PERIODONTAL POCKET AND BONE LOSS

Dr. SAIMA AKRAM BUTT DEPARTMENT OF PERIODONTOLOGY

DEFINITION
Pocket can be defined as deepening of the gingival sulcus. If this happens due to coronal migration of the marginal gingiva it is called as gingival pocket or pseudo- pocket Deepening due to apical migration of the junctional epithelium is referred to as the true pocket

CLASSIFICATION
Can be classified on the basis of: . Depending upon its morphology - gingival/false/relative pocket - periodontal/absolute/true pocket . Depending upon its relationship to crestal bone: - suprabony/supracrestal/ supra alveolar pocket - infrabony/ intrabony/ subcrestal/ intra-alveolar pocket

CLASSIFICATION
.Depending upon the number of surfaces invloved - simple pocket- involving one tooth surface - compound pocket- involving two or more tooth surfaces - complex pocket- where the base of the pocket is not in direct communication with the gingival margin. It is also known as spiral pocket these types are most common in furcation areas

CLASSIFICATION
. Depending upon the nature of the soft tissue wall
of the pocket
- Edematous pocket - Fibrotic pocket . Depending upon the disease activity - Active pocket - Inactive pocket

CLINICAL SIGNS
1. Enlarged, bluish red marginal gingiva with a rolled edge separated from the tooth surface 2. A bluish red vertical zone extending from the gingival margin to the alveolar mucosa 3. A break in the facio lingual continuity of the interdental gingiva

4. Shiny, discolored and puffy gingiva associated with exposed root surfaces

CLINICAL SIGNS
5. Gingival bleeding, purulent exudate from the
gingival margin
6. Mobility, extrusion and migration of teeth 7. The development of diastema where none had existed previously

SYMPTOMS
1. Localized pain or a sensation of pressure in the gingiva after eating, which gradually diminishes 2. A foul taste in localized areas 3. A tendency to suck material from the interproximal spaces 4. Radiating pain deep in the bone 5. A gnawing feeling or feeling of itching in the gums

6. The urge to dig a pointed instrument in to the gums and relief is obtained from the resultant bleeding

SYMPTOMS
7. Patient complains that food sticks between the teeth or that the teeth feels loose or a preference to eat on the other side 8. Sensitivity to heat and cold; toothache in the absence of caries

PATHOGENESIS
.Colonization of gram positive bacteria supragingivally and its extension in to the gingival sulcus and conversion of gram +ve aerobes to gram ve anaerobes. .This causes changes in the junctional epithelium which proliferates along the root surface in the form of finger like projections. . As a result the coronal portion detaches from the root and the apical portion of the junctional epithelium migrates. . As a result of aggressive growth and action of gram ve bacteria the neutrophils emigrate in large numbers

PATHOGENESIS
. This disrupts epithelial barrier causing open communication . Tissue destruction occurs due to the products released by neutrophils as well as the bacteria . This causes resorption of the alveolar bone . Finally a periodontal pocket is establised!

CHANGES IN THE SOFT TISSUE WALL

- The blood vessels are engorged and dilated . The connective tissue is edematous and densely infiltrated with plasma cells, lymphocytes and poly morpho nuclear leukocytes.

CHANGES IN ROOT SURFACE WALL

STRUCTURAL CHANGES: 1. Presence of pathologic granules 2. Areas of increased mineralization 3. Areas of root caries CHEMICAL CHANGES: Mineral content of exposed cementum is increased. Hence a highly resistant calcified layer to decay is formed. This can be harmful if the adsorbed products are toxic CYTOTOXIC CHANGES: Bacterial penetration on to the cementum can be found as deep as cemento-dentinal junction. Endotoxins are also detected

POCKET CONTENTS
.
. . . . . .
Micro organisms and their products

Dental plaque Gingival fluid Food remnants Salivary mucin Desquamated epithelial cells Leukocytes

POCKET WALL
- If the inflammatory fluid and cellular exudate predominates, the pocket wall is bluish red, soft, spongy and friable with a smooth, shiny surface. at a clinical level this is referred to as edematous pocket. - If there is a relative pre-dominance of newly formed connective tissue cells and fibre, the pocket wall is more firm and pink. this refers to a fibrotic pocket.

PERIODONTAL POCKETS AS HEALING LESIONS

- PDL pockets are chronic inflammatory lesions and

as such are constantly undergoing repair.

- complete healing, however does not occur because of the persistence of the bacterial attack, which continues to stimulate an inflammatory response, causing degeneration of the new tissue formed in the continuous effort at repair

TREATMENT
-PSEUDO GINGIVAL POCKET: . Scaling and root planing . Re evaluation and maintenance

. If persistent pockets: - go for Gingivectomy and gingivoplasty

TREATMENT
TRUE/PERIODONTAL POCKET . Scaling and root planing . Re evaluation and maintenance . Removal of pocket wall . Removal of tooth side of the pocket

TREATMENT
SUPRA-BONY POCKET
-ANTERIOR TEETH: 1. Scaling and root planing 2. maintenance If pocket persists go for: - curettage
In moderate to severe pockets go for: - Flap surgery utilizing crevicular incisions

BONE LOSS
. Changes that occur in bone due to periodontitis are crucial because the destruction of bone is responsible for tooth loss. . Normally the height and density of the alveolar bone are maintained by an equilibrium, regulated by local and systemic influences between bone formation and resorption. . When resorption exceeds formation bone height, density or both are reduced.

BONE DESTRUCTION BY EXTENSION OF GINGIVAL INFLAMMATION

. The most common cause of bone destruction in periodontal disease is the extension of inflammation from the marginal gingiva in to the supporting PDL tissues. . The inflammatory invasion of the bone surface and the initial bone loss that follows marks the transition from gingivitis to periodontitis. . The transition from gingivitis to periodontitis is associated with changes in the composition of plaque. In the advanced stages the number of motile organisms and spirochetes increases whereas the coccoid and straight rods decreases.

RATE OF BONE LOSS

. If the patient has poor oral hygiene with no dental care, the rate of bone loss averages to about: - 0.2 mm a year for facial surfaces - 0.3 mm a year for proximal surfaces when the periodontal disease is allowed to progress.

. However the rate of bone loss may vary depending on the type of disease present.

PATTERNS OF ALVEOLAR BONE DESTRUCTION

. The types of pockets that form and the patterns of tissue destruction that occur may depend on the pathway of the inflammatory process. . However the pathway of least resistance is taken and is most commonly the connective tissue sheath that surrounds the neurovascular bundles. . Generally, the alveolar crestal type of PDL fibers create an effective barrier to the spreading inflammation. This is another reason why the supporting alveolar bone is invaded before the PDL ligament.

HORIZONTAL BONE LOSS

. On the facial and the lingual surfaces of the teeth, the neurovascualr bundle are located in the periosteum on the outer surface of the bone. In the interproximal bone the vessels and nerves are located within the cancellous portion of the bone.

. So when the inflammation spreads through the loose connective tissue sheath, it invades and destroys the supporting alveolar bone first and then spreads laterally to alveolar bone proper and PDL ligament.
. This results in suprabony PDL pockets and horizontal pattern of bone loss.

VERTICAL BONE LOSS

. In certain circumstances, in occlusal trauma particularly, the crestal PDL fibers are weakened and hence the pathway of least resistance is now modified and the inflammation now enters directly in to the PDL space. . This results in the resorption of principal fibers and alveolar bone proper before the supporting bone, thereby separating the most coronal portion of the supporting alveolar bone from the PDL and tooth.

. This bone resorption pattern is angular or vertical and pockets are of infrabony type.