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PERIODONTAL
POCKET
Dr. D.Navya, MDS
INTRODUCTION
 Periodontal pocket is defined as
a pathologically deepened gingival
sulcus [Carranza,10th Edi]
 A pathologic fissure between a tooth and the
crevicular epithelium, and limited at its apex by the
junctional epithelium. [GPT]
 Clinically speaking, the lesion should be termed a
“diseased gingival attachment”
18-07-2023 2
SAUL SCHLUGER, RALPH YUODELIS, ROY C PAGE, ROBERT H. JOHNSON
Periodontal Diseases 2nd Edition
CLASSIFICATION
18-07-2023 CARRANZA Clinical Periodontology 10th
Edition
3
SUPRABONY
 base of pocket is
coronal to the crest of
the bone.
 Horizontal bone loss
 Interproximally,
transseptal fibers are
arranged horizontally
 Pdl fibers are
arranged in their
normal pattern
18-07-2023 4
•Apical
•Vertical / Angular bone
loss
•Interproximally,
transseptal fibers are
arranged obliquely
•Angular pattern
INFRABONY
CLASSIFICATION
 Simple Compound
Complex/Spiral
18-07-2023 CARRANZA Clinical Periodontology 10th
Edition
6
ACTIVE & INACTIVE
POCKETS
 Active pocket :-
 underlying bone Is lost
 diagnosed clinically by bleeding
Inactive pocket:
 after phase I therapy the inflammatory changes in
pocket wall subside, rendering the pocket inactive
with decreased depth.
 They may heal by long junctional epithelium
18-07-2023 7
CLINICAL FEATURES
 a bluish – red vertical zone from the gingival
margin to the alveolar mucosa
 gingival bleeding
 suppuration
 tooth mobility
 diastema formation
 localized pain or pain “deep in the bone”
18-07-2023 CARRANZA Clinical Periodontology 10th
Edition
8
Clinical
Features
 Bluish red
discoloration
 Flaccidity
 Smooth & shiny
surface
 Pitting on pressure
 Gingival wall- pink &
firm
18-07-2023 CARRANZA Clinical Periodontology 10th
Edition
9
Histopathological
Features
 Circulatory
stagnation
 Destruction of
gingival fibers
 Atrophy of
epithelium & edema
 Edema &
degeneration
 Predominant Fibrotic
changes
Clinical
Features
 Bleeding on probing
 Pain On Probing
 Pus
18-07-2023 CARRANZA Clinical Periodontology 10th
Edition
10
Histopathological
Features
 Increased
vasculature
 Degeneration of
epithelium
 Ulceration
 Suppurative
inflammation
18-07-2023
CARRANZA Clinical Periodontology 10th
Edition
11
HISTOPATHOLOGY
SOFT TISSUE WALL
 Connective tissue – edematous, with plasma
cells(80%),PMNs (scattered)
- shows proliferative and
degenerative changes
 Blood Vessels – dilated, engorged, increase in
no.
 JE – Shorter than normal sulcus
 Severe degeneration occurs at lateral wall
18-07-2023
CARRANZA Clinical Periodontology 10th
Edition
12
MICROTOPOGRAPHY OF
GINGIVAL WALL
 Pocket wall is constantly changing as a result of
interaction between host & bacteria
 Gingival wall has Following Areas :-
1. Relative quiescence
2. Bacterial accumulation
3. Emergence of leukocytes
4. Leukocyte – bacteria interaction
5. Intense epithelial desquamation
6. Ulceration
7. Areas of hemorrhage
18-07-2023
CARRANZA Clinical Periodontology 10th
Edition
13
18-07-2023 14
18-07-2023 15
PERIODONTAL POCKETS AS
HEALING LESION
 Constantly undergoes repair
 Complete healing doesn't occur
 Condition of soft tissue depends on changes
(Destructive / Constructive)
 Edematous Pocket Wall
 Fibrous Pocket Wall
 Edematous & Fibrous Pockets represent
opposite extremes of same pathologic
process,not different entities
18-07-2023
CARRANZA Clinical Periodontology 10th
Edition
16
CONTENTS OF POCKET
 Microorganisms & their products
 Gingival Fluid
 Food remnants
 Salivary mucin
 Desquamated epithelial cells
 Leukocytes
 Plaque covered with calculus
 Purulent exudate (living, degenerated. necrotic
leukocyte, living &dead bacteria, serum, scant
amount of fibrin)
18-07-2023
CARRANZA Clinical Periodontology 10th
Edition
17
SIGNIFICANCE OF PUS
FORMATION
 The presence of pus or the ease with which it can
be expressed from the pocket merely reflects the
nature of the inflammatory changes in the pocket
wall.
