Department of Periodontology. PERIODONTAL POCKETS. Guided by: Dr.Saravana Kumar Presented by: . SAVAN UNNI IV th Year BDS C.D.C.R.I
TOPIC• Define and classify pockets.Write in detail about the pathogenesis and histo- pathological changes that occur during pocket formation? April 2001 Essay. October 1996 Essay.
DEFINITION• The periodontal pocket is defined as a pathologically deepened gingival sulcus.• A sulcus depth of 2-3mm is considered normal.
CLASSIFICATIONBased on its Morphology:GINGIVAL POCKETPERIODONTAL POCKETCOMBINED POCKET
CLASSIFICATION• Based on its relationship to crestal bone: Suprabony/Supracrestal/Supra alveolar pocket. Infrabony/Intrabony/Subcrestal/Intra alveolar pocket.
CLASSIFICATION• Based on number of surfaces involved: Simple Pocket. Compound Pocket. Complex Pocket.
CLASSIFICATION• Based on soft tissue wall of the pocket: Edematous pocket Fibrotic Pocket
CLASSIFICATION• Based on the disease activity: Active Pocket. Inactive Pocket.
GINGIVAL POCKET• Formed by gingival enlargement without destruction of underlying periodontal tissues.• The sulcus is deepened because of the increased bulk of the gingiva.
PERIODONTAL POCKET• It occurs due to destruction of the supporting periodontal tissues. It can be of two types• Suprabony pocket• Infrabony pocket
SUPRABONY POCKET • Also know as Supracrestal or Supra alveolar. • The base of the pocket is coronal to the level of underlying bone. • Bone loss is horizontal
INFRABONY POCKET• Also known as Infrabony or subcrestal or intra alveolar pocket.• The base of the pocket is apical to the level of adjacent bone• Bone loss is vertical.
Classification based on involved tooth surfaces.• SIMPLE POCKET: Involving one tooth surface.• COMPOUND POCKET: Involving two or more tooth surfaces.• COMPLEX POCKET/SPIRAL POCKET: Here the base of the pocket is not in direct communication with gingival margin.
PATHOGENESIS.• Accumlation of micro organisms on the supragingival toothsurface and its extension into gingival sulcus.• Inflammatory changes in the connective tissue wall of the gingival sulcus.• Cellular & fluid inflammatory exudate causes degeneration of the connective tissue including the gingival fibers.
• Collagen fibers gets destroyed apical to the junctional epithelium and the area becomes occupied by inflammatory cells and edema.• The coronal portion of the junctional epithelium detaches from the root as the apical portion migrates.• Polymorphonuclear neutrophils invade the coronal end of the junctional epithelium in increasing numbers.
• 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 separate from the root.
Mechanism Of Collagen Loss:• There are two mechanisms involved:• FIRST MECHANISM: Collagenases and other enzymes secreted by fibroblasts, polymorphonuclear leukocytes ,and macrophages. These enzymes degrade the collagen and other matrix macromolecules into small peptides which are called as matrix metalloprotinases.
• SECOND MECHANISM : 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.
HISTOPATHOLOGY EPITHELIAL CHANGES: • Epithelium becomes degenerated and atrophied. • Inner aspect of the pocket wall becomes ulcerated. • Pus occurs in the pocket with suppurative inflammation of the inner wall.
HISTOPATHOLOGY CONNECTIVE TISSUE CHANGES: • The connective tissue is edematous and densely infiltrated with plasma cells,lymphocytes,and pmn’s. • Blood vessels are increased in number,dilated and engorged in subepithelial connective tissue layer. • Single or multiple necrotic foci are present in the connective tissue. • Proliferation of endothelial cells,with newly formed capillaries ,fibroblasts,and collagen fibers.