Preo 💙

• Gingival sulcus


  The area of separation between the surrounding epithelium and the surface of the encompassed tooth

  
• Healthy sulcular depth


  • 3 millimeters or less
  • Readily self-cleansable with a properly used toothbrush or the supplemental use of other oral hygiene aids
• Gingival and periodontal pocket


  • Extensions of the gingival sulcus, which exists in health
  • Indicate the presence of an abnormal depth of the gingival sulcus near the point at which the gingival tissue contacts the tooth

  
• Gingival pocket


  • Formed by gingival enlargement without destruction of underlying periodontal tissue
  • The epithelial attachment does not migrate, it simply remains at the same attachment level found in pre-pathological health
  • No destruction of the connective tissue fibers (gingival fibers) or alveolar bone occurs

  
• Periodontal pocket


  • Associated with the destruction of underlying supportive tissues
  • One of the most important clinical features of periodontal disease
• Pathogenesis of periodontal pocket

  Initiated by accumulation and extension of microorganisms into gingival sulcus
• Types of periodontal pockets according to location

  • Gingival pocket
  • Periodontal pocket
• Types of periodontal pockets according to relation to alveolar crest


  • Suprabony pocket
  • Infrabony pocket
• Suprabony pocket


  • The base of the pocket is coronal to the level of underlying bone
  • The bone loss is horizontal
• Infrabony pocket


  • The base of the pocket is apical to the level of adjacent bone
  • The bone loss is vertical
• Methods of pocket detection


  • Careful exploration with periodontal probe
  • Radiographic (using calibrated silver points or gutta percha points)
• Classification of periodontal probes


  • First generation (conventional, hand held)
  • Second generation (pressure-sensitive)
  • Third generation (computerized)
  • Fourth generation (three-dimensional)
  • Fifth generation (ultra-sonographic)
• Biologic or histologic pocket depth


  Distance between gingival margin and base of the pocket, measured histologically
• Clinical or probing pocket depth


  Distance to which a probe penetrates the pocket, using a standardized force of 25 grams
• Extent of disease


  • The proportion of the dentition affected by the disease in terms of percentage of teeth
  • Localized (up to 30% of teeth affected)
  • Generalized (more than 30% of teeth affected)

  
• Probing techniques to reveal extent of disease


  1. Occlusal view (six surfaces measured)

  2. Furcation involvement (using specially designed probe)

  3. Internal crater (probe placed obliquely from both facial and lingual surfaces)
• Root surface wall of the pocket


  As the pocket deepens, collagen fibers embedded in the cementum are destroyed, and cementum becomes exposed to the oral environment
• Using a periodontal probe

  1. Insert probe parallel to vertical axis of tooth

  2. Walk probe circumferentially around tooth to detect deepest penetration

  3. Place probe obliquely from facial and lingual surfaces to explore deepest point of pocket beneath contact point

  
• Periodontal probe


  Tapered, rod-like instrument calibrated in millimeters, with a blunt rounded tip
• Purpose of periodontal probes


  • Locate, measure, and mark pockets
  • Determine course and individual configuration of pockets
• Root surface wall of pocket

  • Medial wall of pocket
  • As pocket deepens, collagen fibers embedded in cementum are destroyed and cementum becomes exposed to oral environment
• Changes to exposed root surface

  • Structural changes
  • Chemical changes
  • Cytotoxic changes
• Structural changes to exposed root surface


  • Deposition of minerals from saliva (Ca, F, P, Mg)
  • Area of hypermineralization
  • Proteolysis of Sharpey's fibers
  • Area of demineralization
  • Root caries
  • Hypersensitivity to thermal changes and sweets
  • Potential pulp exposure
• Chemical changes to exposed root surface


  Absorption of Ca, P, Mg, F from saliva, altering cementum composition and making it resistant to caries
• Cytotoxic changes to exposed root surface

  • Bacteria and endotoxins penetrate cementum and dentinal tubules
  • Fragmentation and breakdown of cementum surface
• Contents of periodontal pocket


  • Microorganisms
  • Bacterial products (enzymes and endotoxins)
  • GCF
  • Remnants of food
  • Salivary mucin
  • Desquamated epithelial cells
  • Leukocytes
  • Plaque covered calculus
  • Purulent exudates
• Zones in bottom of periodontal pocket

  • Cementum covered by calculus
  • Attached plaque
  • Unattached plaque
  • Zone of attachment of junctional epithelium
  • Zone of semi-destroyed connective tissue fibers
• Areas in gingival wall of periodontal pocket


  • Areas of relative quiescence
  • Areas of bacterial accumulation
  • Areas of leukocyte emergence
  • Areas of leukocyte-bacteria interaction
  • Areas of intense epithelial desquamation
  • Areas of ulceration
  • Areas of hemorrhage
• Clinical features of periodontal pocket

  • Bluish red discoloration
  • Flaccidity of tissue
  • Smooth shiny surface
  • Pitting on pressure
  • Pink or firm gingival wall (fibrotic changes)
  • Bleeding on probing
  • Painful probing
  • Presence of pus
  • Thickened marginal gingiva
  • Loss of stippling
  • Tooth mobility and diastema formation

  
• Severity of degenerative changes in pocket wall is not necessarily related to pocket depth
• Mechanisms of collagen loss


  1. Collagenases and other enzymes secreted by cells degrade collagen (matrix metalloproteinases)

  2. Fibroblasts phagocytize and degrade collagen fibers
• Stages of periodontal disease activity

  • Period of quiescence or inactivity
  • Period of exacerbation or activity
  • Period of remission and quiescence
• During active period, pocket appears thin and ulcerated, with infiltrate of plasma cells and PMNs