Periodontal Pocketing

• Normal anatomy ?

  Important to know normal anatomy so we can recognise deviations

  
• Cell connections?

  desmosome = cell to cell connection

  Hemidesmosome = cell to surface connection
• Junctional Epithelium definition ?

  The critical connection interface between soft and hard tissue in the gingival crevice
• JE qualities?

  • length = 0.25 - 1.35 mm
  • Thickness = 30 - 100 micometers
  • coronally = 15-30 cells thick
  • Apically = 1-3 cells thick
  • hemidesmosome attachment to enamel
  • fewer desmosomes = permeability
  • No keratinised layer at surface
  • adjacent to tooth cells are flat + parallel to tooth
• Pocket definition?

  a pathologically altered gingival crevice
• Emerging asso w perio disease?

  • COPD
  • osteoporosis
  • Cognitive decline
  • rheumatoid arthritis
• Established perio connections?

  • diabetes
  • CVD
  • adverse pregnancy outcomes
• Accuracy of probing affected by?

  • correct probing instruments
  • tight gingival cuffs
  • probing pressure
  • angulation / access
  • obstructions - calculus, ledges, pearls, cavities, bulbosities
• Radiographs can determine ?

  • presence of TRUE pocketing which is bone loss alongside clinically probed pocket
  • Degree of bone loss
  • Supra of infrabony defect
  • Presence of walled bony defect - bind mindful it is only a 2D image
• Clinical considerations?

  • codes 3 and 4 can be recorded despite no loss of attachments
  • definitive diagnosis from alveolar bone levels on rads
• Classification of a pocket?

  once periodontal it can either be suprabony or infrabony

  
• What are the pocket contents?

  • plaque
  • calc
  • GCF
  • cells
  • bacterial enzymes
  • Toxins
  • Metabolites
• What is the pocket wall made up of?

  • gingival ep
  • gingival connective tissue
  • sulcus ep
  • JE
• Pocket size?

  • narrow
  • Epithelial lining adjacent to and follows tooth contour
  • Calc deposits = pocket wall contours to calculus (probing inaccuracies)
  • firmness of gingiva influential in confining and shaping sub gingival calc deposits
• What is a gingival pocket?

  a pocket formed by gingival enlargement whithout apical migration of the junctional epithelium

  AKA

  • flase pocket
  • pseudopocket
  • Relative pocket
• How does a gingival pocket form?

  margin of gingiva moves occlusally due to inflammation without deeper perio structures becoming involved so no apical migration of the JE
• In a gingival pocket the tooth wall is ?


  enamel
• All gingival pockets are?

  suprabony
• A suprabony defect is where?

  the base of the pocket is coronal to the alveolar bone crest
• Causes of gingival pockets?

  1. gingivitis
  2. gingival enlargement - drug induced or conditions that cause thickening or tissue enlargement
• Why cant the terms hypertrophy or hyperplasia be used to describe gingival overgrowth/enlargement?

  need a microscope to Dx this

  
• Drug induced enlargement ?

  anti hypertensives: calcium channel blockers

  • nifedipine
  • amlodipine

  Immunosuppressant:

  • cyclosporin

  Antiepileptic:

  • epanutin aka phenytoin
• HGF ?

  • causes gingival enlargement
  • isolated disorder caused by gene mutation
  • begins with 2nd dentition eruption
  • can be at birth or with primary but rare
  • can be feature of syndrome with epilepsy, learning diffs and hypertrichosis
• Granulomatous disorders that cause thickening / tissue enlargement?

  • chrons
  • orofacial granulomatosis
  • Sarcoidosis
• Other causes of false pockets - blood dyscrasias?

  • acute leukaemia
  • neutropenia
  • agranulocytosis
• The plaque content in gingival pocket?

  steady balance between bio community and environment
• Mature plaque?

  • less dense microcolonies
  • species diversity
  • see image

  
• Plaque in perio disease sites?

  • more anerobic
  • more gram negative
  • inc heterogenicity of species
  • more motile species
• Steps in dev of a gingival pocket ?

  • plaque collects at and below GM
  • bacterial products (enzymes and toxins) breakdown epithelial intercellular substances that leads to ulceration of sulcular epithelium
  • Widening of intercellular space allows injurious agents into the CT and epithelium
  • Continued exposure to plaque organs continues inflam process and + pocket depth
  • chronic ging = establish lesion devs
• Inflammatory reaction in connective tissue ?

  blood vessels dilate

  =

  increased BF

  increased permeability

  inflammatory exudate

  Oedema from fluid leaking into tissues

  =

  redness

  swelling

  bleeding on probing
• Chronic inflammatory lesions ?

  1. destruction and healing (new collagen and angiogenesis) occur simultaneously
  2. Fibrosis may result = firm and harm gingiva
  3. established gingivally site can remain stable or be active and progress to periodontitis
• A periodontal "true" pocket?

  a pocket formed as a result of disease or degeneration where the JE migrates apically along the root cementum

  Deeper perio structures are involved:

  • PDL
  • cementum
  • Bone
• Perio pocket formation?

  • plaque extends subging
  • Inflam extends apically and laterally into CT
  • CT fibres are destroyed under the base of sulcus at apical border of JE
  • inflam spreads through loose CT alongside the BV to the bone
  • Most commonly inflam enters bone trough small vessel channels in alveolar crest
  • Inflam spreads through bone marrow and out into PDL
  • Ep migrates along root
  • Perio pocket formed is lined with pocket epithelium
  • JE remains partially intact at base
  • Alveolar bone loss occurs
• What is the pocket tooth wall in periodontal pockets?

  enamel, root and cementum
• Where is the base of periodontal pocket?

  cementum at the level of attached periodontal tissues
• Intrinsic pocket hard wall surface influences?

  surface quality?

  • retention of plaque/calculus
  • Cleansability

  Resistance to damage?

  • physical/mech
  • Chemical

  Permeability?

  • endotoxin
• What is considered as an acquired surface change?

  • plaque
  • stain
  • endotoxin
  • Calculus
• Structural defects of the root surface?

  • cracks
  • Grooves
  • Cavities
  • Hypoplasia
  • Abrasion and erosion
  • Restoration
• Infrabony pockets?

  base of pocket below or apical to alveolar bone crest
• Classification of infrabony defect?

  one wall defect

  Two wall defect

  Three wall defect