periodontal pocket. definition a periodontal pocket is defined as pathologically deepened gingival...
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PERIODONTAL POCKET
DEFINITION
• A periodontal pocket is defined as pathologically deepened gingival sulcus.
• It is one of the most important clinical features of periodontal diseases.
CLASSIFICATION
• Gingival pocket• Periodontal Pocket
Suprabony(supracrestal/supraalveolar)
Intrabony(infrabony/subcrestal/intraalveolar)
CLINICAL FEATURES
• Bluish red,thickend marginal gingiva• Bluish red vertical zone(GM AM)• Gingival bleeding• Suppuration• Tooth mobility• Diastema formation• Symptoms-localised pain/pain deep in the bone
PATHOGENESIS
• Inflammatory changes in CT of GS• Cellular&fluid inflm. exudate causes• degeneration of CT&gingival fibers• Just apical to JE collagen fibers destroyed• Area is occupied by inflammatory cells & edema
PATHOGENESIS Contd..
• Two mechanism of collagen loss
Collagenases+Enzymes secreated by fibroblasts,PMNs&Macrophages- MMPs became extracellular &destroyes collegen
fibroblast phagocytise collagen fibers by extending cytoplasmic process to the ligamentum-cementum interface°rade collagen fibrils&fibrils of cementum matrix
PATHOGENESIS Contd..
• As a result of the loss of collagen the apical cells of JE proliferate along the root ,extending finger like projections 2/3cells in thickness.
• PMNs invade the coronal end of JE in no.• PMNs not joined to one another/to epithelial cells by
desmosomes
PATHOGENESIS Contd..
Relative volume of PMNs reaches 60%/more of JE
Tissue losses cohesiveness detach from tooth surface
Coronal portion of JE detach from the root as the apical portion migrate
Resulting in its apical shift &oral SE gradually occupies increased portion of the sulcus(pocket lining)
PATHOGENESIS Contd…
• Extension of the JE along the root requires the presence of healthy epithelial cells.
• Marked degeneration/necrosis of JE impairs rather than accelerates pocket formation(NUG-ulcer and not pocket formation)
HISTOPATHOLOGY
C.T.-Edematous&densely infilterated
plasma(80%),lymphocytes,PMNs
-various degree of degeneration
-single/multiple necrotic foci
-proliferation of endothelial cells
-newly formed capillaries,fibroblast,
colagen fibres
HISTOPATHOLOGY Contd
J.E.-at base of pocket is much shorter than sulcus
-coronoapical length 50-100µm
-variation in length,width
&condition of epithelial cells
HISTOPATHOLOGY Contd
• Epithelial of lateral wall of pocket shows proliferative°enerative changes
• Epithelial buds/interlacing cords of
epithelial cells from lateral wall adjacent
inflamed c.t. Apically than JE• Epithelial projections+remainder
of lateral epithelium infiltrated
with leucocytes &edema
HISTOPATHOLOGY Contd
• Cells under go vascular degeneration
&rupture to form vesicles• Progressive degeneration&necrosis of
epithelium ulceration of lateral wall• Exposure of underlying CT
&suppuration
BACTERIAL INVASION
• Filaments,rods&coccoid organism with gm-ve cell walls found in intercellular spaces(CP)
• P.gingivalis&P.intermedia&AA in Gingiva (AP)• Bacteria invade intercellular spaces &accumulate on BL• Some cross BL &invade CT (Bacterial invasion/translocation)
MICROTOPOGRAPHY OF THE GINGIVAL WALL OF THE POCKET
• Several irregular&oval/elongated areas(pocket wall) with adjacent distance 50-200µm(SEM)
• Following areas 1-Areas of relative quiescence 2-Areas of bacterial accumulation 3-Areas of emergence of leukocytes 4-Areas of leukocyte-bacteria interaction 5-Areas of intense epithelial desquamation 6-Areas of ulceration 7-Areas of hemorrhage
PERIODONTAL POCKET AS HEALING LESIONS
• PP are ch infl lesion constantly repair• Distructive & constructive changes
Edematous pocket Fibrotic pocket
POCKET CONTENTS
• Debris consisting microorganism&products(enzymes,endotoxins&metabolic products)
• Gingival fluid remnants,salivary mucin• Desquamated epithelial cells&leukocytes• Purulent exudate consists of living,degenerated&scant
amount of fibrin
SIGNIFICANCE OF PUS FORMATION
• Pus is common feature of periodontal diseases• Secondary sign• Reflects nature of inflammatory changes in pocket wall• Not indicated severity of the supporting tissue
ROOT SURFACE WALL
• In deepen pocket, collagenous fibers embedded in cementum destroyed&exposed to oral environment
• Remanants of sharpey’s undergo degeneration &create environment for penetration of viable bacteria
• Pathologic granules represent areas of collagen degeneration(optical/electron microscopy)
ROOT SURFACE WALL Contd..
