Understanding Periodontal Pockets: Causes, Symptoms, and Treatment

Posted on Aug 24, 2024 in Biology

Periodontal Pocket

A periodontal pocket is a pathologically deepened gingival sulcus.

Suprabony Pocket

  • Base of pocket is coronal to the crest of the bone (horizontal bone loss).
  • Interproximally, transseptal fibers are arranged horizontally.
  • Periodontal ligament (PDL) fibers are arranged in their normal pattern.

Infrabony Pocket

  • Apical to the crest of the bone (vertical/angular bone loss).
  • Interproximally, transseptal fibers are arranged obliquely (angular pattern).

Classification

  • Number of Sites: Simple, Compound, Complex/Spiral
  • Nature of Soft Tissue Wall: Edematous, Fibrotic
  • Activity: Active, Inactive

Clinical Features

Symptoms

  • Localized pain or sensation of pressure (diminishes over time)
  • Foul taste or odor
  • Tendency to suck material from interproximal areas
  • Radiating pain “deep in the bone”
  • Urge to dig with a pointed object
  • Gnawing feeling or itchy gums
  • Food getting stuck between teeth
  • Loose teeth
  • Sensitivity to heat and cold
  • Toothache in the absence of caries

Clinical Signs

  • Sulcus depth more than 3 mm
  • Enlarged bluish-red margin
  • Bluish-red vertical zone
  • Break in the bucco-lingual continuity
  • Shiny, puffy gingiva with exposed root surfaces

Histopathology

Soft Tissue Wall

  • Lateral wall: Severe degenerative changes
  • Epithelial buds and interlacing strands project into connective tissue, often apically beyond the junctional epithelium.
  • Densely infiltrated with leukocytes and edema from inflamed connective tissue.

Junctional Epithelium

  • Much shorter than normal (corono-apical length reduced to about 50-100 μm)
  • Cells show signs of degeneration

Connective Tissue

  • Appears edematous and densely infiltrated with plasma cells and polymorphonuclear neutrophils (PMNs)
  • Blood vessels are dilated and engorged

Structure of Pocket Epithelium

Unattached epithelial lining of the pocket, extending from the sulcular epithelium to the junctional epithelium. It is characterized by:

  • Marked proliferation of rete ridges around inflamed connective tissue papillae
  • Tendency to microulceration

Muller, Glauser & Schroeder ’82

  • Does not attach to the tooth surface
  • Forms irregular ridges and thin coverings over connective tissue papillae, which occasionally ulcerate
  • Consists of only a few cells that show a tendency to differentiate
  • Basal lamina complex with discontinuities and multiplications

Microtopography

  • Relative quiescence
  • Bacterial accumulation
  • Emergence of leukocytes
  • Leukocyte-bacteria interaction
  • Intense epithelial desquamation
  • Ulceration
  • Areas of hemorrhage

Root Surface Wall

  • Structural, chemical, and cytotoxic changes
  • Pathologic granules
  • Increased mineralization
  • Demineralization
  • Root caries

Pathogenesis

Host Factors

  • Immune response
  • Genetic predisposition
  • Systemic illness
  • Stress
  • Diet

Local Factors

  • Calculus deposition
  • Tooth crowding
  • Tooth morphology
  • Saliva

Plaque Factor

  • Volume
  • Type (beneficial vs. non-beneficial)

Infrabony Pocket Formation

  • Large blood vessels exiting from one side of the alveolus
  • Forceful wedging of food into the interproximal region
  • Trauma from occlusion (producing crestal damage)
  • Plaque fronts on adjacent teeth advancing at different rates apically

Depth of Probe Penetration

Depends on:

  • Size of the probe
  • Force applied (0.75 N)
  • Direction of penetration
  • Resistance of tissues
  • Convexity of the crown

Periodontal Abscess

A localized purulent inflammation in the periodontal tissues (lateral/parietal abscess).

Causes

  • Infection of the pocket
  • Lateral extension of inflammation from the pocket
  • Incomplete calculus removal
  • Pockets with a tortuous course (forming in the cul-de-sac)

Periodontal Cyst

Proliferation of epithelial cell rests of Malassez.

Types

  • Lateral dentigerous cyst
  • Primordial cyst of supernumerary tooth germ
  • Stimulation of epithelial rests by infection from a periodontal abscess

Treatment of Periodontal Pockets

New Attachment Techniques

  • Non-graft associated procedures
  • Graft associated procedures
  • Combined techniques

Other Procedures

  • Removal of the pocket wall
  • Removal of the tooth side of the wall

Basic Periodontal Examination (BPE)

  • Uses a WHO probe (3.5-5.5 mm with a black band)
  • Divides the mouth into sextants
  • Scores all teeth based on probing depth, bleeding, and calculus

BPE Scores

  • 0: No pockets > 3.5 mm, no calculus/overhangs, no bleeding after probing
  • 1: No pockets > 3.5 mm, no calculus/overhangs, but bleeding after probing
  • 2: No pockets > 3.5 mm, but supra- or subgingival calculus
  • 3: Probing depth 3.5-5.5 mm (black band partially visible)
  • 4: Probing depth > 5.5 mm (black band entirely within the pocket)

Clinical Attachment Level (CAL)

The gold standard in periodontal diagnosis, representing the clinical approximation of connective tissue attachment loss.

