PERIODONTAL POCKET

OUTLINE
 CLASSIFICATION  PULP CHANGES ASSOCIATED WITH
 CLINICAL FEATURES PERIODONTAL POCKETS
 PATHOGENESIS  RELATION OF ATTACHMENT LOSS
 HISTOPATHOLOGY AND BONE LOSS TO POCKET DEPTH
• Soft Tissue Wall  AREA BETWEEN THE BASE OF THE
• Microtopography of the Gingival POCKET AND THE ALVEOLAR BONE
Wall of the Pocket  RELATIONSHIP OF THE
• Periodontal Pockets as Healing PERIODONTAL POCKET TO BONE
Lesions • Differences between Infrabony and
• Pocket Contents Suprabony Pockets
•  PERIODONTAL ABSCESS
Root Surface Wall
  PERIODONTAL CYST
PERIODONTAL DISEASE ACTIVITY
 SITE SPECIFICITY
 DEFINITION

• “A PATHOLOGICALLY DEEPENED
GINGIVAL SULCUS.”
 CLASSIFICATION
1. DEPENDING ON MECHANISM OF POCKET
FORMATION.
2. DEPENDING ON THE RELATION OF THE
POCKET BASE TO THE ALVEOLAR CREST.
3. DEPENDING ON THE NO. OF SURFACES
INVOLVED.
1.DEPENDING ON MECHANISM
• GINGIVAL POCKET / PSEUDO POCKET
FORMED BY GINGIVAL ENARGEMENT WITHOUT DESTRUCTION
OF UNDERLYING PERIODONTAL TISSUES.

• PERIODONTAL POCKET
FORMED BY APICAL MIGRATION OF THE JUNCTIONAL
EPITHELIUM AND DESTRUCTION OF SUPPORTING
PERIODONTAL TISSUES.
 2.DEPENDING ON THE RELATION BETWEEN
POCKET BASE AND THE BONE CREST
• SUPRABONY / SUPRACRESTAL /
SUPRAALVEOLAR
BOTTOM OF THE POCKET IS CORONAL
TO THE UNDERLYING ALVEOLAR
BONE.

• INFRABONY / INTRABONY /
SUBCRESTAL / INTRAALVEOLAR
BOTTOM OF THE POCKET IS APICAL
TO THE BASE OF THE POCKET AND
THE LATERAL POCKET WALL LIES
BETWEEN THE TOOTH AND THE
BONE.
 3.DEPENDING ON THE NO. OF SURFACES
INVOLVED

SIMPLE POCKET
COMPOUND POCKET
COMPLEX/SPIRAL

POCKET.
 CLINICAL FEATURES
• Bluish red thickened marginal gingiva.
• Bluish red vertical zone from margin to alveolar mucosa.
• Bleeding.
• Suppuration.
• Tooth mobility.
• Diastema formation.
• Pain- Localized or Deep in the bone.

**These are only suggestive of presence of a pocket. Careful

periodontal probing is the only way to locate the pocket and
to determine its full extent.
 Pathogenesis
Increased plaque
Bacterial challenge.
accumulation

Formation of
Inflammation of gingiva.
periodontal pocket
 Pathogenesis

• Healthy gingiva - Few microbes—Coccoid cells

and straight rods.

• Diseased gingiva — increased no. of spirochetes

and motile rods.

• Changes in the microflora accompany the

transition from gingival sulcus to periodontal
pocket.
 Pathogenesis
Gingiva is
• Pocket formation bulky, Plaque
starts as an separates
apically
accumulation

inflammatory change
in C.T wall of gingival
sulcus
Cells of J.E.
Inflammatory
Proliferate along
Exudate
Root, detach
Cells & fluid
coronally

Cells form
MMPs, Fluid destroys
phagocytes Gingival fibers
collagen
 Histopathology
• Epithelium at the gingival crest is generally intact and
thickened.

• Junctional Epithelium is reduced in height, only 50-

100 microns. Cells may exhibit slight to moderate
degeneration.