• Penetration of growth of bacteria leads to fragmentation&breakdown of the cementum
• Results in areas of necrotic cementum,seprated from the tooth by masses of bacteria
• Endotoxin also detected in the cemental wall of periodontal pocket
DECALCIFICATION&REMINERALIZATION OF CEMENTUM
• se mineralization an exchange,on exposure to the oral cavity of minerals&organic components at cementum saliva interface
• se in disease root surface,Ca,Mg,P,&F
• Microhardnes remains unchanged
• Hypermineralised zone 10-20µm thick& up to 50µm
AREAS OF DEMINERALIZATION
• Commonly related to root caries• Exposure to oral fluid&bacterial plaque results
proteolysis of sharpey’s fibers• Cementum may be softened &undergo
fragmentation&cavitation• Active root caries lesions-yellowish/light brown
areas ,covered with plaque&soft• Inactive lesions- darker with smooth surface&harder
consistency• Actinomyces viscosus major organism& others
A.naeslundii,S.mutans,S.salivarious,S.sanguis&B.cereus
SURFACE MORPHOLOGY OF THE TOOTH WALL OF PP
1-cementum covered by calculus2-attached plaque3-the zone unattached plaque4-the zone where JE is attached to the tooth5-zone of semidestroyed CT fibres3,4,5-plaque free zones-it is remember that plaque free zone refers to attached plaque -unattached plaque contains gm+ve
cocci,rods,filaments,fusiforms&spirochetes-most apical zone contains gm-ve rods&cocci
PERIODONTAL DISEASE ACTIVITY
• PP go through periods of excervation&quiescence
• Period of quiescence:
*reduced inflammatory response
*little/no bone&CT attachment loss
*unattached plaque with gm-ve motile&anaerobic bacteria
PERIODONTAL DISEASE ACTIVITY Contd..
• Period of excervation: *bone & CT attachment loss *pocket deepens *this period may lost for days/months&is followed
by period of remission/quiescence
• These periods of quiescence& excervation are also known as period of activity&period of inactivity
SITE SPECIFICITY
• Periodontal destruction does not occur in all parts of the mouth but rather on a few teeth at a time or even only some aspect of some teeth at any given time
• Severity of periodontal diseases increases by the development of new disease site, the increased breakdown of existing sites
PULP CHANGES ASSOCIATED WITH PERIODONTAL POCKETS
• Spread of infection from PP may cause pathologic changes in the pulp
• Such changes give rise to painful symptoms
• Involvement of pulp in the periodontal diseases through apical foramen/lateral canals
RELATION OF CAL&BONE LOSS TO POCKET DEPTH
• Severity of attachment loss is generally not correlated with pocket depth
• Degree of attachment loss depends on the location of the base of the pocket on the root surface
• Where as pocket depth is the distance between the base of the pocket &crest of the gingival margin
AREA BETWEEN THE BASE OF POCKET&ALVEOLAR BONE
• Distance between apical end of JE &alv bone is constant
• Distance between apical end of calculus &alv bone is constant in human PP=1.97mm±33.16%
• Distance between attached plaque to bone is never less than0.5mm&never more than2.7mm
PERIODONTAL ABSCESS
• It is a localized purulent inflammation in the periodontal tissues.
• Also known as lateral/parietal abscess• Abscess localized in gingiva(gingival abs)
• Microscopically: -localized accumulation of viable&non viable
PMNs pus(center) -acute inflammatory reaction surrounds the
purulent area &overlying epithelium -acute abscess chronic abcess
PERIODONTAL CYST
• Uncommon lesion that produces localized destruction of periodontal tissue along a lateral root surface ,most often in mandibular canine premolar area
• Microscopically :The cystic lining may be-loosely arranged,nonkeratinized,thickend,proliferating epithelium-thin nonkertinized epithlium-an odantogenic keratocyst
MCQ-1
• How much probing pocket depth of a clinically normal gingival sulcus in humans
(a)1-2mm
(b)2-3mm
(c )3-4mm
(d)4-5mm
MCQ-2
• The pocket is formed by gingival enlargement without underlying periodontal destruction is called
(a)Pseudo pocket
(b)True pocket
(c )subcrestal pocket
(d)Infrabony pocket
MCQ-3
• Which type of pocket is most common in furcation areas
(a)Simple pocket
(b)Compound pocket
(c )spiral pocket
(d)Supracrestal pocket
MCQ-4
• A patient has a chief complain of pain in upper right first molar. On examination a purulent inflammation with 8mm of pocket depth was observed on facial aspect of 16.What is the confirmatory diagnosis of that lesion?
(a)Periodontal cyst
(b)Periodontal abscess
( c)Periapical cyst
( d)Gingival abscess
MCQ-5
• One of the following lesions have a reduced inflammatory response and little or no loss of connective tissue and bone. A buildup of unattached plaque, with its gram-negative, motile and anaerobic bacteria .
(a)period of specificity (b)period of quiescence (c)period of exacerbation (d)period of inactivity
MCQ-6
• The severity of periodontal diseases is depends on
(a)probing pocket depth
(b)loss of attachment
(c)periodntal abscess
(d)gingival abscess
MCQ-7
• Which of the following factor is responsible for flaccidity in the gingival wall of the periodontal pocket
(a)circulatory stagnation
(b)destruction of gingival fibers
(c)atrophy of the epithelium
(d)edema and degeneration