 It is not an indication of the depth of the pocket or
the severity of the destruction of the supporting
tissues.
 Extensive pus formation may occur in shallow
pockets, whereas deep pockets may exhibit little or
no pus.
18
18-07-2023
CARRANZA Clinical Periodontology 10th
 Pus is a common feature of periodontal
disease, but it is only a secondary sign.
 Localized accumulation of pus constitutes
an abscess.
18-07-2023 19
CARRANZA Clinical Periodontology 10th
ROOT SURFACE WALL
 Pocket deepens
 Collagen fibers in cementum – destroyed
 Exposure of cementum to environment
 Penetration of bacteria into cementum
 Areas of necrotic cementum separated by
masses of bacteria
18-07-2023
CARRANZA Clinical Periodontology 10th
Edition
20
 Pathologic granules - represent areas of
collagen degeneration or areas where collagen
fibrils have not been fully mineralized initially.
 Clinically – softening of cementum surface which
is usually asymptomatic but painful on probing.
 Treatment should be aimed at removal of
necrotic areas by root planing
18-07-2023
CARRANZA Clinical Periodontology 10th
Edition
21
MINERALIZATION OF
CEMENTUM
INCREASED MINERALIZATION:-
 They are probably a result of an exchange of
minerals and organic compounds at cementum
at cementum saliva interface
 Mineral content of exposed cementum increases
 Ca,Mg,P,F - in diseased roots
 This increases resistance to decay
 Selvig et. al (1977) – these zones as a layer 10-
20µm thick with areas as thick as 50µm
18-07-2023 22
CARRANZA Clinical Periodontology 10th
Edition
AREAS OF DEMINERALIZATION:-
 Exposure to oral fluid and bacterial plaque
causes proteolysis of embedded remnants of
sharpey’s fibers
 The cementum undergoes fragmentation and
cavitations leading to root caries
 Dominant microorganism – Actinomyces
viscosus
[ Syed et al(1975)]
18-07-2023 23
CARRANZA Clinical Periodontology 10th
 Caries of cementum requires special attention
when pocket is treated
 Necrotic cementum must be treated by scaling &
root planing until firm tooth surface is reached
18-07-2023 24
CARRANZA Clinical Periodontology 10th
SURFACE MORPHOLOGY OF
TOOTH WALL
18-07-2023
CARRANZA Clinical Periodontology 10th
Edition
25
PERIODONTAL DISEASE
ACTIVITY
 Earlier – Loss of attachment is slow but
continuously progressive phenomenon
 Now – Periodontal disease activity (specificity of
plaque bacteria)
 Pockets undergo periods of exacerbation &
Quiescence
 Results in episodic bursts of activity followed by
periods of remission
18-07-2023
CARRANZA Clinical Periodontology 10th
Edition
26
ACTIVITY Vs INACTIVITY
 Period of
Quiescence
 Inflammatory
response
 Little /no bone & CT
loss
18-07-2023
CARRANZA Clinical Periodontology 10th
Edition
27
 Built up of
unattached plaque
with Gm –ve, Motile
anaerobic bacteria
 Bone & CT loss
 Pocket deepens
 Proliferation Of Grm
+ve bacteria
SITE SPECIFICTIY
 Periodontal destruction doesn't occur in all parts
of the mouth at same time
 But it occurs on few teeth at a time or even only
some aspects of some teeth at any given time
 This is site specificity
 Severity of periodontitis increases with
development of new disease sites & increased
breakdown of existing sites.
