Periodontal Pocket

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DEFINITION
Periodontal pocket is pathologically deepened gingival sulcus.
It is bordered by the tooth on one side, by ulcerated epithelium on the other and has the junctional epithelium at its base. A periodontal pocket is an area that is inaccessible for plaque removal, resulting in the establishment of the following feedback mechanism for further plaque buildup: plaque -- gingival inflammation -- periodontal inflammation -- periodontal pocket formation -- more plaque buildup.

CLASSIFICATION
I. Depending on Morphology:
A. Gingival/pseudo pocket – Deepening of the gingival sulcus, mainly owing to an increase in the size of the gingiva, without any appreciable loss of the underlying tissues or apical migration of the junctional epithelium.
B. Periodontal pocket (Fig. 1)
i. Suprabony pocket
ii. Infrabony pocket
C. Combined pocket
II. Depending on the number of surfaces involved (Fig. 2):
A. Simple - involve one tooth surface.
B. Compound - This type of pocket involves two or more tooth surfaces. The base of the pockets is in direct communication with the gingival margin along each of the involved surface.
C. Complex/Spiral- This type of pocket originates on one tooth surface and twists around the tooth to involve one or more additional surfaces. The only communication with gingival margin is at surface where the pocket originates.
III. Depending on disease activity:
A. Active pocket
B. Inactive pocket
IV. Depending on the nature of soft tissue wall:
A. Edematous
B. Fibrotic
V. Depending on the lateral wall of the pocket:
A. Suprabony: consist of soft tissue alone
B. Infrabony: consist of both soft tissue and bone. Thealveolar bone becomes a part of the pocket wall.


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Fig. 1: Different types of pocket



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Fig. 2: Classification of pocket according to involved tooth surface



CLINICAL FEATURES
Symptoms
Following are the symptoms which are suggestive of the presence of periodontal pocket:
• Localized pain or a sensation of pressure after eating, which gradually diminishes
• Radiating pain deep in the bone
• A foul taste in localized areas
• A gnawing feeling or feeling of itching in the gingiva
• Urge to dig with pointed instrument into the gingiva
• A tendency to suck material from the interproximal spaces
• Sensitivity to heat and cold and toothache in the absence of caries.
Clinical signs: Following are the clinical signs which are suggestive of the presence of periodontal pocket:
• Enlarged, bluish red thickened marginal gingiva with a rolled edge separated from the tooth surface
• Bluish-red vertical zone extending from the gingival margin to the alveolar mucosa
• A break in the faciolingual continuity of the interdental gingiva
• Shiny, discolored and puffy gingiva associated with the exposed root surfaces
• Gingival bleeding and suppuration from the gingival margin
• Extrusion, mobility, diastema and migration of teeth (Fig. 3).



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Fig. 3: Extrusion and diastema associated with periodontal pocket



PATHOGENESIS
The following old theories related to pathogenesis of periodontal pocket are presented as useful background for the interpretation of current and future concepts:
1. Destruction of gingival fibers is a prerequisite for the initiation of pocket formation— Fish
2. The initial change in pocket formation occurs in cementum— Gottlieb
3. Stimulation of the epithelial attachment by inflammation rather than destruction of gingival fibers is the prerequisite for the initiation of periodontal pocket— Aisenberg
4. Pathologic destruction of the epithelial attachment due to infection or trauma is the initial histologic changes in pocket formation— Skillen
5. The periodontal pocket is initiated by invasion of bacteria at the base of the sulcus or the absorption of bacterial toxins through the epithelial lining of the sulcus— Box
6. Pocket formation is initiated as a defect in sulcus— Becks
7. Proliferation of the epithelium of the lateral wall, rather than epithelium at the base of the sulcus, is the initial change in the formation of periodontal pocket — Wilkinson
8. Two stage pocket formation—James & Counsell
a. Proliferation of the subgingival epithelium (epithelial attachment).
b. Loss of superficial layers of proliferated epithelium, which produces space or pocket.
9. Inflammation is the initial change in the formation of periodontal pocket— J. Nuckolls
10. Pathologic epithelial proliferation occurs secondary to non- inflammatory degenerative changes in periodontal membranes.
The most accepted recent concept is that the apical migration of apical cells of junctional epithelium and deattachment of coronal portion of junctional epithelium leads to intraepithelial cleft and pocket formation and deepening. Figure 4 clearly show how the periodontal pocket is formed.



