Periodontal Pocket DSV-341 PDF

Dr.Mohammad Shoyab Khan Lecturer PERIODONTAL POCKET Division of Periodontics Department of Preventive Dental Sciences Prince Sattam Bin Abdulaziz University...

Dr.Mohammad Shoyab Khan Lecturer PERIODONTAL POCKET Division of Periodontics Department of Preventive Dental Sciences Prince Sattam Bin Abdulaziz University E-mail – [email protected]  PERIODONTAL POCKET Periodontal pocket is defined as a Pathologically deepened gingival sulcus. Deepening of gingival sulcus may be due to: 1. Coronal movement of the gingival margin. 2. Apical displacement of the gingival attachment or 3. Combination of the two processes. POCKET FORMATION THAT INDICATES EXPANSION IN TWO DIRECTON (ARROWS)  SULCUS VERSUS PERIODONTAL POCKET SULCUS PERIODONTAL POCKET Gingival sulcus is a space When sulcus deepens due between the neck of the to apical migration of tooth and circumferential junctional epithelium gingival tissue accomplished by attachment loss , it is referred as periodontal pocket.  CLASSIFICATION OF PERIODONTAL POCKET SIMPLE ,COMPOUND AND GINGIVAL POCKET OR PERIODONTAL POCKET (TRUE POCKET) COMPLEX POCKET PSEUDO POCKET SUPRA BONY INTRA BONY (SUPRA CRESTAL /SUPRA ALVEOLAR ) (INFRA BONY/ SUBCRESTAL/ INTRA ALVEOLAR)  GINGIVAL POCKET (PSEUDO POCKET)  FORMED BY GINGIVAL ENLARGEMENT WITHOUT DESTRUCTION OF THE UNDERLYING PERIODONTAL TISSUES.  THE SULCUS IS DEEPENED BECAUSE OF THE INCREASED BULK OF THE GINGIVA GINGIVAL POCKET  PERIODONTAL POCKET Occurs with the destruction of supporting periodontal tissues Suprabony (supra-crestal or supra- Intrabony (infrabony, subcrestal or alveolar intra-alveolar) Bottom of the pocket is coronal Bottom of the pocket is apical to to the underlying bone. the alveolar bone. SIMPLE ,COMPOUND AND COMPLEX POCKET SIMPLE COMPOUND COMPLEX POCKET POCKET POCKET  Differences between suprabony and infrabony pocket Suprabony pocket Infrabony pocket Base of pocket is coronal to Base of pocket is apical to the crest of level of alveolar bone alveolar bone Pattern of bone destruction Pattern of bone destruction is is horizontal vertical Interproximally, restored Interproximally, transseptal transseptal fibers are fibers are oblique arranged horizontally Facial and lingual surfaces: Facial and lingual surfaces: PDL fibers – horizontal PDL fibers – angular pattern of oblique course adjacent bone  RADIOGRAPHIC AND MICROSCOPIC FEATURE INFRABONY POCKETS WITH OF INFRABONY VERTICAL BONE LOSS POCKET Suprabony Infrabony Suprabony Infrabony  CLINICAL FEATURE CLINICAL SIGNS -  A bluish red thickened marginal gingiva , a bluish red vertical zone from gingival margin to the alveolar mucosa Gingival bleeding and suppuration , tooth mobility , diastema formation SYMPTIOMS - Localized pain or pain “deep in the bone” The only reliable method of locating periodontal Pocket and determining their extent is - careful Probing along each tooth surface.  CORRELATION OF CLINICAL AND HISTOPATHOLOGIC FEATURE OF PERIODONTAL POCKET CLINICAL FEATURE HISTOPATHOLOGIC FEATURE 1. THE GINGIVAL WALL OF THE POCKET PRESENTS 1. THE DISCOLORATION IS CAUSED BY CIRCULATORY VARIOUS DEGREES OF BLUISH RED DISCOLORATION; STAGNATION; FLACCIDITY BY THE DESTRUCTION OF FLACCIDITY; A SMOOTH, SHINY SURFACE; AND PITTING ON GINGIVAL FIBERS SMOOTH, SHINY SURFACE BY ATROPHY PRESSURE. OF THE EPITHELIUM AND EDEMA; AND THE PITTING ON PRESSURE BY EDEMA AND DEGENERATION. 