Periodontal Pockets Overview

Periodontal Pocket

• A periodontal pocket is a pathologically deepened gingival sulcus
• It is a critical clinical sign of periodontal disease
• Caused by coronal movement of gingival margin, apical displacement of gingival attachment, or a combination of both

Classification of Periodontal Pockets

• Gingival Pocket (Pseudopocket): Formed by gingival enlargement without destruction of supporting tissue. The sulcus is deepened due to gingival swelling.

• Periodontal Pocket: Occurs with destruction of supporting periodontal tissues.

  • Suprabony (Supracrestal or Supraalveolar): The bottom of the pocket is above the level of the underlying alveolar bone.
  • Intrabony (Infrabony, Subcrestal or intraalveolar): The bottom of the pocket is below the level of the adjacent alveolar bone. The lateral pocket wall lies between the tooth surface and the alveolar bone.

Images of Pocket Types

• Diagrams showing the different types of periodontal pockets (gingival, suprabony, and intrabony) are mentioned

Bone Destruction Patterns

• Vertical or angular defects: Occur in an oblique direction, leading to a hollowed-out trough in the bone alongside the root

• Osseous craters: Concavities in the crest of interdental bone, confined within the facial and lingual walls

• Bulbous bone contours: Bony enlargement, adaptation to function/buttressing bone formation

• Reverse architecture: Loss of interdental bone, facial and lingual plates without concomitant loss of radicular bone

• Ledges: Plateau-like bone margins caused by resorption of thickened bony plates

Pocket Classification by Number of Walls

• Three-walled defects: Bordered by three osseous surfaces

• Two-walled defects: Bordered by two osseous surfaces (interdental craters)

• One-walled defect: One osseous surface is present

Pocket Classification by Soft Tissue Wall

• Edematous pocket: Bluish-red, soft, spongy, and friable pocket wall with a smooth, shiny surface.

• Fibrotic pocket: More firm and pink pocket wall, characterized by a relative predominance of newly formed connective tissue cells and fibers.

Pocket Classification by Disease Activity

• Active pocket: Show clinical criteria of bleeding or bleeding and suppuration, the pocket epithelium is thinned or ulcerated; activity not necessarily related to depth of the pocket and can have tissue destruction note and discharge from pocket
• Inactive pocket: Less obvious inflammation characterized by less bleeding and less visible pus

Pocket Characteristics

• Clinical features: Bluish-red, thickened gingival margins, a bluish-red vertical zone from gingival margin to alveolar mucosa, gingival bleeding/suppuration, tooth mobility, and diastema formation. A rolled edge separating the gingiva from the tooth surface. A break in the facial-lingual continuity of interdental gingiva; Shiny, puffy gingiva leads to exposed root surface.
• Histopathology: Edematous connective tissue dense infiltration with plasma cells (approximately 80%); Lymphocytes and some PMNs; increased in number, dilated and engorged blood vessels particularly in the sub-epithelial connective tissue layer. Varying degrees of connective tissue degeneration; Single or multiple necrotic foci;
• Significance of Pus: Pus formation is a secondary sign associated with periodontal disease, indicating inflammatory changes in the pocket wall. Not an indication of pocket depth or severity of supporting tissue destruction
• Periodontal Pocket as a Healing Lesion: A chronic inflammatory lesion constantly undergoing repair. Complete healing does not commonly occur because of persistence of bacterial attack. Destructive and constructive processes are involved, and their balance defines the pocket wall characteristics. Pocket wall is bluish-red, soft, spongy, and friable, with a smooth, shiny surface

Periodontal Pocket Probing

• The only reliable method for locating and determining periodontal pocket depths is probing.
• Measured using the distance from the gingival margin to the probing depth.

Pocket Content

• Debris, microorganisms, enzymes, endotoxins and other metabolic products
• Gingival fluid
• Food remnants
• Salivary mucin
• Desquamated epithelial cells
• Leukocytes
• Calcified deposits and plaque

Root Surface Wall

• As the pocket deepens, collagen fibers embedded in the cementum are destroyed
• Cementum becomes exposed, creating favorable environment for bacterial penetration, causing degeneration fragmentation, and breakdown of the cementum surface
• Leading to a necrotic cementum layer, separating from the intact part of the tooth structure of the tooth

Other Important Considerations

• Periodontal Disease Activity: Pockets go through periods of inactivity/quiescence and periods of activity/exacerbation
• Site Specificity means that periodontal destruction does not typically occur everywhere in the mouth simultaneously. It often targets particular teeth or areas.
• Spread of infection to pulp

Area Between Base of Pocket and Alveolar bone

• The distance (in millimeters) between the base of the pocket and the alveolar bone remains relatively constant.

This quiz explores the concept of periodontal pockets, critical indicators of periodontal disease. Participants will learn about the classification of gingival and periodontal pockets, including their types and characteristics. Visual aids are included to enhance understanding of the different pocket types.