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Fig. 4: Pathogenesis of periodontal pocket




Junctional epithelium at the base of the pocket is usually shorter than that of normal sulcus. The coronoapical length of junctional epithelium is reduced to only 50 to 100 μm. The epithelium at the gingival crest of a periodontal pocket is generally intact and thickened, with prominent rete pegs.
The connective tissue is edematous and densely infiltrated with approximately 80% of plasma cells, lymphocytes and PMNs. The blood vessels are increased in number, dilated and engorged. The connective tissue presents proliferation of the endothelial cells with newly formed capillaries, fibroblasts and collagen fibers. Some bacteria may invade the intracellular space and are found between deeper epithelial cells and accumulate on the basement lamina. P. gingivalis, P. intermedius and Aggregatibacter actinomycetemcomitans traverse the basement lamina and invade the subepithelial connective tissue. Microtopography of the Gingival Wall of the Pocket:
There are different areas showing different type of
activity in the soft tissue wall of the pocket due to the host- microbial interactions.
1. Areas of relative quiescence, showing a relatively flat surface with minor depressions and mounds and occasionalshedding of cells.
2. Areas of bacterial accumulation, which appear as depressions on the epithelial surface, with abundant debris and bacterial clumps penetrating into the enlarged intercellular spaces. These bacteria are mainly cocci, rods, and filaments with a few spirochetes.
3. Areas of emergence of leukocytes, where leukocytes appear in the pocket wall through holes located in the intercellular spaces.
4. Areas of leukocyte-bacteria interaction, where numerous leukocytes are present and covered with bacteria in an apparent process of phagocytosis. Bacterial plaque associated with the epithelium is seen either as an organized matrix covered by a fibrin-like material in contact with the surface of cells or as bacteria penetrating into the intercellular spaces.
5. Areas of intense epithelial desquamation, which consist of semi-attached and folded epithelial squames, sometimes partially covered with bacteria.
6. Areas of ulceration with exposed connective tissue
7. Areas of hemorrhage with numerous erythrocytes.
Pocket contents: Periodontal pockets consist of microorganism and their products (enzymes, endotoxins and
other metoblic products), GCF, salivary mucin, food debris, desquamated epithelial cells and leukocytes. Purulent exduate consist of living, degenerated and necrotic leukocytes, living and dead bacteria, serum and fibrin.
Root surface wall changes:
The root surface wall of periodontal pockets often undergo changes that are significant because they may perpetuate the periodontal infection, cause pain and complicate periodontal treatment. Root surface wall may undergo into structural, chemical and cytotoxic changes. Structural changes: It include presence of pathologic granules which represent area of collagen degradation.
There may be areas of hypermineralization or demineralization causing root caries.Chemical changes: The mineral content of exposed cementum is increased. Exposed cementum absorbs calcium, phosphorus, and fluorides from its local environment, making it possible to develop a highly calcified layer that appears to be highly resistant to decay.
This ability of cementum to absorb from its environment,on the other hand, may be detrimental if these absorbed materials are toxic to the surrounding tissues. Cytotoxic changes: Endotoxins are found in the cementum of periodontally involved teeth. Endotoxin limits the proliferation and attachment of fibroblasts to the diseased root surfaces.
CLINICAL ASSESSMENT
The only reliable method of locating and determiningperiodontal pocket extent is careful exploration of the gingival margin along each tooth surface with a periodontal probe. The probe should be inserted parallel to the vertical axis of the tooth (Fig. 5) and walked circumferentially around each surface of each tooth to
detect the areas of deepest penetration. Probe tip penetrates the most coronal intact fibers of the connective tissues attachment and goes about 0.3mm apical to the junctional epithelium in periodontal pocket. The probing forces of about 0.75N have been found to be well tolerated. Probe reading that falls between two caliberated marks on the probe should be rounded


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Fig.5: Pocket probing- probe is inserted parallel to the vertical axis of the tooth



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upwards to the next highest millimeter e.g if the probe penetrates far enough to cover the 4mm mark, it should be recorded as 5mm.
Gutta percha points or caliberated silver points can be used with radiograph to assist in determining the level of attachment of periodontal pockets.
Periodontal pocket is pathologically deepened gingival sulcus. Can be pseudo or true pockets Simple, compound or complex pockets Suprabony or infrabony pockets.