18-07-2023 28
CARRANZA Clinical Periodontology 10th
PULPAL CHANGES
 Spread of infection from periodontal pocket to
pulp causes pathological changes in pulp
 Involvement of pulp occurs through either apical
foramen or lateral canals via PDL
18-07-2023 29
CARRANZA Clinical Periodontology 10th
Edition
1.Periodontal pocket deepens
into apex and secondarily
involve pulp
2.Periodontal pocket can
infect pulp through lateral wall
POCKET DEPTH Vs CAL
18-07-2023 30
 Pocket depth – distance between base of pocket &
gingival margin
 Clinical Attachment Level [CAL] – distance
between base of pocket & fixed portion on the
crown like CEJ
CARRANZA Clinical Periodontology 10th
18-07-2023 31
18-07-2023 32
POCKET DEPTH & BONE
LOSS
 Severity of bone loss is generally but not always
correlated to pocket depth.
 Extensive attachment & bone loss may be
accompanied by recession of gingival margin
where pocket can be less
 Slight bone loss can occur with deep pockets
18-07-2023 33
CARRANZA Clinical Periodontology 10th
PERIODONTAL ABSCESS
 Localized purulent inflammation in periodontal
tissues
 Also called lateral abscess/ parietal abscess
 Classification
 Abscess in supporting periodontal tissues along
lateral aspect of root
 Abscess in soft tissue wall of deep pocket
 Mainly Grm –ve anerobic rods
 Others – grm –ve cocci,diplococci,fusiforms &
spirochetes
18-07-2023 34
 Formation
 Infection from pocket deeply into supporting
periodontal tissue
 Lateral extension of inflammation from inner surface
of pocket into connective tissue
 Formation in a pocket with tortuous course around
root
 Incomplete removal of calculus
 With perforation of lateral wall of root in endodontic
therapy
18-07-2023 35
DETECTION OF POCKET
 Inserted parallel to vertical
axis of tooth
 WALKED circumferentially
around each surface of
each tooth
 Graduated periodontal probe with
a standardized tip diameter of
approximately 0.4–0.5 mm
 Probing force should be 25g or 0.75N
[Van der Velden (1979), Chamberlain et
al(1985)]
18-07-2023
CARRANZA Clinical Periodontology 10th
Edition
36
WHEN TO PROBE ?
INTIAL PROBING
 Usually masked by heavy inflammation &
abundant calculus. So cannot be done
accurately.
 Purpose – determine whether tooth can be
saved or should be extracted.
SECOND PROBING
 Establish accuracy of level of attachment &
degree of involvement of roots & furcation
 Sulcus can be safely probed after periodontal
surgery – 3 months post op
18-07-2023
CARRANZA Clinical Periodontology 10th
Edition
37
TREATMENT
 According to pocket depth, periodontitis can be
divided into
Purpose of surgical treatment
 To eliminate the pathologic changes in pocket
wall.
 To create a stable, easily maintainable state.
 To promote periodontal regeneration if possible.
18-07-2023 38
THERAPY FOR GINGIVAL
POCKETS
 Factors to be considered
 Character of the pocket wall
Edematous Fibrotic
 SRP SRP followed by gingivectomy
Modified Widman Flap Technique (in
marked enlargements)
 Accessibility of the pocket
18-07-2023 39
THERAPY FOR SLIGHT
PERIODONTITIS
 Pockets are shallow, small degree of bone loss
 A thorough Scaling & root planing is sufficient
18-07-2023 40
THERAPY FOR MODERATE TO SEVERE
PERIODONTITIS IN ANTERIORS
 Scaling & root planing
 Papilla preservation flap- For esthetics in wide
embrasures
 In narrow embrasures – sulcular incision
 Modified widman flap – when esthetics are not
concerned
 When bone contouring is needed – apically
displaced flap with bone contouring is technique
of choice
18-07-2023 41
THERAPY FOR MODERATE TO SEVERE
PERIODONTITIS IN POSTERIORS
 Offers no esthetic problem but difficult
accessibility
18-07-2023 42
TREATMENT
18-07-2023 43
Pseudopocket
Scaling & Root Planing
Re –evaluation
Persistent pockets
Gingivectomy & Gingivoplasty
Periodontal pocket
Scaling & root planing
Re- evaluation
Resective & Regenerative therapy
18-07-2023 44
 A through and sound knowledge of nature of
pocket along with its lining, contents and the
tooth wall surface is necessary for appropriate
planning of its treatment
 However, the benefit to the patient should
always be minded in long run.
