THE PERIODONTAL POCKET

By

Dr. Marcel Hallare

Defined as a pathologically deepened gingival sulcus One of the most important clinical features of periodontal disease

Same pocket depth with different amounts of recession

CLASSIFICATION Gingival pocket (pseudo pocket)

Type of pocket formed by gingival enlargement without destruction of the underlying periodontal structures The sulcus is deepened because of the bulk of the gingiva

Periodontal pocket (true pocket)

Occurs with destruction of the supporting periodontal tissue Progressive pocket deepening leads to destruction of the supporting periodontal tissue and loosening of the teeth

TWO TYPES OF PERIODONTAL POCKETS:

Suprabony (supracrestal or supraalveolar) in which the bottom of the pocket is coronal to the underlying alveolar bone Intrabony (infrabony, subcrestal or intraalveolar) in which the bottom of the pocket is apical to the level of the adjacent alveolar bone

Different types of periodontal pockets

Gingival Pocket Intrabony Pocket

Suprabony Pocket

CLINICAL FEATURES

The only reliable method of locating periodontal pockets and determining their extent is careful probing of the gingival margin along each tooth surface

Play video

Extent of pocket revealed by periodontal probe on mesial of central incisor

PATHOGENESIS
The initial lesion in the development of periodontitis is in inflammation of the gingiva in response to a bacterial challenge Pocket formation starts as an inflammatory change in the connective tissue wall of the gingival sulcus The cellular and fluid inflammatory exudates causes degeneration of the surrounding connective tissue including the gingival fibers

Just apical to the junctional epithelium collagen fibers are destroyed and the area becomes occupied by inflammatory cells and edema Two mechanisms are considered to be associated with collagen loss:
1.

Collagenases and other enzymes secreted by various cells in healthy and inflamed tissue such as fibroblasts, polymorphonuclear leukocytes, and macrophages become extracellular and destroy collagen: these enzymes that degrade collagen and other matrix macromolecules into small peptides and are called matrix

metalloproteinases
2.

Fibroblasts phagocytize collagen fibers by extending cytoplasmic processes to the ligament-cementum interface and degrade the inserted collagen fibrils and the fibrils of the cementum matrix

Because of the loss of collagen the apical cells of the junctional epithelium proliferate along the root extending fingerlike projections two to three cells in thickness The coronal portion of the junctional epithelium detaches from the root as the apical portion migrates As a result of inflammation, polymorphonuclear neutrophils (PMNs) invade the coronal end of the junctional epithelium in increasing numbers When the relative volume of PMNs reach approximately 60% or more of the junctional epithelium, the tissue loses cohesiveness and detaches from the tooth surface

Thus the sulcus bottom shifts apically and the oral sulcular epithelium occupies a gradually increasing portion of the sulcular (pocket) lining With continued inflammation, the gingiva increases in bulk, and the crest of the gingival margin extends coronally The junctional epithelium continues to migrate along the root and separates from it Leukocytes and edema from the inflamed connective tissue infiltrate the epithelium lining the pocket, resulting in various degrees of degeneration and necrosis Transformation of a gingival sulcus into a periodontal pocket creates an area where plaque removal becomes impossible

HISTOPATHOLOGY

Periodontal Pockets as Healing Lesions

Periodontal pockets are chronic inflammatory lesions and as such are constantly undergoing repair Complete healing does not occur because of the persistence of the bacterial attack which continues to stimulate an inflammatory response causing degeneration of the new tissue elements formed in the continuous effort at repair The condition of the soft tissue wall of the periodontal pocket results from the interplay of the destructive and constructive tissue changes

Their balance determines clinical features such as color, consistency, and surface texture of the pocket wall If the inflammatory fluid and cellular exudates predominate, the pocket wall is bluish-red, soft, spongy, and friable, with a smooth, shiny surface If there is a relative predominance of newly formed connective tissue cells and fibers, the pocket wall is more firm and pink

Pocket Content
Contain debris consisting principally of microorganisms and their products (enzymes, endotoxins, and other metabolic products), gingival fluid, food remnants, salivary mucin, desquamated epithelium cells, and leukocytes Plaque-covered calculus usually project from the tooth surface Purulent exudates, if present, consists of living, degenerated, and necrotic leucocytes; living and dead bacteria; serum; and a scant amount of fibrin

Maxillary molar and periodontal pocket still intact.

Root Surface Wall

Caries of the cementum requires special attention when the pocket is treated The necrotic cementum must be removed by scaling and root planning until firm tooth surface is reached, even if this entails extension into the dentin

Extracted canine. Red tissue represents the remaining attachment prior to extraction.

PERIODONTAL DISEASE ACTIVITY

Periodontal pockets go through periods of exacerbation and quiescence, resulting from episodic bursts of activity followed by periods of remission Periods of quiescence periods of inactivity) are characterized by a reduced inflammatory response and little or no loss of bone or connective tissue attachment

A build-up of unattached plaque with its gramnegative, motile, and anaerobic bacteria starts a period of exacerbation (periods of activity) in which bone and connective tissue attachment are lost and the pocket deepens This period may last for days, weeks, or months and is eventually followed by a period of remission or quiescence in which gram-positive bacteria proliferate and a more stable condition is established

SITE SPECIFICITY
Periodontal destruction does not occur in all parts of the mouth at the same time but rather on a few teeth at a time or even only some aspects of some teeth at any given time This is referred to as the site specificity of periodontal disease

Periodontal abscess, lingual view

Periodontal abscess, facial view

Periodontal absecess

Periodontal abscess

Gingival abscess