1. The Periodontal Pocket

2. Definition
Periodontal pocket is defined as a pathologic deepening of the gingival sulcus.

3. Classification Based on the course of the pocket
2. Based on the attachment of junctional epithelium
3. Based on the type of pocket wall

4. I. Based on the course of the pocket –
A. Simple pocket
B. Compound pocket
C. Complex pocket

5. II. Based on the attachment of junctional epithelium –
Gingival pocket(Pseudopocket) –
Formed by enlargement of the gingiva without destruction of the underlying periodontal tissues.
The sulcus is deepened by the increase in bulk of the gingiva.

6. B. Periodontal pocket(True pocket) –
Occurs due to destruction of the supporting periodontal tissues
Deepening leads to destruction and loosening and exfoliation of the tooth

7. Periodontal pockets are further classified into – Suprabony pocket (Supra crestal or Supraalveolar) - Base of pocket is coronal to the crest of the alveolar bone Intrabony pocket (Infrabony or Subcrestal or Intraalveolar) - Base of pocket is apical to the crest of the alveolar bone
Suprabony pocket
Intrabony pocket

8. Difference between Suprabony and Infrabony Pockets
Suprabony Pocket
Infrabony Pocket
Base of pocket is coronal to the crest of the alveolar bone
Base of pocket is apical to the crest of the alveolar bone
Bone destruction - horizontal
Bone destruction – vertical / angular
Transeptal fibers restored after disease are arranged horizontally
Transeptal fibers restored after disease are arranged obliquely
On the facial & lingual surfaces, PDL fibers beneath the pocket follow a horizontal – oblique pattern
On the facial & lingual surfaces, PDL fibers beneath the pocket follow an angular pattern

9. III. Based on the type of pocket wall - Edematous - Fibrous

10. Clinical features of Periodontal Pocket
Clinical signs -
Gingival bleeding
Bluish red , thickened marginal gingiva
Suppuration
Tooth mobility
Diastema formation
Symptoms -
Localized pain – (pain deep in the bone)

11. Clinical and Histopathologic Features of the Periodontal Pocket
Clinical Features
Histopathologic Features
Bluish red color
Smooth , shiny surface
Pitting on pressure
Circulatory stagnation
Atrophy of epithelium, edema
Edema, degeneration of tissues
Pink, firm pocket wall
Fibrotic changes
Bleeding
Due to increased vascularity
Thinning and degeneration of epithelium
Engorged blood vessels
When probed, inner aspect of pocket wall is painful
Due to ulceration of inner aspect of pocket wall
Discharge of pus on digital pressure
Due to suppurative inflammation of inner wall

12. Pathogenesis of Periodontal Pocket
Initial lesion in development of periodontitis
Inflammation of the gingiva
(due to bacterial challenge)

13. Pocket formation -
Starts as an inflammatory change in the connective tissue wall of the gingival sulcus
The exudate causes degeneration of surrounding connective tissue(gingival fibers)
Apical to the junctional epithelium – collagen fibers are destroyed
The area is occupied by inflammatory cells

14. Mechanism of Collagen Loss –
Collagenases – secreted by fibroblasts, PMNs, macrophages
Fibroblasts – phagocytize collagen fibers
Once collagen is destroyed – apical cells of junctional epithelium proliferate along the root
The coronal portion of junctional epithelium detaches from the root and PMNs invade

15. Thus the sulcus bottom shifts apically
Formation of Pocket
TOOTH
Gingival sulcus/ crevice
Gingival Epithelium
Thus the sulcus bottom shifts apically
The initial deepening of the pocket occurs between junctional epithelium and root
Sulcular Epithelium
Junctional Epithelium

16. Histopathology of Pocket Formation
Soft Tissue Wall Changes –
Connective tissue is edematous, densely infiltrated with inflammatory cells( Plasma cells)
Blood vessels-engorged, numerous, dilated
C.T shows degeneration and foci of necrosis
Proliferation of new capillaries, fibroblasts,collagen fibers
Junctional epithelium - marked variations in the length, width and thickness are seen.(50-100µm)

