Perio Slide #6

8/13/2019 Perio Slide #6

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The Periodontal Pocket

and

Patterns of Alveolar Bone LossMalik Hudieb, BDS, PhD

Department of Preventive DentistryFaculty of Dentistry

Jordan University of Science and Technology


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The Gingival Sulcus

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins


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Pathogenesis-theperiodontalpocket

Inflammatory change in gingival sulcusconnective tissue wall.

Destruction of collagen fibers apical to JE.

Proliferation of apical cells of the JE alongthe root.

Detachment of the coronal portion of JEfrom the root, due to increased PMN


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Gingival pocket

Periodontal pocket

Two Types of Periodontal Pockets


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Gingival Pockets


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Gingival Pocket

Gingival pocketadeepening of the

gingival sulcus as a result of inflammation


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Gingival Pocket

There is NO apical migration of the JE.

However, the coronal portion of the JE

detachesfrom 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.


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Healthy Gingival Sulcus

In health, the JE

attaches along its entire

lengthto the enamel of

the tooth.


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Gingival Pocket

In gingivitis, the coronal

portion of the JE

detachesfrom the tooth

resulting in a slight increase

in probing depth.


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Gingival Pocket

In gingivitis, there

usually is tissue

swellingthat also

results in an increase

in probing depth.


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Characteristics of Gingival

Pockets

There is no apical migration of JE.

The JEremains coronalto the CEJ.

Gingival pockets are also called

pseudopockets (false) No destruction

of PDL fibers or alveolar bone.


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Periodontal pocket


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Periodontal pocket

Periodontal pocketa pathologic

deepening of the gingival sulcus as a

result of Apical migrationof the junctional epithelium

Destructionof periodontal ligament fibers

Destructionof alveolar bone


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The Periodontal Pocket


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Two Types of Periodontal

Pockets

Suprabony periodontal pocket Infrabony periodontal pocket


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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).


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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

with inthe cratered-out area of

bone alongside the root

surface.


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Disease Sites


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Attachment Loss

Attachment lossis the destruction of the

fibers and alveolar bonethat support the

teeth.

The base of a pocket may exhibit a very

irregular pattern of tissue destruction.


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Irregular Tissue Destruction


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Disease Site

Adisease siteis 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.


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Active Disease Site

Active disease sitea disease site that

shows continued apical migration of the

junctional epitheliumover time


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Active Disease Site

Example:

The deepest reading on the Distal surface

of the mandibular right first molar:3 months ago5 mm.

Today6 mm


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Inactive Disease Site

Inactive disease sitea disease site that

is stable, with the attachment level of the

JE remaining at the same level for aperiod 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.


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Inactive Disease Site

Inactive disease site

Example, the deepest reading on the distal

surface of the mandibular right first molarhas remained at 5 mm for 12 months.


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Assessing Disease Sites

Disease activity should be assessed with a

periodontal probe at regular intervals and

recorded in the patient chart or

computerized record.


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Characteristics ofPeriodontal Pockets


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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.


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Changes in Alveolar Bone


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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.


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Pathogenesis-boneresorption

Inflammatory infiltrate extends from gingiva tobone along the course of blood vessels.

Less frequently, inflammation extends directlyinto PDL to the interdental septum.

Facially and lingually, inflammation spreads

along the outer periosteal surface of the boneand penetrates the marrow spaces.


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Rate of Bone Loss

Loe et al.(1986): Srilankan tea workers, no oralhygiene, no treatment:

Average rate of bone loss: 0.2mm/year

(facially), 0.3mm/year (interproximally).

Varies depending on the type of diseasepresent. 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 0.05-0.09mm/year


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Alveolar Bone in Health

In health, the crest of the alveolar bone is

located approximately 2 (1.97) mm apical to

(below) the CEJs.


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Alveolar Bone in Gingivitis

In gingivitis, the crest of the alveolar bone islocated approximately 2 mm apical to (below) the

CEJs.

JE is at its normal level


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Alveolar Bone in Periodontitis

In periodontitis, bone destruction may be

severe and progressive .


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Patterns of Bone Loss


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Horizontal bone loss

Vertical bone loss

Two Patterns of Bone Loss


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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


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Horizontal Pattern of Bone Loss

Results in a practically even overall

reduction in bone height


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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


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Vertical Pattern of Bone Loss

Results in a trenchlike area of missing bone

alongside the root


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Pathways of Inflammationinto the Bone


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Copyright 2011 W olters Kluwer Health | Lippincott Williams & Wilkins


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Vertical Bone Loss

Occurs when the crestal periodontal

ligament fibers are weakened and no

longer act as an effective barrier to

inflammation


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Pathway in Vertical Bone Loss Into the gingival

connective tissue

Directly into the PDLspace

Into the alveolar bone


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Copyright 2011 W olters Kluwer Health | Lippincott Williams & Wilkins


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Bone Defects in Periodontitis

Infrabonydefects are classified on the

basis of the number of osseous (bony)

walls.


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One-Wall Intrabony Defect


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Two-Wall Intrabony Defect


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Three-Wall Intrabony Defect


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Interproximal Osseous Crater


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Contour of Interdental Bone Normal Osseous Crater

Assessment of furcation


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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.


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Furcation Involvement

Furcation involvementoccurs on a

multirooted toothwhen the periodontal

infection invades the area between andaround the roots.

This results in a loss of alveolar bone

between the roots of the tooth.


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Keep in mind that furcation involvement may

be related to the presence of:

1. Enamel pearls.

2. Presence of accessory canals in furcaion

area.


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