The periodontal pocket
-Introduction : Periodontitis begins with gingivitis and if the inflammatory process is allowed to continue, it will progressively invade deeper periodontal tissues in most patients.
The inflammatory process itself carries the potential to stimulate periodontal tissue resorption and periodontal pocket formation.
1-Definition : The periodontal pocket is a pathological deepening of the gingival groove. It is one of the main clinical signs of periodontal diseases. The progressive formation of pockets leads to the destruction of the periodontal support tissues, as well as the mobility and expulsion of teeth.
2-Classification : Periodontal pockets are classified according to their morphology and their relationship with adjacent structures as follows:
- Classification according to morphology :
-Gingival pocket (relative) false pocket : the groove is deepened because the volume of the gum is increased. The pocket results from gingival hypertrophy without destruction of the sub-adjacent periodontal tissues.
-Periodontal pocket (absolute) true pocket: The groove is deepened, there is destruction of the periodontal supporting tissues. There are two types of absolute pocket:
– Supra bony pocket
-Infrabony pocket
- Classification according to the number of affected surfaces:
-Simple : only one surface of the tooth is affected. (A)
-Compound : two or more surfaces of the tooth are affected. The base of the pocket communicates directly with the gingival margin along each of the affected surfaces. (B)
-Complex : It is a spiral pocket that begins on one surface and wraps around the tooth to reach one or more other surfaces. The only communication with the gingival margin is at the surface where the pocket began its formation. (C)
The periodontal pocket
- Classification according to their relationship to adjacent structures
– Supra bony pocket : in which the bottom of the pocket is coronal to the subadjacent alveolar bone. Bone destruction is horizontal.
-Infrabony pocket: (intrabony, subcrestal, or intraalveolar ): in which the bottom of the pocket is apical due to the level of the adjacent alveolar bone. In this case the lateral wall of the pocket is located between the dental surface and the alveolar bone. Bone destruction is vertical or angular.
Pockets of varying depth and type may appear on different surfaces of the same tooth and on adjacent surfaces of the same interdental space.
- Classification according to the number of walls limiting destruction
– four-walled infrabony pocket: limited by several surfaces of the same tooth and several bony surfaces
-three-walled infrabony pocket : limited by a dental wall and three bony walls
-two-walled infrabony pocket : limited by two dental walls and two bony walls
-single-walled infrabony pocket : limited by a dental wall, a bony face and soft tissues.
The periodontal pocket
The periodontal pocket
The periodontal pocket
3- Highlighting the periodontal pocket: The only sure method to locate the periodontal pockets and determine their extent is to carefully explore the gingivodental sulcus along the surface of each tooth with a probe . The instrument used is the periodontal probe
4-Clinical signs and symptoms: The clinical signs that indicate the presence of periodontal pockets are:
– Hypertrophied reddish-blue gingival margin, separated from the tooth surface by a rolled ridge.
-Breakage of the vestibulolingual continuity of the interdental gingiva.
– Shiny, discolored and swollen gums, associated with exposed roots.
-gingival bleeding
– Purulent exudate on the gingival margin, or appearance of this exudate after digital pressure.
-Mobility, extrusion and migration of teeth.
-Presence of a diastema where there had never been one before.
Periodontal pockets are usually painless , but they can cause the following symptoms:
– localized pain or feeling of pressure after meals which gradually diminishes
-a tendency to suck debris from interproximal spaces.
-pain radiating inside the bone
– Sensitivity to hot and cold, while there are no dental caries.
5-Formation of the periodontal pocket:
Pocket formation begins with an inflammatory transformation of the connective tissue wall of the gingival sulcus caused by local irritation.
The inflammatory cellular and fluid exudate leads to degeneration of the surrounding connective tissue, including the gingival fibers.
Accompanying the inflammation, epithelial attachment proliferates along the root.
The coronal portion of the epithelial attachment detaches from the root when the apical portion migrates.
Page and Schroeder established a classification of the stages of pathogenesis
Initial lesion : characterized by hypervascularization near the junctional epithelium, increased gingival fluid flow, shift of leukocytes to the junctional epithelium and gingival sulcus, extracellular serum proteins, alterations of the coronal portions of the junctional epithelium, and loss of collagen fibers around gingival blood vessels.
Early lesion : marked by exaggeration of the signs of the initial lesion, the presence of lymphocytes below the junctional epithelium where acute inflammation is concentrated, alterations of fibroblasts, greater destruction of gingival collagen fibers and an initial proliferation of basal cells of the junctional epithelium.
Established lesion : In an established lesion, signs of acute inflammation persist: plasma cells predominate, there is accumulation of extravascular immunoglobulins, destruction of collagen fibers continues, there is proliferation, apical migration, and lateral extension of the junctional epithelium, formation of an early periodontal pocket is possible, but there is no appreciable bone destruction.
Advanced lesion : it is typical of periodontitis. The spread of the lesion leads to destruction of the bone and the periodontal ligament
6-Description:
- the soft tissue wall : gingival wall: it is composed of edematous connective tissue , infiltrated with plasma cells, lymphocytes, and leukocytes.
- the hard wall : represented by the dental surfaces.
- pocket contents : pockets contain microorganisms and their products (enzymes, endotoxin, and other metabolic products), dental plaque, gingival fluid, food debris, salivary mucin, desquamated epithelial cells, and leukocytes as well as pus. (purulent pocket)
- the bottom of the pocket : made up of healthy epithelial cells from the residual epithelial attachment which temporarily form the pocket.
7-Pocket danger: the pocket danger is linked to:
-toxicity : the periodontal pocket is a source of infection.
– durability : the presence of the pocket promotes the accumulation of deposits responsible for the inflammation which maintains and deepens the pocket.
-evolution : in the absence of treatment, the deepening of the pocket occurs through progressive destruction of the desmodontal fibers.
-ignorance : because it is not very apparent and generally painless.
8-Treatment of the periodontal pocket: The treatment of the pocket consists of reducing its depth. The methods used are divided into two groups:
– the first is based on non-surgical therapies using initial preparation, and irrigation with antiseptics and antibiotics.
– the 2nd group uses surgical therapies such as gingivectomy and flap surgery.
The periodontal pocket
-Conclusion :
The prevention of gingivitis and periodontitis by avoiding their onset and treating them in their early stages constitutes the major objective of periodontics.
Bibliography:
-EAPAWLAK and Ph.M.HOAG manual of periodontology MASSON Paris Barcelona Milan Mexico 1988
-Irving GLICKMAN Clinical periodontology prevention, diagnosis and treatment of periodontal diseases in the context of general dentistry.
The periodontal pocket
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