Periodontal Pockets Overview

Study Notes

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

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.

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

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

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.

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

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

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.

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

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