periodontal pocket & periodontal abscess

1. Dr. Enas Elgendy
Ass. Professor of Oral Medicine,
Periodontology& Oral Diagnosis
Faculty of Dentistry
Kafrelsheikh University

2. Periodontal pocket
• Periodontal pocket is pathologically deepened gingival sulcus due to
apical migration of junction epithelium on the root surface with
subsequent separation and hyperplasia of the gingiva resulting from
inflammation
• It is consider one of the important clinical features of periodontal
disease.

3. Measurement Periodontal Pocket
The probing pocket depth is the distance from
the gingival margin to the bottom of the pocket
(end of the probe).

4. Clinical attachment level/loss
It is the distance from the CEJ to the end of the
probe (bottom of the pocket). It is more constant
measurement.

5. The measurement of the pocket
depth is mainly influenced by the
following factors:-
a) The thickness of the probe.
b) Malposition of the probe due to anatomic features
such as the contour of the tooth surface.
c) The pressure applied on the instrument during probing
(Constant force probe).

6. Deeping of the pocket
• The apical migration of the epithelial attachment during pocket
formation is hindered mainly by the principal gingival fibers, which lies
apical to the junctional epithelium.
• The inflammatory process with in the gingival connective tissue might
result in destruction of C.T fibers, and stimulate the epithelium to
proliferate apically, destroying the subjacent collagen fibers.

7. Deeping of the pocket
• The proliferating epithelium have some lysing effect on the
collagen fibers or cause degeneration of gingival fibers by pressure
atrophy.
• It suggested the migration of epithelial rete pegs apically, which
extend between the principal fibers causing its detachment
N.B.: In all the above explanations, the inflammatory process
initiates the reactions.

8. Stage I: The initial lesion :2- 4 days Stage II: The early lesion.: 4- 7 days
Stage III: The established lesion.: 14-21 days Stage IV: The advanced lesion: 21 days

9. 9
Stages of Periodontal Disease

10. Classification of Pockets
Gingival pocket
(pseudo pocket)
The sulcus is deepened because
gingival enlargement without
destruction of the underlying
periodontal tissue (without
apical migration of J.E).
Periodontal pocket
(true pocket)
It is due to apical proliferation
of junctional epithelium and
destruction of the underlying
supporting structures.

11. Classification of Periodontal Pockets
Periodontal pockets are classified according to the relation
of the base of the pocket to the alveolar crest into:
Suprabony (supracrestal
or supraalveolar)
The bottom of the
pocket is coronal to
the underlying alveolar
bone.
Intrabony (infra bony
pocket, subcrestal, or
intraalveolar)
The bottom of the
pocket is apical to the
underlying alveolar
bone.

12. Different types of periodontal pockets. A, Gingival pocket, There is no destruction of
the supporting periodontal tissue. B, Suprabony pocket, the base of the pocket is
coronal to the level of underlying bone. Bone loss is horizontal. C, Intrabony pocket,
the base of the pocket is apical to the level of adjacent bone. Bone loss is vertical.

13. Distinguishing features of the Suprabony pocket and
the Infrabony pocket
Suprabony pocket Infrabony pocket
1- The base of
the pocket
Coronal to the crest of the
alveolar bone
Apical to the crest of the
alveolar bone
2- Pattern of
bone
destruction
Horizontal Vertical
3-PL fibers Transeptal fibers are
arranged horizontally in
the space between the
base of the pocket and the
alveolar bone.
Transeptal fibers are arranged
obliquely from cementum
beneath the base of the
pocket over the crest to the
cementum of the adjacent
tooth

15. Classification of Periodontal Pockets
Periodontal pockets are classified according to
the number of tooth surfaces involved into:
Simple pocket: involves one tooth surface
Compound pocket: involves more than one
tooth surface but the base and orifice of the
pocket are located on the same tooth surface.
Complex pocket: spiral pocket that involves
more than one tooth surface where the base
and the orifice are not located on the same
surface.

16. Classification of pockets according to involved tooth surface. A,
Simple pocket. B, Compound pocket. C, complex pocket (spiral
pocket).
A CB

17. Classification of Periodontal Pockets
Intrabony pocket can be classified according to
The number of the
remaining osseous walls
1- One osseous wall infraboney
pocket
2- Tow osseous wall infraboney
pocket
3- Three osseous wall infraboney
pocket
4- Combined osseous defect: in
which the number of the osseous
walls in the apically differ from that
in occlusally. combination of one,
two or three wall defect
The depth and width of
the defect:
1. Narrow deep,
2. Wide deep,
3. Narrow shallow
4. Deep shallow pocket.

18. A, Three wall defect
B, Two wall defect
C, One wall defect

19. Combined defect – combination of one, two or three wall defect

20. Periodontal pocket
According to the relation of the base
of the pocket to the alveolar crest into
Suprabony Intrabony
According to the number of tooth
surfaces involved into
Simple Compound Complex
The number of the remaining osseous walls The depth and width of the defect
1. Narrow deep,
2. Wide deep,
3. Narrow shallow
4. Deep shallow pocket
1- One osseous wall
2- Tow osseous wall
3- Three osseous wall
4- Combined osseous defect

23. The furcation is the area located
between individual roots. The progress
of inflammatory periodontal diseases
may ultimately results in attachment
loss sufficient enough to affect the
bifurcation or tri-furcation of multi-
rooted teeth.