18-07-2023 45

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5.pocket.pptx

  • 2. INTRODUCTION  Periodontal pocket is defined as a pathologically deepened gingival sulcus [Carranza,10th Edi]  A pathologic fissure between a tooth and the crevicular epithelium, and limited at its apex by the junctional epithelium. [GPT]  Clinically speaking, the lesion should be termed a “diseased gingival attachment” 18-07-2023 2 SAUL SCHLUGER, RALPH YUODELIS, ROY C PAGE, ROBERT H. JOHNSON Periodontal Diseases 2nd Edition
  • 3. CLASSIFICATION 18-07-2023 CARRANZA Clinical Periodontology 10th Edition 3
  • 4. SUPRABONY  base of pocket is coronal to the crest of the bone.  Horizontal bone loss  Interproximally, transseptal fibers are arranged horizontally  Pdl fibers are arranged in their normal pattern 18-07-2023 4 •Apical •Vertical / Angular bone loss •Interproximally, transseptal fibers are arranged obliquely •Angular pattern INFRABONY
  • 5. CLASSIFICATION  Simple Compound Complex/Spiral 18-07-2023 CARRANZA Clinical Periodontology 10th Edition 6
  • 6. ACTIVE & INACTIVE POCKETS  Active pocket :-  underlying bone Is lost  diagnosed clinically by bleeding Inactive pocket:  after phase I therapy the inflammatory changes in pocket wall subside, rendering the pocket inactive with decreased depth.  They may heal by long junctional epithelium 18-07-2023 7
  • 7. CLINICAL FEATURES  a bluish – red vertical zone from the gingival margin to the alveolar mucosa  gingival bleeding  suppuration  tooth mobility  diastema formation  localized pain or pain “deep in the bone” 18-07-2023 CARRANZA Clinical Periodontology 10th Edition 8
  • 8. Clinical Features  Bluish red discoloration  Flaccidity  Smooth & shiny surface  Pitting on pressure  Gingival wall- pink & firm 18-07-2023 CARRANZA Clinical Periodontology 10th Edition 9 Histopathological Features  Circulatory stagnation  Destruction of gingival fibers  Atrophy of epithelium & edema  Edema & degeneration  Predominant Fibrotic changes
  • 9. Clinical Features  Bleeding on probing  Pain On Probing  Pus 18-07-2023 CARRANZA Clinical Periodontology 10th Edition 10 Histopathological Features  Increased vasculature  Degeneration of epithelium  Ulceration  Suppurative inflammation
  • 11. HISTOPATHOLOGY SOFT TISSUE WALL  Connective tissue – edematous, with plasma cells(80%),PMNs (scattered) - shows proliferative and degenerative changes  Blood Vessels – dilated, engorged, increase in no.  JE – Shorter than normal sulcus  Severe degeneration occurs at lateral wall 18-07-2023 CARRANZA Clinical Periodontology 10th Edition 12
  • 12. MICROTOPOGRAPHY OF GINGIVAL WALL  Pocket wall is constantly changing as a result of interaction between host & bacteria  Gingival wall has Following Areas :- 1. Relative quiescence 2. Bacterial accumulation 3. Emergence of leukocytes 4. Leukocyte – bacteria interaction 5. Intense epithelial desquamation 6. Ulceration 7. Areas of hemorrhage 18-07-2023 CARRANZA Clinical Periodontology 10th Edition 13
  • 15. PERIODONTAL POCKETS AS HEALING LESION  Constantly undergoes repair  Complete healing doesn't occur  Condition of soft tissue depends on changes (Destructive / Constructive)  Edematous Pocket Wall  Fibrous Pocket Wall  Edematous & Fibrous Pockets represent opposite extremes of same pathologic process,not different entities 18-07-2023 CARRANZA Clinical Periodontology 10th Edition 16
  • 16. CONTENTS OF POCKET  Microorganisms & their products  Gingival Fluid  Food remnants  Salivary mucin  Desquamated epithelial cells  Leukocytes  Plaque covered with calculus  Purulent exudate (living, degenerated. necrotic leukocyte, living &dead bacteria, serum, scant amount of fibrin) 18-07-2023 CARRANZA Clinical Periodontology 10th Edition 17