Factors Affecting CAL

  • Insertion force of the probe
  • Size and shape of the probe tip
  • Inflammatory status of the tissue

Inadequate Width of Attached Gingiva

Seen in cases where:

  • Pocket depth is below the mucogingival junction (MGJ)
  • Gingival recession extends beyond the MGJ
  • High frenal attachment

Periodontal Abscess Occurrence

  • Infection of the pocket
  • Extension of inflammation from the pocket
  • Cul-de-sac lesions
  • Improper calculus removal (leading to gingival shrinkage and pocket orifice occlusion)
  • Trauma

Tooth Mobility

Occurs in two stages:

  1. Intra-socket (initial tooth mobility)
  2. Secondary tooth mobility

Mobility Grading

  • Grade I: 0.5 mm movement bucco-lingually or mesio-distally
  • Grade II: 1-2 mm movement bucco-lingually or mesio-distally
  • Grade III: Apical movement (tooth depressible in the socket)

Causes of Mobility

  1. Loss of attachment
  2. Trauma from occlusion
  3. Abscess
  4. Post-surgically
  5. Pathology of the jaws
  6. Periapical disease

Fremitus Test

Patient bites while the clinician feels for vibrations on the tooth surface with a wet finger placed partially on the tooth and gingiva.

Fremitus Grading

  • Mild: Little vibration felt
  • Moderate: Mobility is felt
  • Severe: Mobility is clearly visible

Characteristics of Gingival Diseases

  • Signs and symptoms confined to the gingiva
  • Presence of dental plaque (initiates and/or exacerbates the lesion)
  • Clinical signs of inflammation
  • Reversibility of the disease by removing etiologies
  • Possible precursor to attachment loss around teeth

Radiographic Changes in Periodontitis

  1. Fuzziness and a break in the continuity of the lamina dura at the mesial or distal aspect of the interdental septum crest
  2. Wedge-shaped radiolucent area at the mesial or distal aspect of the septal bone crest
  3. Destructive process extends across the interdental septum crest, reducing septum height

Periodontal Probing

Lacks sensitivity and reproducibility. Depends on:

  • Force applied (30g for pockets, 50g for osseous defects)
  • Angulation
  • Size of the probe
  • Precision of calibration
  • Presence of inflammation

Florida Probe

Features

  • 0.4 mm tip
  • Sleeve edge for measurement reference
  • Coil spring for constant probing force
  • Computer for data storage

Disadvantages

  • Lack of tactile sensitivity
  • Fixed probing force
  • Underestimation of deep periodontal pockets

Subtraction Radiography

Advantages

  • High correlation between alveolar bone loss and CAL changes
  • Increased detection of small osseous lesions
  • Quantitative and qualitative visualization
  • More sensitive

Disadvantage

  • Requires identical projection alignment during sequential radiographs

Computer Assisted Densitometric Image Analysis (CADIA)

Advantages

  • Measures quantitative changes in bone density over time
  • Higher sensitivity, reproducibility, and accuracy compared to digital subtraction radiography (DSR)

Microbiologic Analysis

Uses

  • Support diagnosis
  • Treatment planning
  • Indicator for disease activity

Bacterial Culturing

Advantage

  • Provides relative and absolute counts of cultured species

Disadvantages

  • Strict sampling conditions
  • Difficulty culturing most organisms
  • Low sensitivity (organisms less than 103 are difficult to detect)
  • Time-consuming
  • Expensive equipment and experienced personnel required

Immunodiagnostic Methods

Direct Immunofluorescence Assay (IFA)

Antibody conjugated with a fluorescein marker binds to bacteria (antigen), forming an immunocomplex.

Indirect IFA

Primary antibody binds to bacteria, forming an immune complex. A secondary fluorescein-conjugated antibody then binds to the primary antibody.

DNA Probes

Types

  1. Whole Genomic: Targets the entire DNA strand, increasing the chance of cross-reactivity with non-target microorganisms. Lower sensitivity and specificity.
  2. Oligonucleotide Probes: Target a variable region of 16sRNA or a specific DNA sequence. Higher sensitivity and specificity.

Advantages over Bacterial Culturing

  1. More sensitive and specific
  2. Requires as few as 104 cells for detection
  3. Multiple species detection with a single test
  4. Does not require viable bacteria
  5. Large sample capacity

Disadvantages

  1. Expensive
  2. Requires expert personnel
  3. Not easily available

BANA Test

:   indicators of risk for dental caries (causing decay above the gumline

reveals the presence and general levels for bacteria indicated as risk factors for periodontal disease