The Periodontal Pocket

and Patterns of Alveolar Bone Loss

Malik Hudieb, BDS, PhD
Department of Preventive Dentistry Faculty of Dentistry Jordan University of Science and Technology

The Gingival Sulcus

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Pathogenesis-the periodontal
pocket
Inflammatory change in gingival sulcus connective tissue wall. Destruction of collagen fibers apical to JE. Proliferation of apical cells of the JE along the root. Detachment of the coronal portion of JE from the root, due to increased PMN

Two Types of Periodontal Pockets

Gingival pocket
Periodontal pocket

Gingival Pockets

Gingival Pocket
Gingival pocketa deepening of the gingival sulcus as a result of inflammation

Gingival Pocket
There is NO apical migration of the JE. However, the coronal portion of the JE detaches from the tooth resulting in a slight increase in probing depth. In many cases, swelling of the gingival tissue also contributes to an increased probing depth.

Healthy Gingival Sulcus

In health, the JE attaches along its entire length to the enamel of the tooth.

Gingival Pocket
In gingivitis, the coronal portion of the JE detaches from the tooth resulting in a slight increase in probing depth.

Gingival Pocket
In gingivitis, there usually is tissue swelling that also results in an increase in probing depth.

Characteristics of Gingival Pockets

There is no apical migration of JE. The JE remains coronal to the CEJ. Gingival pockets are also called pseudopockets (false) No destruction of PDL fibers or alveolar bone.

Periodontal pocket

Periodontal pocket
Periodontal pocketa pathologic deepening of the gingival sulcus as a result of
Apical migration of the junctional epithelium Destruction of periodontal ligament fibers Destruction of alveolar bone

The Periodontal Pocket

Two Types of Periodontal Pockets

Suprabony periodontal pocket

Infrabony periodontal pocket

Suprabony Pocket
(supracrestal, supraalveolar)
It occurs when there is horizontal bone loss. JE is located coronal to the crest of the alveolar bone (above the crest of bone).

Infrabony Pocket
It occurs when there is vertical bone loss.
JE is located apical to the crest of the alveolar bone (below the crest of bone).

Base of the pocket is located within the cratered-out area of bone alongside the root surface.

Disease Sites

Attachment Loss
Attachment loss is the destruction of the fibers and alveolar bone that support the teeth.

The base of a pocket may exhibit a very

irregular pattern of tissue destruction.

Irregular Tissue Destruction

Disease Site
A disease site is an area of tissue destruction. A disease site may involve only one surface of the tooth, such as the distal surface, or several surfaces, or all four

surfaces of the tooth.

Active Disease Site

Active disease sitea disease site that shows continued apical migration of the junctional epithelium over time

Active Disease Site

Example: The deepest reading on the Distal surface of the mandibular right first molar:

3 months ago 5 mm.

Today 6 mm

Inactive Disease Site

Inactive disease sitea disease site that is stable, with the attachment level of the JE remaining at the same level for a period of time For example, the deepest reading on the distal surface of the mandibular right first molar has remained at 5 mm for 12 months.

Inactive Disease Site

Inactive disease site Example, the deepest reading on the distal surface of the mandibular right first molar has remained at 5 mm for 12 months.

Assessing Disease Sites

Disease activity should be assessed with a periodontal probe at regular intervals and recorded in the patient chart or computerized record.

Characteristics of Periodontal Pockets

 A periodontal pocket reflects the history of the disease. The presence of a periodontal pocket does not indicate necessarily that there is active disease at the site.

Changes in Alveolar Bone

Alveolar Bone
Balance between bone formation and resorption. (osteoblast and osteoclast) Regulated by local and systemic factors. Periodontal disease results in an imbalance between formation and destruction.

Pathogenesis-bone resorption
Inflammatory infiltrate extends from gingiva to bone along the course of blood vessels. Less frequently, inflammation extends directly into PDL to the interdental septum. Facially and lingually, inflammation spreads along the outer periosteal surface of the bone and penetrates the marrow spaces.

Rate of Bone Loss

Loe et al. (1986): Srilankan tea workers, no oral hygiene, no treatment: Average rate of bone loss: 0.2mm/year (facially), 0.3mm/year (interproximally). Varies depending on the type of disease present. 3 groups:
1. rapid progression (8%):CAL 0.1-1.0mm/year. 2. moderate progression (81%):CAL 0.05-0.5mm/year. 3. minimal or no progression (11%):CAL 0.050.09mm/year

Alveolar Bone in Health

In health, the crest of the alveolar bone is located approximately 2 (1.97) mm apical to (below) the CEJs.

Alveolar Bone in Gingivitis

In gingivitis, the crest of the alveolar bone is located approximately 2 mm apical to (below) the CEJs. JE is at its normal level

Alveolar Bone in Periodontitis

In periodontitis, bone destruction may be severe and progressive .

Patterns of Bone Loss

Two Patterns of Bone Loss

Horizontal bone loss Vertical bone loss

Horizontal Pattern of Bone Loss

Is the most common pattern of bone loss Results in a fairly even, overall reduction in the height of bone

Horizontal Pattern of Bone Loss

Results in a practically even overall reduction in bone height

Vertical Pattern of Bone Loss

Is the less common pattern of bone loss Results in an uneven reduction in bone height

Results in more rapid progression of bone loss next to the root surface

Vertical Pattern of Bone Loss

Results in a trenchlike area of missing bone alongside the root

Pathways of Inflammation into the Bone

Pathway in Horizontal Bone Loss

Into the gingival connective tissue Into the alveolar bone Into the periodontal ligament

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Vertical Bone Loss

Occurs when the crestal periodontal ligament fibers are weakened and no longer act as an effective barrier to inflammation

Pathway in Vertical Bone Loss

Into the gingival connective tissue Directly into the PDL space Into the alveolar bone

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Bone Defects in Periodontitis

Infrabony defects are classified on the basis of the number of osseous (bony) walls.

One-Wall Intrabony Defect

Two-Wall Intrabony Defect

Three-Wall Intrabony Defect

Interproximal Osseous Crater

Contour of Interdental Bone

Normal Osseous Crater

Assessment of furcation involvement

Using a blunt probe inserted in a horizontal direction. Assessment of buccolingual extension of the probe into the furcation area. Nabers probe: specially designed for assessment of furcation involvement.

Furcation Involvement
Furcation involvement occurs on a multirooted tooth when the periodontal infection invades the area between and around the roots. This results in a loss of alveolar bone between the roots of the tooth.

Keep in mind that furcation involvement may be related to the presence of: 1. Enamel pearls. 2. Presence of accessory canals in furcaion area.