  • 17. SIGNIFICANCE OF PUS FORMATION  The presence of pus or the ease with which it can be expressed from the pocket merely reflects the nature of the inflammatory changes in the pocket wall.  It is not an indication of the depth of the pocket or the severity of the destruction of the supporting tissues.  Extensive pus formation may occur in shallow pockets, whereas deep pockets may exhibit little or no pus. 18 18-07-2023 CARRANZA Clinical Periodontology 10th
  • 18.  Pus is a common feature of periodontal disease, but it is only a secondary sign.  Localized accumulation of pus constitutes an abscess. 18-07-2023 19 CARRANZA Clinical Periodontology 10th
  • 19. ROOT SURFACE WALL  Pocket deepens  Collagen fibers in cementum – destroyed  Exposure of cementum to environment  Penetration of bacteria into cementum  Areas of necrotic cementum separated by masses of bacteria 18-07-2023 CARRANZA Clinical Periodontology 10th Edition 20
  • 20.  Pathologic granules - represent areas of collagen degeneration or areas where collagen fibrils have not been fully mineralized initially.  Clinically – softening of cementum surface which is usually asymptomatic but painful on probing.  Treatment should be aimed at removal of necrotic areas by root planing 18-07-2023 CARRANZA Clinical Periodontology 10th Edition 21
  • 21. MINERALIZATION OF CEMENTUM INCREASED MINERALIZATION:-  They are probably a result of an exchange of minerals and organic compounds at cementum at cementum saliva interface  Mineral content of exposed cementum increases  Ca,Mg,P,F - in diseased roots  This increases resistance to decay  Selvig et. al (1977) – these zones as a layer 10- 20µm thick with areas as thick as 50µm 18-07-2023 22 CARRANZA Clinical Periodontology 10th Edition
  • 22. AREAS OF DEMINERALIZATION:-  Exposure to oral fluid and bacterial plaque causes proteolysis of embedded remnants of sharpey’s fibers  The cementum undergoes fragmentation and cavitations leading to root caries  Dominant microorganism – Actinomyces viscosus [ Syed et al(1975)] 18-07-2023 23 CARRANZA Clinical Periodontology 10th
  • 23.  Caries of cementum requires special attention when pocket is treated  Necrotic cementum must be treated by scaling & root planing until firm tooth surface is reached 18-07-2023 24 CARRANZA Clinical Periodontology 10th
  • 24. SURFACE MORPHOLOGY OF TOOTH WALL 18-07-2023 CARRANZA Clinical Periodontology 10th Edition 25
  • 25. PERIODONTAL DISEASE ACTIVITY  Earlier – Loss of attachment is slow but continuously progressive phenomenon  Now – Periodontal disease activity (specificity of plaque bacteria)  Pockets undergo periods of exacerbation & Quiescence  Results in episodic bursts of activity followed by periods of remission 18-07-2023 CARRANZA Clinical Periodontology 10th Edition 26
  • 26. ACTIVITY Vs INACTIVITY  Period of Quiescence  Inflammatory response  Little /no bone & CT loss 18-07-2023 CARRANZA Clinical Periodontology 10th Edition 27  Built up of unattached plaque with Gm –ve, Motile anaerobic bacteria  Bone & CT loss  Pocket deepens  Proliferation Of Grm +ve bacteria
  • 27. SITE SPECIFICTIY  Periodontal destruction doesn't occur in all parts of the mouth at same time  But it occurs on few teeth at a time or even only some aspects of some teeth at any given time  This is site specificity  Severity of periodontitis increases with development of new disease sites & increased breakdown of existing sites. 18-07-2023 28 CARRANZA Clinical Periodontology 10th
  • 28. PULPAL CHANGES  Spread of infection from periodontal pocket to pulp causes pathological changes in pulp  Involvement of pulp occurs through either apical foramen or lateral canals via PDL 18-07-2023 29 CARRANZA Clinical Periodontology 10th Edition 1.Periodontal pocket deepens into apex and secondarily involve pulp 2.Periodontal pocket can infect pulp through lateral wall
