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DEFINITION
Pocket can be defined as deepening of the gingival sulcus. If this happens due to coronal migration of the marginal gingiva it is called as gingival pocket or pseudo- pocket Deepening due to apical migration of the junctional epithelium is referred to as the true pocket
CLASSIFICATION
Can be classified on the basis of: . Depending upon its morphology - gingival/false/relative pocket - periodontal/absolute/true pocket . Depending upon its relationship to crestal bone: - suprabony/supracrestal/ supra alveolar pocket - infrabony/ intrabony/ subcrestal/ intra-alveolar pocket
CLASSIFICATION
.Depending upon the number of surfaces invloved - simple pocket- involving one tooth surface - compound pocket- involving two or more tooth surfaces - complex pocket- where the base of the pocket is not in direct communication with the gingival margin. It is also known as spiral pocket these types are most common in furcation areas
CLASSIFICATION
. Depending upon the nature of the soft tissue wall
of the pocket
- Edematous pocket - Fibrotic pocket . Depending upon the disease activity - Active pocket - Inactive pocket
CLINICAL SIGNS
1. Enlarged, bluish red marginal gingiva with a rolled edge separated from the tooth surface 2. A bluish red vertical zone extending from the gingival margin to the alveolar mucosa 3. A break in the facio lingual continuity of the interdental gingiva
4. Shiny, discolored and puffy gingiva associated with exposed root surfaces
CLINICAL SIGNS
5. Gingival bleeding, purulent exudate from the
gingival margin
6. Mobility, extrusion and migration of teeth 7. The development of diastema where none had existed previously
SYMPTOMS
1. Localized pain or a sensation of pressure in the gingiva after eating, which gradually diminishes 2. A foul taste in localized areas 3. A tendency to suck material from the interproximal spaces 4. Radiating pain deep in the bone 5. A gnawing feeling or feeling of itching in the gums
6. The urge to dig a pointed instrument in to the gums and relief is obtained from the resultant bleeding
SYMPTOMS
7. Patient complains that food sticks between the teeth or that the teeth feels loose or a preference to eat on the other side 8. Sensitivity to heat and cold; toothache in the absence of caries
PATHOGENESIS
.Colonization of gram positive bacteria supragingivally and its extension in to the gingival sulcus and conversion of gram +ve aerobes to gram ve anaerobes. .This causes changes in the junctional epithelium which proliferates along the root surface in the form of finger like projections. . As a result the coronal portion detaches from the root and the apical portion of the junctional epithelium migrates. . As a result of aggressive growth and action of gram ve bacteria the neutrophils emigrate in large numbers
PATHOGENESIS
. This disrupts epithelial barrier causing open communication . Tissue destruction occurs due to the products released by neutrophils as well as the bacteria . This causes resorption of the alveolar bone . Finally a periodontal pocket is establised!
POCKET CONTENTS
.
. . . . . .
Micro organisms and their products
Dental plaque Gingival fluid Food remnants Salivary mucin Desquamated epithelial cells Leukocytes
POCKET WALL
- If the inflammatory fluid and cellular exudate predominates, the pocket wall is bluish red, soft, spongy and friable with a smooth, shiny surface. at a clinical level this is referred to as edematous pocket. - If there is a relative pre-dominance of newly formed connective tissue cells and fibre, the pocket wall is more firm and pink. this refers to a fibrotic pocket.
- complete healing, however does not occur because of the persistence of the bacterial attack, which continues to stimulate an inflammatory response, causing degeneration of the new tissue formed in the continuous effort at repair
TREATMENT
-PSEUDO GINGIVAL POCKET: . Scaling and root planing . Re evaluation and maintenance
TREATMENT
TRUE/PERIODONTAL POCKET . Scaling and root planing . Re evaluation and maintenance . Removal of pocket wall . Removal of tooth side of the pocket
TREATMENT
SUPRA-BONY POCKET
-ANTERIOR TEETH: 1. Scaling and root planing 2. maintenance If pocket persists go for: - curettage
In moderate to severe pockets go for: - Flap surgery utilizing crevicular incisions
BONE LOSS
. Changes that occur in bone due to periodontitis are crucial because the destruction of bone is responsible for tooth loss. . Normally the height and density of the alveolar bone are maintained by an equilibrium, regulated by local and systemic influences between bone formation and resorption. . When resorption exceeds formation bone height, density or both are reduced.
. However the rate of bone loss may vary depending on the type of disease present.
. So when the inflammation spreads through the loose connective tissue sheath, it invades and destroys the supporting alveolar bone first and then spreads laterally to alveolar bone proper and PDL ligament.
. This results in suprabony PDL pockets and horizontal pattern of bone loss.
. This bone resorption pattern is angular or vertical and pockets are of infrabony type.