Periodontal Pockets: Clinical Features, Diagnosis, and Treatment
Clinical Features of Periodontal Pockets
Symptoms:
- Localized pain or sensation of pressure which diminishes with time
- Foul taste or odor
- Tendency to suck material from interproximal areas
- Radiating pain “deep in the bone”
- Urge to dig with any pointed object
- Gnawing feeling or itchy gums
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 of Periodontal Pockets
Soft tissue wall: Lateral wall – severe degenerative changes…
Epithelial buds, interlacing strands project into connective tissue and frequently further apically than junctional epithelium.
Densely infiltrated with leukocytes and edema from inflamed connective tissue.
Epithelium at gingival crest.
Bacterial invasion – lateral and apical areas.
Junctional epithelium is much shorter than normal.
Corono-apical length is reduced.
Structure of Pocket Epithelium
Unattached epithelial lining of the pocket, which extends from the sulcular epithelium to the junctional epithelium.
Pathogenesis of Periodontal Pockets
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).
Treatment of Periodontal Pockets
New Attachment techniques:
- Non-graft associated procedures
- Graft associated procedures
- Combined techniques
Removal of pocket wall
Removal of tooth side of the wall
Basic Periodontal Examination (BPE)
Use a WHO probe (3.5-5.5mm, black band).
Divide into sextants and walk the probe along all the teeth.
Score all the teeth.
- 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, indicating pocket of 4-5 mm)
- 4 Probing depth >5.5 mm (black band entirely within the pocket, indicating pocket of 6 mm or more)
Frequency of BPE
Examination of records of 47 GDP.
Examined 10 records from each GDP.
21 of notes contained periodontal screening data.
Factors to Consider When Making a Diagnosis
- History
- Age
- Medical history
- Risk factors
- Plaque
- Bleeding
Non-Dental Periodontal Disease (NDPD)
Generalized loss of attachment:
- Resorption of alveolar bone
- Generalized recession
- ABSENCE of pockets
- Good systemic health… receiving professional dental care
Excellent oral hygiene measures.
Characteristics of Gingiva
Thick Gingiva:
Relatively soft tissue, dense fibrotic soft tissue, relatively large amount of soft tissues, thick underlying osseous form.
Thin Gingiva:
Highly scalloped soft tissues, delicate friable soft tissues, minimal amount of attached gingiva, react to insults and disease with gingival recession.
Clinical Diagnosis of Periodontal Pockets
Clinical Attachment Level (CAL): It is the gold standard in the field of periodontal diagnosis to which every other tool is compared.
Assessment of Mucogingival Problems:
- Width of attached gingiva
- Adequate amount of attached gingiva is detected… a positive or negative tension test
Causes of Tooth Mobility
- Loss of attachment
- Trauma from Occlusion (TFO)
- Abscess
- Post-surgically
- Pathology of jaws – cysts, carcinomas, Paget’s disease, fibrous dysplasia etc.
Diagnostic Tests
Fremitus Test:
In this test, the patient is asked to bite, and the vibrations are felt on the tooth surface with a wet finger placed partially on the tooth surface and partly on the gingiva.
BANA Test:
Indicators of risk for dental caries (causing decay above the gumline). The test being offered today by OraMedia is called the BANA test. ‘Saliva Test’ would actually be a misnomer.
Reveals the presence and general levels for bacteria indicated as risk factors for periodontal disease.