2. LESS FREQUENTLY, THE GINGIVAL 2. IN SUCH CASES, FIBROTIC CHANGES PREDOMINATE WALL MAY BE PINK AND FIRM. OVER EXUDATION AND DEGENERATION, PARTICULARLY IN RELATION TO THE OUTER SURFACE OF THE POCKET WALL. 3. BLEEDING IS ELICITED BY GENTLY 3. EASE OF BLEEDING RESULTS FROM INCREASED PROBING THE SOFT-TISSUE WALL VASCULARITY, THE THINNING AND DEGENERATION OF THE OF THE POCKET. EPITHELIUM, AND THE PROXIMITY OF ENGORGED VESSEL TO THE INNER SURFACE.  CORRELATION OF CLINICAL AND HISTOPATHOLOGIC FEATURE OF PERIODONTAL POCKET CLINICAL FEATURE HISTOPATHOLOGIC FEATURE 4. WHEN EXPLORED WITH A PROBE, THE INNER ASPECT OF 4. PAIN ON TACTILE STIMULATION IS CAUSED BY THE THE POCKET IS GENERALLY PAINFUL. ULCERATION OF THE INNER ASPECT OF THE POCKET WALL. 5. IN MANY CASES, PUS MAY BE EXPRESSED WITH THE 5. PUS OCCURS IN POCKETS WITH SUPPURATIVE APPLICATION OF DIGITAL PRESSURE. INFLAMMATION OF THE INNER WALL.  PATHOGENESIS  Healthy gingiva is associated with few microorganism mostly cocoid cells and strait rods. Diseased gingiva is associated with increase number of spirochetes and motile rods. Early concept assumed that after the initial bacterial attack.  More recently it was established that the hosts immunoinflammmatory response to the initial and persistent bacterial attack unlashes mechanism that lead to collagen and bone destruction. These mechanism are related to various cytokines.  POCKET FORMATION STARTS AS INFLAMMATORY CHANGES IN CONNECTIVE TISSUE Loss of collagen by two In junctional epithelium ,PMN increase in large Mechanism number approximately 60% or more Tissue looses cohesiveness and Detaches from the tooth surface Collagenase and Fibroblast phagocyte collagen Other Enzymes Fiber by extending cytoplasmic Process to the ligament cemental Apical shift of junctional epithelium Interface. Loss of collagen , apical cells of junctional epithelium proliferate along the root surface Pocket formation  PATHOGENESIS BASE OF THE PERIODONTAL POCKET APICAL AREA BASE OF THE PERIODONTAL POCKET SHOWING INFLAMMATORY INFILTRATE EXTENSIVE PROLIFERATION OF LATERAL EPITHELIUM  HISTOPATHOLOGY SOFT TISSUE WALL – Connective tissue is edematous and densely infiltrated with plasma cells ( Approximately 80%) Lymphocyte and scattering of PMN Blood vessels are increased in number , dilated and engorged Connective tissue exhibits varying degree of degeneration. Junction epithelium at the base of pocket is usually much shorter than that of normal sulcus. Most severe degenerative changes in the periodontal pocket occurs along the lateral wall.  HISTOPATHOLOGY INTERDENTAL PAPILLA WITH SUPRABONY ULCERATED LATERAL POCKET WALL OF POCKET ON PROXIMAL TOOTH SURFACE PERIODONTAL POCKET  MICROTOPOGRAPHY OF THE GINGIVAL WALL 1. Areas of relative quiescence, showing a relatively flat surface 2. Areas of bacterial accumulation 3. Areas of emergence of leukocytes, 4. Areas of leukocyte–bacteria interaction  MICROTOPOGRAPHY OF THE GINGIVAL WALL 5. Areas of intense epithelial desquamation 6. Areas of ulceration, with exposed connective tissue 7. Areas of haemorrhage, with numerous erythrocytes The leukocyte–bacteria interaction. This would lead to intense epithelial desquamation and finally to ulceration and haemorrhage.  