Periodontal pocketing

• What are different tooth walls in a 6mm pocket?

  - can be enamel & cementum/dentine

  - can be cementum/dentine only

  
• What is periodontal pocketing a result of?

  Immuno-inflammatory response
• What are some established medical associations with periodontal disease?

  • Cardiovascular disease
  • Diabetes
  • Adverse pregnancy outcomes
• What are some emerging associations with periodontal disease?

  • Rheumatoid arthritis
  • Chronic kidney disease
  • COPD
  • Metabolic syndrome
  • Some cancers
  • Cognitive decline
  • Osteoporosis
• Does a BPE of 3 or 4 mean a pocket is present?

  Yes
• What do radiographs show us in terms of periodontal pocketing?

  • Presence of true pocketing (bone loss alongside clinically probed pocket)
  • Degree of bone loss (may be historic)
  • Infrabony defect
  • Presence of walled bony defect (be mindful 2D view of 3D object)

  
• An example of bitewings showing BPE code 3 in posterior teeth

  
• What does the normal anatomy of the gingival crevice of a fully erupted tooth look like?

  
• How are cells connected in the gingival crevice?

  Desmosome - cell structure specialised for cell-to-cell adhesion

  Hemidesmosome - attachment of the JE to tooth surfaces is mediated by hemidesmosomes, internal basal lamina and cuticle.

  This structural complex provides a front-line defense against infections of the dento-gingival junction.

  
• What are the characteristics of the junctional epithelium?

  • Length 0.25-1.35mm

  • Thickness 30 -100micrometres

  • Coronally 15-30 cells thick

  • Apically 1-3 cells thick

  • Adjacent to tooth cells flatten and parallel to tooth

  • Hemi-desmosome attachment to enamel

  • Fewer desmosomes - permeability

  • No keratinised layer at surface

  
• What is the definition of a pocket?

  A pocket is a pathologically altered gingival crevice

  
• How are pockets classified?

  • either gingival or periodontal
  • if periodontal can be suprabony or infrabony

  
• What are the contents of a pocket?

  • Gingival crevicular fluid/cells
  • Bacterial enzymes
  • Toxins and metabolites
• How is the firmness of the gingiva influential to calculus?

  in confining and shaping any subgingival calculus deposits
• What is a gingival pocket?

  A pocket formed by gingival enlargement without apical migration of the junctional epithelium. Sometimes called: False pocket Relative pocket Pseudopocket
• When there is no migration of the junctional epithelium, what is the pocket called?

  • Gingival pocket
  • margin of the gingiva has moved incisally or occlusally without the deeper periodontal structures becoming involved

  
• The tooth wall is _______

  Enamel!

  
• What is meant by 'all gingival pockets are suprabony'?

  The base of the pocket is coronal to the crest of the alveolar bone

  
• What are the causes of gingival pockets?

  • Gingivitis
  • Gingival enlargements/overgrowth
  • Drug induced enlargement
• What are types of drug induced enlargement?

  
• What are some causes of gingival enlargement?

  • Developmental Hereditary Gingival Fibromatosis (HGF)
  • isolated disorder
  • gene mutation
  • multi-system syndrome eg Hypertrichosis, epilepsy, Learning difficulties
  • begins with eruption of perm dentition, Occasionally with primary, Rarely at birth

  
• What are some other causes of false pockets or conditions that cause thickening/enlargement of tissue

  Granulomatous disorders

  
• What is blood dyscrasias?

  • Hematologic disorders that affect the different components of the blood~
  • cause false pockting
  • Acute leukaemia
  • Neutropenia
  • Agranulocytosis

  
• Can you get BPE codes of 3/4 despite their being no loss of attachment?

  Yes A definitive diagnosis from alveolar bone levels can be seen on radiographs
• What does mature plaque consist of?

  • close to tooth: tight palisade bacterial layer, filamentous organisms, rods and cocci, extracellular polymers, superficial later
  • outerlayer less dense micro colonies, species diversity

  
• How does plaque change in periodontally disease sites?

  
• What is the inflammatory reaction in the connective tissue?

  Blood vessels dilate, increasing blood flow, increased permeability, inflammatory exudate, Oedema from the leakage of fluid into the tissue.

  
• What happens where there is continuous exposure to plaque organisms?

  The inflammatory reaction continues and increases the pocket depth Chronic gingivitis 'established lesion' develops

  
• What is a Periodontal pocket?

  A pocket formed as a result of disease or degeneration that caused the junctional epithelium to migrate apically along the cementum. Also called  true pocket  absolute pocket
• What deeper periodontal structures are involved in a periodontal pocket?

  Cementum Periodontal ligament Bone

  
• In a periodontal pocket the tooth wall is made up from a combination of.......?

  Enamel Cementum Root

  
• What is the anatomy of the cemento-enamel junction?

  • 60% overlap of enamel and cementum
  • 30% meet
  • 10% gap

  
• What is at the base of the periodontal pocket?

  Cementum at the level of attacked periodontal tissue

  
• What is the surface of the tooth/hard wall like in a pocket?

  • Surface quality – Retention of plaque/calculus – Cleansability

  • Resistance to damage - Physical/mechanical – Chemical

  • Permeability – Endotoxin
• What is involved in acquired surface change?

  - Plaque - Endotoxin - Calculus

  
• What can be some structural defects in the tooth wall?

  - Cracks/grooves - Caries - Calculus - Hypoplasia - Abrasion and erosion - Staining - Restorations

  
• How is a periodontal pocket initially formed?

  • Plaque extends subgingivally
  • Inflammation extends apically/laterally into the connective tissues
  • Connective tissue fibres are destroyed under base of sulcus at apical border of junctional epithelium
  • Inflammation spreads through loose connective tissue alongside the blood vessels to bone
  • Inflammation enters bone through small vessel channels in the alveolar crest
  • Inflammation spreads through the bone marrow and out into the periodontal ligament

  
• What is the later stage of periodontal pocket formation?

  • Epithelium migrates along the root surface
  • A periodontal pocket is formed lined with pocket epithelium
  • The junctional epithelium remains partially intact at the base of the pocket
  • Alveolar bone loss occurs

  
• What is the difference between suprabony and infrabony periodontal pockets?

  • suprabony has base above/coronal to alveolar bone crest
  • infrabony has base below/apical to alveolar bone crest

  
• What do infrabony defects look like?