• Connective tissue is edematous, densely infiltrated

with plasma cells, lymphocytes & PMNs. Blood
vessels are numerous, dilated, engorged. Varying
degrees of degenerative and necrotic changes are
seen. Few proliferative changes like new blood
vessels, collagen fibers, fibroblasts etc are seen.
 Histopathology
• Lateral wall of pocket: Shows maximum degenerative
changes. Epithelium proliferates & extends into the
adjacent inflamed connective tissue sometimes even
more apically than J.E. This epithelium is densely
infiltrated by WBCs & edema. The cells undergo
degeneration and form vesicles. Progressive necrosis
give rise to ulceration of lateral wall, exposure of the
C.T. and suppuration.
 Histopathology
*Severity of degenerative changes is not
dependent on depth of pocket. Suppuration
and ulceration may be seen with a shallow
pocket and not with a deep one and vice
versa.
*On comparison, it was shown that the
aggressive cases show more degenerative
changes than the chronic ones.
 Bacterial Invasion
• Chronic as well as Aggressive periodontitis cases show bacterial
invasion of the lateral and apical areas of pocket wall.

• Intercellular spaces of epithelium show presence of filaments,

rods, coccoid forms with Gram negative cell wall.

• Bacteria are seen in the exfoliating cells, between deeper

epithelial cells, on basement lamina and also in the subepithelial
connective tissue.

• Porphyromonas gingivalis, Prevotella intermedia, Actinobacillus

actinomycetemcomitans are found in the gingival tissues.
 Micro topography of the gingival
wall of the pocket
• Scanning electron microscopy of the lateral
wall of the pocket reveals the above
mentioned areas that are irregularly oval or
elongated and adjacent to one another.
• Each area measures around 50-200microns.
• Transition from one area to another is a rule
and it indicates interaction between the host
and the bacteria.
Microtopography of the gingival wall of the
pocket
1. Areas of relative quiescence
2. Areas of bacterial accumulation
3. Areas of emergence of leucocytes
4. Areas of leukocyte-bacteria interaction
5. Areas of intense epithelial desquamation
6. Areas of ulceration
7. Areas of hemorrhage
 Periodontal pockets as a healing
lesions
• It is characterized by interplay of destructive
and constructive tissue changes

• The balance between destructive and

constructive changes determines clinical
features such as colour, consistency and
surface texture of the pocket wall.
 Pocket contents
• It consists of debris principally containing
microorganisms and their products, (like enzymes,
endotoxins and other metabolic products) dental
plaque, gingival fluid, food remnants, salivary mucin,
desquamated epithelial cells and leukocytes.

• If purulent exudate is present, it consists of living,

degenerated and necrotic leukocytes (PMNL’s), living
and dead bacteria, serum and a scanty amount of fibrin.

• Pus formation is a common feature in periodontal

disease but it is only a secondary sign
 Root surface wall
– Pathologic granules
– Fragmentation & breakdown of cementum leading to Necrotic
Cementum
– Endotoxins
– Diseased root fragments prevent attachment of gingival fibroblasts

• Decalcification & Remineralization

– Ca, Mg, P& F are increased – resistant to decay

• Areas of Demineralization often related to – Root Caries

– A. viscosus,
– A. naeslundii,
– S. mutans, sanguis,
– S. salivarius & Bacillus cereus.

• Areas of Cellular resorption of cementum & Dentin are common in roots

unexposed to periodontal disease
Surface Morphology of the Tooth Wall of
Periodontal Pockets
 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 and exacerbation are
also known as periods of activity and inactivity
 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.
PULP CHANGES ASSOCIATED WITH
PERIODONTAL POCKETS
• Involvement of the pulp in periodontal
disease occurs through either the apical
foramen or the lateral canals in the root after
infection spreads from the pocket through the
periodontal ligament.

• Atrophic and inflammatory pulpal changes

occur in such cases
RELATION OF ATTACHMENT LOSS AND
BONE LOSS TO POCKET DEPTH

Same pocket depth with different amounts of recession.