MICROTOPOGRAPHY OF THE GINGIVAL WALL A B DIFFERENT AREA CAN DESQUAMATING EPITHILIAL CELLS A-AREA OF QUIESCENT STATE IN POCKET BE SEEN ON POCKET WALL AND LEUKOCYTE B-AREA OF HOMORRHAGE SCANNING ELECTRON MICROGRAPH OF PERIODONTAL POCKET WALL  POCKET CONTENTS  Debris Microorganisms Enzymes, endotoxins, metabolic products of microorganisms  Gingival crevicular fluid , Food remnants , Salivary mucin  Desquamated epithelial cells , Leukocytes , Plaque covered calculus  Purulent exudate: Living, degenerated and necrotic leukocytes , Living and dead bacteria ,Serum Scant amount of fibrin  Pus is a common feature of periodontal disease , but it is only a secondary sign  PERIODONTAL POCKETS AS HEALING LESIONS pockets are chronic inflammatory lesions constantly undergoing repair. persistence of the bacterial attack In inflammation, consistency of pocket wall is edematous In Newly formed connective tissue cells and fibers, the pocket wall is firm and pink and fibrotic POCKET WALL - INNER HALF IS INFLAMED AND ULCERATED OUTER HALF IS DENSELY COLLAGENOUS  SURFACE MORPHOLOGY OF TOOTH WALL 1. Cementum covered by calculus, 2. Attached plaque, 3. The zone of unattached plaque 4. The zone of attachment of the junctional epithelium to the tooth. 5. A zone of semidestroyed connective tissue fibers  PERIODONTAL DISEASE ACTIVITY  Periodontal pockets go through periods of exacerbation and quiescence as a result of episodic bursts of activity followed by periods of remission  Periods of quiescence are characterized by a reduced inflammatory response and little or no loss of bone and connective tissue attachment.  period of exacerbation during which bone and tissue attachment are lost and the pocket deepens  PULP CHANGES ASSOCIATED WITH PERIODONTAL POCKET  Spread of infection from periodontal pockets may cause pathologic changes in the pulp. Involvement of the pulp in periodontal disease occurs either at the apical foramen or lateral canal. This involvement occurs after pocket infection reaches them. RELATIONSHIP OF ATTACHMENT LOSS AND BONE LOSS TO POCKET DEPTH The severity of the attachment loss is generally, but not always correlated to the depth of the pocket. The degree of attachment loss depends upon the location of the base of the pocket on the root surface. Pockets of the same depth maybe associated with different degrees of attachment loss RELATIONSHIP OF ATTACHMENT LOSS AND BONE LOSS TO POCKET DEPTH Different pocket depths with the same amount of attachment loss.  PERIODONTAL ABSCESS PERIODONTAL ABSCESS IS A LOCALIZED PURULENT INLAMMATION IN THE PERIODONTAL TISSUES IT IS ALSO KNOWN AS A LATERAL ABSCESS OR A PARIETAL ABSCESS  PERIODONTAL ABSCESS FORMATION MAY OCCUR DUE TO 1. extension of infection from a periodontal pocket deep into the supporting periodontal tissues 2. lateral extension of inflammation 3. formation in a pocket with a tortuous course around the root. 4. incomplete removal of calculus during treatment of a periodontal pocket.  GINGIVAL ABSCESS ABSCESSES THAT ARE LOCALIZED IN THE GINGIVA CAUSED BY INJURY TO THE OUTER SURFACE OF THE GINGIVA GINGIVAL ABSCESS DO NOT INVOLVE THE SUPPORTING STRUCTURES IT MAY OCCUR IN THE PRESENCE OR ABSENCE OF A PERIODONTAL POCKET  LATERAL PERIODONTAL CYST  Lateral periodontal cyst, is an uncommon lesion  produces localized destruction of the periodontal tissues along a lateral root surface  most often it is present in the mandibular canine and premolar area  it is derived from rests of Malassez  periodontal cyst is usually asymptomatic REFERENCES  Newman & Carranza`s Clinical Periodontology. Michael G. Newman, Henry Takei, Fermin A. Carranza and Perry R. Klokkevold. 13th Edition, 2018. Saunders.