1. Stage IV Gingivitis: The Advanced Lesion
Extension of the lesion into alveolar bone characterizes a fourth stage known
as the advanced lesion[] or phase of periodontal breakdown
CLASSIFICATION
The periodontal pocket, defined as a pathologically deepened
gingival sulcus, is one of the most important clinical features of
periodontal disease. All different types of periodontitis, as outlined in
, share histopathologic features such as tissue changes in the
periodontal pocket, mechanisms of tissue destruction, and healing
mechanisms. They differ, however, in their etiology, natural history,
…
CLINICAL FEATURES
Clinical signs that suggest the presence of periodontal pockets include a
bluish red, thickened marginal gingiva; a bluish red, vertical zone from the
gingival margin to the alveolar mucosa; gingival bleeding and suppuration;
tooth mobility; diastema formation; and symptoms such as localized pain or
pain “deep in the bone.” The only reliable method of locating periodontal
pockets and determining their extent is careful probing of the gingival margin
along each tooth surface and ). On the basis of depth alone, however, it is
sometimes difficult to differentiate between a deep normal sulcus and a
shallow periodontal pocket. In such borderline cases, pathologic changes in
the gingiva distinguish the two conditions.
Pathogenesis
The initial lesion in the development of periodontitis is the inflammation of the
gingiva in response to a bacterial challenge. Changes involved in the
transition from the normal gingival sulcus to the pathologic periodontal pocket

2. are associated with different proportions of bacterial cells in dental plaque.
Healthy gingiva is associated with few microorganisms, mostly coccoid cells
and straight rods. Diseased gingiva is associated with increased numbers of
spirochetes and motile rods. However, the microbiota of diseased sites cannot
be used as a predictor of future attachment or bone loss because their
presence alone is not sufficient for disease to start or progress.
Histopathology
Soft Tissue Wal
The connective tissue is edematous and densely infiltrated with plasma cells
(approximately 80%), lymphocytes, and a scattering of PMNs. The blood
vessels are increased in number, dilated, and engorged, particularly in the
subepithelial connective tissue layer. The connective tissue exhibits varying
degrees of degeneration. Single or multiple necrotic foci are occasionally
present. In addition to exudative and degenerative changes, the connective
tissue shows proliferation of the endothelial cells, with newly formed
capillaries, fibroblasts, and collagen fibers.
The junctional epithelium at the base of the pocket is usually much shorter
than that of a normal sulcus. Although marked variations are found as to
length, width, and condition of the …
Pulp Changes Associated with Periodontal Pockets
The spread of infection from periodontal pockets may cause pathologic
changes in the pulp. Such changes may give rise to painful symptoms or may
adversely affect the response of the pulp to restorative procedures.
Involvement of the pulp in periodontal disease occurs through either the apical
foramen or the lateral pulp canals after pocket infection reaches then.
Atrophic and inflammatory pulpal changes occur in such cases (see Chapters
52 and 63).
Relationship of Attachment Loss and Bone Loss to Pocket Depth
The severity of the attachment loss in pocket formation is generally but not
always correlated with the depth of the pocket. This is because the degree of

3. attachment loss depends on the location of the base of the pocket on the root
surface, whereas pocket depth is the distance between the base of the pocket
and the crest of the gingival margin. Pockets of the same depth may be
associated with different degrees of attachment loss and pockets of different
depths may be associated with the same amount of attachment loss
Severity of bone loss is generally, but not always, correlated with pocket
depth. Extensive attachment and bone loss may be associated with shallow
pockets if the attachment loss is accompanied by recession of the gingival
margin, and slight bone loss can occur with deep pockets.
Periodontal Abscess
A periodontal abscess is a localized purulent inflammation in the
periodontal tissues. It is also known as a lateral abscess or parietal
abscess. Abscesses localized in the gingiva, caused by injury to the
outer surface of the gingiva, and not involving the supporting
structures are called gingival abscesses. Gingival abscesses may
occur in the presence or absence of a periodontal pocket .
Periodontal abscess formation may occur in the following ways:
1 Extension of infection from a periodontal pocket deeply into the
supporting periodontal tissues and localization of the suppurative
inflammatory process along the lateral aspect of the root.
2 Lateral extension of inflammation from the inner surface of a
periodontal pocket into the connective tissue of the pocket wall.
Formation of the abscess results when drainage into the pocket space
is impaired.
3 Formation in a pocket with a tortuous course around the root. A
periodontal abscess may form in …
Lateral Periodontal Cyst
The periodontal cyst, also called lateral periodontal cyst, is an uncommon
lesion that produces localized destruction of the periodontal tissues along a

4. lateral root surface, most often in the mandibular canine-premolar area. It is
considered to be derived from rests of Malassez or other proliferating
odontogenic rests.
A periodontal cyst is usually asymptomatic, without grossly detectable
changes, but it may present as a localized, tender swelling. Radiographically,
an interproximal periodontal cyst appears on the side of the root as a
radiolucent area bordered by a radiopaque line. Its radiographic appearance
cannot be differentiated from that of a periodontal abscess.
Microscopically, the cystic lining may be (1) a loosely arranged, thin,
nonkeratinized, epithelium, sometimes with thicker proliferating areas or (2)
an odontogenic keratocyst.
References
Chapter 13 – The Periodontal Pocket
Fermin A. Carranza,
Paulo M. Camargo
NAME: MAJED MUTEQ
ID : 432800234