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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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