

Signs• enlarged,bluish red marginal gingiva with a

rolled edge seprated from the tooth surface.• Bluish red vertical zone extending from the

gingival margin to the alveolar mucosa.• A break in the faciolingual continuity of the

interdental gingiva.• Shiny,discolored and puffy gingiva

associated with exposed root surface.

clinical features

• Gingival bleeding , purulent ` from the gingival margin.

• Mobility , extrusion and migration of teeth.

• The development of diastema.

• Localised pain or a sensation of pressure in the gingiva after eating,which gradually dimnishes.

• A foul taste in localized areas• Radiating pain “deep in the bone”.• Feeling of itching in the gums• The urge to dig a pointed instrument into

the gums and relief is obtained from the resultant bleeding.

• Sensitivity to heat and cold.

symptoms

The gram-positive bacteria lays down on the on the supragingival tooth surface and extentd in to the gingival sulcus.

As a result of inflammation,the following changes are seen in the junctional epithelium-

PATHOGENESIS

changes in junctional epithelium

prolifeartes along the root surface (finger like projections)

coronal portion detaches apical portion of from the root junctional epithelium migrates

due to bacterial enzymes and physical replaced by pocket epithelium forces exerted by them

First event

• Colonization of Gram-positive bacteria supragingivally and its extension into the gingival sulcus and conversion of Gram-positive aerobes to Gram-negative anaerobs.

aggressive growth and action of Gram- negative bacteria

Emigration of neutrophils in large numbers Disruption of epithelial barrier causing open communication

Second event

loss of chemotactic gradient

tissue destruction due to products released by neutrophils as well as

bacteria

resorption of alveolar bone periodontal pocket is established

• Once the pocket is formed , the following microscopic features are present-

Changes in the soft tissue wall: the blood vessels are dilated. The connective tissue is edematous and

densely infiltrated with plasma cells , lymphocytes.

HISTOPATHOLOGY

• Filaments , rods , cocoid organisms with predominent gram (-) cell walls have been found in intercellular spaces of the epithelium.

• Bacteria may invade the intercellular space under epithelial cells but they are also found between deeper epithelial cells and accumulating on the basement lamina.

BACTERIAL INVASION

• The inflammatory response triggered by bacterial plaque unleashes a complex cascade of events , aimed at destroying and removing bacteria , necrotic cells .

• The host cells such as neutrophiles , macrophages , fibroblasts , epithelial cells and others , produce proteinases , cytokines and prostaglandins that can damage or destroy the tissue .

MECHANISM OF TISSUE DISTRUCTION-

• Under scanning electron microscope the following areas have been noted:

1.areas of bacterial accumulation- which appears as depression on the epithelial surface with abundant debris and bacterial clumps penetrating into the enlarged intercellular spaces.

2.areas of emergence of leukocytes – leukocytes appear in pocket wall through holes located in the intracellular spaces .

3. Area of leukocytes – bacteria interaction numerous leukocytes are present and covered with bacteria in an apparent process of phagocytosis .

MICROTOPOGRAPHY OF THE GINGIVAL WALL OF THE POCKET

4. Area of intense epithelial desquamation -consist of semiattached and folded epithelial squames .

5.area of ulceration with exposed connective tissue

6.area of hemorrhage with numerous erythrocytes.

• IT is characterized by interplay of destructive and constructive tissue changes .

- The destructive changes are characterized by fluid and cellular inflammatory exudates and by the associated changes initiated by the plaque bacteria .

- The constructive changes consist of the formation of blood vessels in an effort to repair the tissue damage caused by inflammation .

• The balance between the destructive and constructive changes determines the clinical feature such as colour , consistency , and surface texture .

PERIODOTAL POCKET AS HEALING LESION

• It consists of – debris - containing micro-organisms and

their products (enzyme , endotoxin , and other metabolic products).

dental plaque Gingival fluid food remnants salivary mucin desqumated epithelial cell and

leucocytes

POCKET CONTENTS

• If the purulent exudate is present , it consist of-

living , degenerated and necrotic leukocytes , living and dead bacteria , serum and a scanty amount of fibrin .

pus formation is common feature in periodontal disease but it only secondary sign .

• 1- STRUCTURAL CHANGES – A- presence of pathologic granules B- areas of increase mineralization C- areas of demineralization / root caries• 2- CHEMICAL CHANGES – the mineral content of exposed cementum increased . Mineral increased in root surface – calcium ,

magnesium , phosphate , floride and others .

• 3- CYTOTOXIC CHANGES – bacterial penetration into cementum can be found as deep as cementodentinal junction .

in addition , bacterial products such as endotoxins have also been detected .

CHANGES IN ROOT SURFACE WALL

• 1-cementum covered by calculus.• 2-attached plaque.• 3-the zone of unattached plaque.• 4-the zone where the junctional

epithelium is attached to the tooth.• 5-the zone of semi destroyed C.T. fibers.

Surface morphology of the tooth wall of the periodontal pockets

ZONES IN THE BASE OF PERIODONTAL POCKET

Periodontal probes are used to locate, measure, and mark pockets, as well as determine their course on individual tooth surfaces.

DIAGNOSIS

• Periodontal probes may be divided into:First generation probes are conventional, and hand held probes, e.g. conventional

periodontal probes.Second generation probes are pressure –

sensitive probes. It has been shown that, with forces up to 30gms the probe tip remains within junctional epithelium and forces up to 50gms are necessary to diagnose osseous defects. This probe did solve many problems of the conventional probes, but lacked tactile sensitivity.

Third generation probes are computerized probes. Gibbs et al designed Florida probe. E.g.-Foster Miller Probe, Toronto Automated Probes, which can detect the cemento-enamel junction.

Fourth generation probes are the three dimensional probes in which sequential probe positions are measured.

Fifth generation probes are ultrasonographic probes which provides painless probing to the patient. The guidance path is predetermined in these probes.

There are three types of periodontal probes. They are:1. Calibrated periodontal probes

2. Naber’s furcation probe

3. Computer assisted probes

TYPES OF PERIODONTAL PROBES

• There are two different pocket depths:- The biologic depth is the distance between the gingival margin and the base of the pocket (coronal end of junctional epithelium). This can be measured only by histological sections.- The probing depth is the distance to which the probe penetrates into the pocket.

POCKET PROBING

• The depth of penetration of the probe in the connective tissue apical to the junctional epithelium in a periodontal pocket is about 0.3mm.

• The probing forces of 0.75N have been found to be well tolerated and accurate.

• The probe should be inserted parallel to the vertical axis of the tooth and “walked” circumferentially around each tooth to detect the areas of deepest penetration.

• To detect an interdental crater the probe should be placed obliquely from both the facial and the lingual surface to explore the deepest point of the pocket located beneath the contact point.

• To detect furcation involvement in multi-rooted teeth, use of specially designed Naber’s probe allows an easier and more accurate exploration of the horizontal component of furcation lesion.

PROBING TECHNIQUE

• Probing of pockets is done at various times for diagnosis and for monitoring the course of treatment and maintenance.

• Initial probing: Done to determine whether the tooth can be saved or should be extracted.

• Second probing: Done to establish accurately the level of attachment and degree of involvement of roots and furcations.

When to probe

TREATMENT