17. Bacterial Invasion of Pocket
Porphyromonas gingivalis
Prevotella intermedia
Actinobacillus actinomycetemcomitans
Bacteria invade the intercellular spaces under the exfoliating epithelial cells

18. Microtopography of the pocket wall
Areas of quiescence – shedding of cells seen
Areas of bacterial accumulation - in the intercellular spaces
Areas of emergence of leukocytes - in the intercellular spaces
Areas of leukocyte bacterial interaction
Areas of intense epithelial desquamation
Areas of ulceration - exposure of connective tissue
Areas of hemorrhage – numerous erythrocytes

19. Periodontal pockets as healing lesions
Periodontal pockets are chronic inflammatory lesions which undergo repair
The condition of the soft tissue wall of the periodontal pocket results from the interplay of destructive and constructive tissue changes.
The balance between the destructive and constructive changes determines the clinical features of the pocket wall.
Based on this there is either formation of edematous or fibrotic pocket wall.

20. Pocket contents Microorganisms and their products
Gingival fluid, food remnants
Desquamated epithelial cells
Leukocytes
Significance of pus formation
It is only a secondary sign
It reflects the nature of inflammatory changes in the pocket wall
Not an indication of depth of the pocket or severity of destruction

21. Root surface changes of Pocket
Cause pain
Recurrence of infection
Complicate the treatment

22. Deepening of the pocket
Collagen fibers in the cementum degenerate
Exposure of cementum to oral environment
Penetration and growth of bacteria
Areas of necrotic cementum formation

23. Changes in Root Structural changes in Root Chemical changes in Root
Cytotoxic changes in Root

24. Structural changes in Root: 1. Presence of pathological granules 2
Structural changes in Root: 1.Presence of pathological granules 2.Areas of increased mineralization - Highly mineralized layer increases the tooth resistance to decay 3. Areas of demineralization - Commonly related to root caries, dominant organism is A.viscosus

25. Chemical changes - Increased calcium, phosphorous, magnesium, fluoride
Cytotoxic changes -The diseased root fragments
- Decrease fibroblast attachment
- Induce an inflammatory response

26. Surface morphology of the tooth wall of periodontal pocket
1.Cementum covered by calculus
2. Attached plaque
3. The zone of unattached plaque
4. The zone of junctional epithelial attachment
5. Zone of semi destroyed connective tissue fibers
Zones 3,4 &5 form the plaque free zone
Width of the plaque free zone depends on the type of tooth and the depth of pocket.

28. Periodontal disease activity
Periodontal pockets progress through periods of quiescence and exacerbation. The periods of quiescence and exacerbation are also known as periods of inactivity and activity.

29. Pulpal changes associated with periodontal pocket
Spread of infection from periodontal pocket cause pathological changes in the pulp leading to painfull symptoms .
Involvement of the pulp may occur by spread of infection through apical foramen or by lateral canals in the root.

30. Relationship of attachment loss and bone loss to pocket depth
Pocket formation causes loss of attachment of the gingiva and denudation of the root surface.
The severity of attachment loss does not correlate with the depth of the pocket

31. Different pocket depths with the same amount of attachment loss

32. Periodontal Abscess
It is a localized purulent inflammation in the periodontal tissues.
Also called as - Lateral abscess, Parietal abscess
Abscesses localized in the gingiva, due to injury, which does not involve the supporting tissues is called as Gingival Abscess

33. Periodontal Abscess

34. Microscopic features of Periodontal Abscess
Localized accumulation of PMNs in periodontal pocket wall
PMNs liberate enzymes digest tissue & cells pus (present in centre of abscess)
Overlying epithelium exhibits intravascular & extracellular edema
Invasion of leukocytes
Chronic Abscess – when purulent content drains through a fistula into outer gingival surface

35. Periodontal Cyst Uncommon
Lesion that produces a localized destruction of the periodontal tissues along the lateral root surface
Seen in mandibular canine – premolar region

36. Microscopic features of Periodontal Cyst
The cystic lining contains -
- Loosely arranged, non – keratinized, thickened, proliferating epithelium
- Non – keratinized, thin epithelium

37. Thank You