24. Classification of furcation
Involvement:
1- Glickman (1958): Horizontal Classification
2- Hamp et al. (1975): Horizontal Classification
3- Tarnow and Fletcher (1984): Vertical Classification

25. Glickman (1958): Horizontal classification:
Grade I: It incipient involvement into furcation with
suprabony pockets and no interradicular bone loss.
Grade II: involvement of the interradicular bone
without through-and-through probability.
Grade III: Through-and through loss of interradicular
bone.
Grade IV: Through-and through loss of interradicular
bone, with total exposure of furcation owing to
gingival recession.

26. 2- Hamp et al. (1975): Horizontal Classification :
Grade I (initial): Loss of interradicular bone less
than or equal to one-third.
Grade II (partial): Loss of interradicular bone
greater than one-third but not through and
through.
Grade III (total): through-and through loss of
interradicular bone.

27. 3- Tarnow and Fletcher (1984): Vertical Classification:
Grade A: Vertical loss of 1 to 3mm
Grade B: Vertical loss of 4 to 6mm
Grade C: Vertical loss of 7+ mm.

28. Grade I
Grade IIIGrade II

29. Periodontal Abscess

30. Abscess of the Periodontium
The periodontal abscess is a localized purulent
inflammation of the periodontal tissues.

31. Periodontal abscess
It has been classified into three diagnostic groups:
Gingival abscess Periodontal abscess Pericoronal abscess

32. Etiology of periodontal abscess
1. Periodontal abscesses often arise as acute exacerbation of a
preexisting pocket.
2. Improper scaling that may force bacteria or dislodge
calculus fragment into the tissue.
3. Occlusion of the orifice of deep periodontal pocket:
Inadequate scaling which will allow calculus to remain in the
deepest pocket area, while the resolution of the
inflammation at pocket area will occlude the normal
drainage and then cause the abscess formation.
4. After receiving systemic antibiotic therapy.
5. Poorly controlled diabetes mellitus has been considered a
predisposing factor for periodontal abscess formation.
6. Perforation of the tooth wall by an endodontic instrument.
7. Tooth fracture and foreign body impaction.

33. Etiology of periodontal abscess
The existence of tortuous pockets (with cul-de-
sac) which eventually become isolated, may
favor the formation of abscess.

34. periodontal abscess resulting from partial healing of a
periodontal pocket over residual calculus.

35. Clinical features
I-Acute periodontal abscess versus Chronic Abscess:
Abscesses are classified as acute or chronic.
• The acute abscess is often an exacerbation of a chronic
inflammatory periodontal lesion. Influencing factors include
increased number and virulence of bacteria present,
combined with lowered tissue resistance and lack of
spontaneous drainage. The drainage may have been
prevent by deep, tortuous pocket morphology, debris, or
closely adapted pocket epithelium blocking the pocket
orifice.
• The chronic abscess forms after the spreading infection has
been controlled by spontaneous drainage, host response,
or therapy. Once homeostasis between the host and
infection has been reached, the patient may have few or no
symptoms.

36. Acute abscess Chronic abscess
Painful, red, edematous, smooth,
ovoid swelling of the gingival tissues.
No pain or dull pain
Exudate may be expressed with
gentle pressure.
Localized inflammation and a fistulous
tract often associated with deep
pocket.
The tooth may be percussion
sensitive and feel elevated in the
socket .
Slight tooth elevation
Fever and regional
lymphadenopathy are occasional
findings.
Usually without systemic involvement
Compares the signs and symptoms of the acute and chronic abscess.

37. II- Periodontal versus Pulpal Abscess
Periodontal abscess Pulpal abscess
Associated with pre-existing periodontal
pocket.
Offending tooth may have large restoration
or deep caries. May have no periodontal
pocket.
Tests show vital pulp Tests show non-vital pulp
Swelling usually includes gingival tissue,
with occasional fistula.
Swelling often localized to apex, with a
fistulous tract.
Pain usually dull and localized. Pain often severe and difficult to localize.
Sensitivity to horizontal percussion Sensitivity to vertical percussion.
Radiographs show periodontal angular
bone loss and furcation radiolucency.
Radiographic changes along the lateral
wall of the root
Radiographic changes at the apical region.

39. Diagnosis of periodontal abscess
Diagnosis of a periodontal abscess requires correlation of the history and
clinical and radiograghic findings. It is based on:
• Symptoms revealed by the patient,
• The signs found during the oral examination.
• A periodontal abscess is usually associated with pre-existing periodontitis.
• Drainage of the pus may occur during periodontal probing or without
provocation.
• Careful medical and dental history and radiographic examination.