A, Gingival pocket with no recession. B, Periodontal pocket of
si milar depth as in A, but with some degree of recession.
C, Pocket depth same in A and B, but with still more recession.
Different pocket depths with the same amount of attachment
loss. Arrows point to bottom of the pocket. The distance
between the arrow and the cementoenamel junctions remains
the same despite different pocket depths
 AREA BETWEEN THE BASE OF THE POCKET
AND THE ALVEOLAR BONE

• 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 ± 33.16%.
• The distance from attached plaque to bone is never less
than 0.5 mm and never more than 2.7 mm.
• These findings suggest that the bone-resorbing activity
induced by the bacteria is exerted within these
distances
Relationship of Periodontal Pocket
To Bone
• In intrabony pockets, the base of the pocket is
apical to the crest of the alveolar bone, and the
pocket wall lies between the tooth and the bone.
Intrabony pockets most often occur
interproximally but may be located on the facial
and lingual tooth surfaces. Most often the pocket
spreads from the surface on which it originated to
one or more contiguous surfaces. The suprabony
pocket has its base coronal to the crest of the bone
 Distinguishing Features of the Suprabony and
Intrabony Pockets
Suprabony Pocket
1. The base of the pocket is coronal to
the level of thealveolar bone.
2. The pattern of destruction of the
underlying bone is horizontal.
3. Interproximally, the transseptal fibers that
are restored during progressive
periodontal disease are arranged
horizontally in the space between the
base of the pocket and the alveolar bone
4. On the facial and lingual surfaces, the
periodontal ligament fibers beneath the
pocket follow their normal horizontal-
oblique course between the tooth and the
bone
Infrabony Pocket
1. The base of the pocket is apical to the crest of
the alveolar bone so that the bone is adjacent to
the soft tissue wall
2. The bone destructive pattern is vertical (angular)
3. Interproximally, the transseptal fibers are
oblique rather than horizontal. They extend from
the cementum beneaththe base of the pocket
along the bone and overthe crest to the
cementum of the adjacent tooth
4. On the facial and lingual surfaces, the
periodontal ligament fibers follow the angular
pattern of the adjacent bone. They extend from
the cementum beneath the base of the pocket
along the bone and over the crest to join with
the outer periosteum.
 PERIODONTAL ABSCESS
• A periodontal abscess is a localized purulent
inflammation in the periodontal tissues It is
also known as a lateral or parietal abscess
Periodontal abscess formation may occur in the following ways:

1. Extension of infection from a periodontal pocket deeply into the

supporting periodontal tissues and localization of the suppurative
inflammatory process along the lateral aspect of the root.
2. Lateral extension of inflammation from the inner surface of a periodontal
pocket into the connective tissue of the pocket wall. Localization of the
abscess results when drainage into the pocket space is impaired
3. In a pocket that describes a tortuous course around the root, a
periodontal abscess may form in the culde- sac, the deep end of which is
shut off from the surface.
4. Incomplete removal of calculus during treatment of a periodontal pocket.
In this instance, the gingival wall shrinks, occluding the pocket orifice, and
a periodontal abscess occurs in the sealed-off portion of the pocket.
5. A periodontal abscess may occur in the absence of periodontal disease
after trauma to the tooth or perforation of the lateral wall of the root in
endodontic therapy.
 Classification of Periodontal
abscesses
1. Abscess in the supporting periodontal tissues
along the lateral aspect of the root

2. Abscess in the soft tissue wall of a deep

periodontal pocket.
 PERIODONTAL CYST
Origin:
1. Odontogenic cyst caused by proliferation of the
epithelial rests of Malassez; the stimulus initiating the
cellular activity is not known.
2. Lateral dentigerous cyst retained in the jaw after tooth
eruption.
3. Primordial cyst of supernumerary tooth germ.
4. Stimulation of epithelial rests of the periodontal
ligament by infection from a periodontal abscess or the
pulp through an accessory root canal.
• A periodontal cyst is usually asymptomatic
and without grossly detectable changes, but it
may present as a localized tender swelling.
• Radiographically, an interproximal periodontal
cyst appears on the side of the root as a
radiolucent area bordered by a radiopaque
line. Its radiographic appearance cannot be
differentiated from that of a periodontal
abscess