  • 29. POCKET DEPTH Vs CAL 18-07-2023 30  Pocket depth – distance between base of pocket & gingival margin  Clinical Attachment Level [CAL] – distance between base of pocket & fixed portion on the crown like CEJ CARRANZA Clinical Periodontology 10th
  • 32. POCKET DEPTH & BONE LOSS  Severity of bone loss is generally but not always correlated to pocket depth.  Extensive attachment & bone loss may be accompanied by recession of gingival margin where pocket can be less  Slight bone loss can occur with deep pockets 18-07-2023 33 CARRANZA Clinical Periodontology 10th
  • 33. PERIODONTAL ABSCESS  Localized purulent inflammation in periodontal tissues  Also called lateral abscess/ parietal abscess  Classification  Abscess in supporting periodontal tissues along lateral aspect of root  Abscess in soft tissue wall of deep pocket  Mainly Grm –ve anerobic rods  Others – grm –ve cocci,diplococci,fusiforms & spirochetes 18-07-2023 34
  • 34.  Formation  Infection from pocket deeply into supporting periodontal tissue  Lateral extension of inflammation from inner surface of pocket into connective tissue  Formation in a pocket with tortuous course around root  Incomplete removal of calculus  With perforation of lateral wall of root in endodontic therapy 18-07-2023 35
  • 35. DETECTION OF POCKET  Inserted parallel to vertical axis of tooth  WALKED circumferentially around each surface of each tooth  Graduated periodontal probe with a standardized tip diameter of approximately 0.4–0.5 mm  Probing force should be 25g or 0.75N [Van der Velden (1979), Chamberlain et al(1985)] 18-07-2023 CARRANZA Clinical Periodontology 10th Edition 36
  • 36. WHEN TO PROBE ? INTIAL PROBING  Usually masked by heavy inflammation & abundant calculus. So cannot be done accurately.  Purpose – determine whether tooth can be saved or should be extracted. SECOND PROBING  Establish accuracy of level of attachment & degree of involvement of roots & furcation  Sulcus can be safely probed after periodontal surgery – 3 months post op 18-07-2023 CARRANZA Clinical Periodontology 10th Edition 37
  • 37. TREATMENT  According to pocket depth, periodontitis can be divided into Purpose of surgical treatment  To eliminate the pathologic changes in pocket wall.  To create a stable, easily maintainable state.  To promote periodontal regeneration if possible. 18-07-2023 38
  • 38. THERAPY FOR GINGIVAL POCKETS  Factors to be considered  Character of the pocket wall Edematous Fibrotic  SRP SRP followed by gingivectomy Modified Widman Flap Technique (in marked enlargements)  Accessibility of the pocket 18-07-2023 39
  • 39. THERAPY FOR SLIGHT PERIODONTITIS  Pockets are shallow, small degree of bone loss  A thorough Scaling & root planing is sufficient 18-07-2023 40
  • 40. THERAPY FOR MODERATE TO SEVERE PERIODONTITIS IN ANTERIORS  Scaling & root planing  Papilla preservation flap- For esthetics in wide embrasures  In narrow embrasures – sulcular incision  Modified widman flap – when esthetics are not concerned  When bone contouring is needed – apically displaced flap with bone contouring is technique of choice 18-07-2023 41
  • 41. THERAPY FOR MODERATE TO SEVERE PERIODONTITIS IN POSTERIORS  Offers no esthetic problem but difficult accessibility 18-07-2023 42
  • 42. TREATMENT 18-07-2023 43 Pseudopocket Scaling & Root Planing Re –evaluation Persistent pockets Gingivectomy & Gingivoplasty
  • 43. Periodontal pocket Scaling & root planing Re- evaluation Resective & Regenerative therapy 18-07-2023 44
  • 44.  A through and sound knowledge of nature of pocket along with its lining, contents and the tooth wall surface is necessary for appropriate planning of its treatment  However, the benefit to the patient should always be minded in long run. 18-07-2023 45