40. Radiographic examination
• It may reveal some degree of bone loss ranging
from widening of periodontal space to a dramatic
radiographic bone loss.
• Radiograph alone can not be relied on for the
diagnosis of periodontal abscess since (give
reasons):
1- In early stages of the lesion no radiographic
changes can be detected.
2- Abscess on the facial and lingual surface are
obscured by the radio-opacity of the roots

41. Treatment approaches
The periodontal abscess is the third most
prevalent emergency infection after periapical
abscess and pericoronitis. Treatment of the
periodontal abscess includes two phases:
• Resolving the acute lesion
• Followed by the management of the resulting
chronic condition.

42. Treatment approaches
I-Acute Abscess
• The acute abscess is treated to alleviate
symptoms, control the spread of infection, and
establish drainage. Before treatment, the
patient’s medical history, dental history, and
systemic condition are reviewed and evaluated
(such as rise temperature fever,
lymphadenopathy) to assist in the diagnosis and
to determine the need for systemic antibiotics.

43. Treatment approaches
Drainage through Periodontal
Pocket:
The peripheral area around the
abscess is anesthetized with
sufficient topical and local
anesthetic to ensure comfort.
The pocket wall is gently
retracted with a periodontal
probe or curette in an attempt to
initiate drainage through the
pocket entrance. Gentle digital
pressure and irrigation may be
used to express exudates and
clear the pocket.

46. Treatment approaches
Drainage through External Incision:
• The abscess is dried and isolated with gauze
sponges. Topical anesthetic is applied,
followed by local anesthetic injected
peripheral to the lesion. A vertical incision
through the most fluctuant center of the
abscess is made with a #15 surgical blade.
• Pus is expressed and the wound edges
approximated under light digital pressure with
a moist gauze pad.

47. Drainage through External Incision:

48. Indications for antibiotic therapy in the
patients with acute abscess
1. In abscesses presenting with severe swelling and
inflammation, cellulitius (non-localized,
spreading infection) aggressive mechanical
instrumentation should be delayed in favor of
antibiotic therapy so as to avoid damage to
healthy contiguous periodontal tissues.
2. The lesions are large, deep, inaccessible and
drainage cannot be established.
3. Fever
4. Regional lymphadenopathy
5. Immunocompromised patient

49. Antibiotic options for periodontal
infection
• Amoxicillin, 500 mg 3 times a day
for 3 days (1 g loading dose)
• Penicillin allergy:
1- Clindamycin 300 mg 4 times a day
for 3 days (600 mg loading dose)
2- Azithromycin 500 mg four times a
day for 3 days (1.0-g loading dose)

50. Instruction after drainage
• Area then painted with antiseptic. Patients
without systemic complications are instructed to
rinse with a solution of 1 tsp. salt in a glass of
warm water and periodic application of
chlorhexidine gluconate either by rinsing or
locally with a cotton-tipped applicator.
• Analgesics may be prescribed for comfort.
• Patient is followed up until swelling and
symptoms have disappeared and then the lesion
is ready for the usual treatment of chronic
periodontitis.

51. Treatment approaches
Chronic Abscess
• As with a periodontal pocket, the chronic abscess is usually
treated with scaling and root planing or surgical therapy.
Surgical treatment is suggested when deep vertical or
furcation defects are encountered that are beyond the
therapeutic capabilities of nonsurgical instrumentation. As
with the acute abscess antibiotic therapy may be indicated.

52. Fistula is observed in attached gingiva of maxillary right canine.
Elevated flap shows the cause to be a root fracture.

54. Gingival Abscess
Treatment of the gingival abscess is aimed at reversal of the
acute phase and, when applicable, immediate removal of the
cause. To ensure procedural comfort, topical or local
anesthesia by infiltration is administered. The fluctuant area is
incised with a #15 scalpel blade, and exudate may be
expressed by gentle digital pressure. Any foreign material
(e.g., dental floss, impression material) is removed. The area is
irrigated with warm water and covered with moist gauze
under light pressure. Once bleeding has stopped, the patient
is dismissed with instructions to rinse with warm salt water
every 2 hours for the remainder of the day. After 24 hours the
area is reassessed, and if resolution is sufficient, scaling not
previously completed is undertaken. If the residual lesion is
large or poorly accessible, surgical access may be required.

55. Pericoronal Abscess
As with the other abscesses of the periodontium, the
treatment of the pericoronal abscess is aimed at management
of the acute phase, followed by resolution of the chronic
condition. The acute pericoronal abscess is properly
anesthetized for comfort, and drainage is established by
gently lifting the soft tissue operculum with a periodontal
probe or curette. If the underlying debris is easily accessible, it
may be removed, followed by gentle irrigation with sterile
saline. If there is regional swelling, lymphadenopathy, or
systemic signs, systemic antibiotics may be prescribed. The
patient is dismissed with instructions to rinse with warm salt
water every 2 hours, and the area is reassessed after 24 hours.
If discomfort was one of the original complaints, appropriate
analgesics should be employed.

56. Once the acute phase has been controlled, the partially erupted
tooth may be definitively treated with either surgical excision of
the overlying tissue or removal of the offending tooth.