LANDMARK STUDIES RELATED
Armitage GC, Svanberg GK, Loe H. Microscopic evaluation of clinical measurements of connective tissue attachment levels. Journal of Clinical Periodontology 1977; 4:173.
Armitage et al evaluated the penetration of a probe in healthy beagle, dog’s specimens using a standardized force of 25 grams. They reported that probe penetrated the epithelium to about 2/3rd of its length in heathly specimens, it stopped 0.1mm short of its apical end in gingivitis specimens and in periodontitis specimens probe tips went past the most apical cells of the junctional epithelium. Thus, probe penetration varies depending on the force of introduction and the degree of tissue inflammation.
Glauser WM, Schroeder HE. The Pocket Epithelium: A Light and Electronmicroscopic Study. Journal of Periodontology 1982; 53: 133 – 144.
The study was conducted on biopsy material of 8 beagle dogs between the age of 1 – 4 years following the application of cotton floss ligatures for periods of 4 to 21 days or up to 5 months, block biopsies comprising dental and gingival tissues were taken on the buccal side. The tissues were processed for light and electronmicroscopic examination. The observation revealed that the pocket epithelium (1) does not attach to the tooth,
(2) forms irregular ridges and, over connective tissue papillae, thin coverings which occasionally ulcerate, (3) consists of cells only some of which show a tendency to differentiate, (4) presents a basal lamina complex with discontinuities and multiplications, and (5) is infiltrated mainly by, T and B lymphocytes and plasma cells, and is transmigrated by neutrophilic granulocytes.
POINTS TO PONDER
Periodontal pocket is a soft tissue change thus can be not detected during radiographic examination.
Biologic/histologic depth is the distance between the gingival margin and base of the pocket (coronal end of the junctional epithelium).
Clinical/probing depth is the distance between the gingival margin to the base of the probeable crevice upto which probe penetrates into the pocket.
BIBLIOGRAPHY
1. Aleo JJ, De Renzis FA, Farber PA et al. The presence and biologic activity of cementum - bound endotoxin. J Periodontol 1974;45:
672.
2. Aleo JJ, Vandersall DC. Cementum - Recent concepts related to Periodontal Disease Therapy. DCNA 1980;24:627-50.
3. Armitage GC, Svanberg GK, Loe H. Microscopic evaluation of clinical measurements of connective tissue attachment levels. J Clin Periodontol 1977; 4:173.
4. Carranza FA, Camargo PM. The periodontal pocket. In, Newman, Takei, Carranza. Clinical Periodontology 9th ed WB Saunders 2003;336-53.
5. Glauser WM, Schroeder HE. The Pocket Epithelium: A Light and Electronmicroscopic Study. J Periodontol 1982;53:133-44.


MCQs

A pseudopocket (or gingival pocket) is formed by the:
A. Coronal migration of the gingival margin
B. Coronal migration of the epithelial attachment
C. Apical migration of the gingival margin
D. Apical migration of the epithelial attachment

2. Periodontal pockets can BEST be detected by
A. Radiographic detection
B. The color of the gingival
C. The contour of the gingival margin
D. Probing the sulcular area

3. A compound periodontal pocket is:
A. Spiral type of pocket
B. Present on two or more tooth surfaces
C. Infrabony in nature
D. All of the above

4. Periodontal pocket wall between tooth and bone is:
A. Infrabony pocket
B. Suprabony pocket
C. Gingival pocket
D. Pseudo pocket

Answers
 1A             2. D            3. B                   4. A

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