Veterinary Dentistry
2nd Opinion
Animal Dentistry
Solutions
No. 5 October
2016---01Nov2016
A BLOG by DH DeForge,
VMD
Fellow of the Academy
of Veterinary Dentistry
1-800-838-3368
Finding the Cure: CAT
STOMATITIS
Dr. DeForge Discusses
Breakthrough Surgery for Treatment of Cat Stomatitis
Feline Stomatitis Radiowave
Radiosurgery with Guided Bone Regeneration
Feline Stomatitis has been investigated by animal dentists for over twenty-five years. The etiology of this very painful pathology has yet to be determined. It has been, universally, recognized as one of the most painful oral conditions in the feline. The classic treatment for it in general practice has revolved around the usage of corticosteroids and antibiotics to suppress the immune response and treat soft tissue infection-inflammation.
Feline Stomatitis has been investigated by animal dentists for over twenty-five years. The etiology of this very painful pathology has yet to be determined. It has been, universally, recognized as one of the most painful oral conditions in the feline. The classic treatment for it in general practice has revolved around the usage of corticosteroids and antibiotics to suppress the immune response and treat soft tissue infection-inflammation.
The treatment by surgeons and animal
dentists, for the last 20 years, after the completion of oral radiology and
histopathology diagnostics, has been whole mouth extraction or extraction of
all teeth distal to the canine teeth. Only half of the felines with this type of
extraction surgery reach full recovery. Depending on the author, 4-5 patients
out of each 10 felines treated with whole mouth extraction revert to some
degree of the oral inflammatory state within 6-18 months post-surgery. As a
treatment alternative, Feline Stomatitis Radiowave Radiosurgery-Guided Bone
Regeneration has been developed by Dr. DeForge. It completely and permanently
reverses the oral inflammation and pain evidenced in feline stomatitis
patients.
Feline Stomatitis [FS], the most painful
oral disease in the feline, has many faces and names. It is the most
misunderstood, frustrating, and refractive of all feline oral conditions seen
by the general practitioner as well as the oral specialist. As noted, it has
been studied in detail by many researchers over the last twenty five years and
its etiology is still unknown.
FS has many pseudonyms depending on the
author who is referencing the pathology. It has been coined Lymphocytic
Plasmacytic Stomatitis, Gingivostomatitis, Immune Mediated Feline Refractory
Stomatitis, and Feline Generalized Oral Inflammatory Disease. The
histopathology of oral biopsies in these cats evidences a predominance of
plasma cells, lymphocytes, and neutrophils. A polyclonal gammopathy is commonly
noted.
Pathology Noted:
The name of the disease is not as significant as the pain that is caused by this disease. Feline Stomatitis [FS] produces a chronic non-responsive generalized oral pain affecting the gingiva, mucosa, palate, lingual and lingual-sublingual area; the glosso-pharyngeal arches; the commissures; and entire pharynx. Depending on the feline, all mentioned or site-specific pathology centers can be identified.
The name of the disease is not as significant as the pain that is caused by this disease. Feline Stomatitis [FS] produces a chronic non-responsive generalized oral pain affecting the gingiva, mucosa, palate, lingual and lingual-sublingual area; the glosso-pharyngeal arches; the commissures; and entire pharynx. Depending on the feline, all mentioned or site-specific pathology centers can be identified.
Historically
Non-Productive Treatments:
The inflammation is progressive. There is no successful medical treatment for this disease. The inflammation can be hidden with glucocorticoids, immunosuppressants, herbs, gold salts, antibiotics, analgesics, vitamins, probiotics, local topical anesthetics, salicylate therapy, and multiple anti-inflammatory protocols. None are effective in the long term. Most often the pain relief is short lived while on these medicines and discomfort quickly returns.
The inflammation is progressive. There is no successful medical treatment for this disease. The inflammation can be hidden with glucocorticoids, immunosuppressants, herbs, gold salts, antibiotics, analgesics, vitamins, probiotics, local topical anesthetics, salicylate therapy, and multiple anti-inflammatory protocols. None are effective in the long term. Most often the pain relief is short lived while on these medicines and discomfort quickly returns.
Laser therapy is controversial in feline
stomatitis and is not recommended by this author. Airway blockage caused by
laser usage in the distal pharynx can lead to respiratory embarrassment or
patient loss. In the J Vet Dent 24(4);240-249, 2007-J. Lewis, A Tsugawa, &
A Reiter-[Use of C02 Laser as an Adjunctive Treatment for Caudal Stomatitis in
a Cat] inclusion of a case report in which the laser was utilized and states:
"It is difficult to determine what role the laser treatment played in
resolution of the inflammation, especially after extraction of the remaining
canine teeth performed at the fourth and last ablative laser treatment."
Sub-Groups of FS:
Three sub-groups of FS have been identified by this author. Juvenile [4 months to 18 months]; Adult onset 18 months to 10 years; and Geriatric or Late Onset [10 to 20+ years].
Three sub-groups of FS have been identified by this author. Juvenile [4 months to 18 months]; Adult onset 18 months to 10 years; and Geriatric or Late Onset [10 to 20+ years].
A monomicrobial form of oral inflammatory
disease, in very young felines, affecting the gingiva and moving into the
alveolar mucosa at the mucogingival junction has been identified. It is seen in
Bartonella positive felines.
Many young Bartonella positive felines,
less than a year old, with a specific sub-type of feline oral inflammatory
disease, most often, will respond to Azithromycin therapy as described by
William D. Hardy, Jr, VMD at the National Veterinary Labs [info@natvetlab.com]. Dr. Hardy states, "veterinarians should consider
Bartonella in their differential diagnosis as the etiologic agent for a subset
of cats with oral inflammatory disease." Dr. Bill Hardy is to be
recognized for his important clinical investigations into the study of
Bartonella in cats and the multiple pathologies that they can cause. He is to
be applauded for the information he has brought to feline medicine in this New
Millennium through the Feline Bartonella test he has innovated. If a young
patient, less than one year, that is Bartonella positive does not respond to
Azithromycin therapy, it is most likely Juvenile FS and should be referred to
an oral specialist/dentist/surgeon for diagnosis and treatment.
Bartonella and
Stomatitis:
It must be emphasized that this author does not feel that Bartonella is the etiologic agent for FS. Azithromycin does definitely reverse some, oral inflammatory disease patients under twelve months of age that are Bartonella positive. In older Bartonella positive felines that have FS, treatment with Azithromycin does not help reverse the pathology.
It must be emphasized that this author does not feel that Bartonella is the etiologic agent for FS. Azithromycin does definitely reverse some, oral inflammatory disease patients under twelve months of age that are Bartonella positive. In older Bartonella positive felines that have FS, treatment with Azithromycin does not help reverse the pathology.
Signs of FS:
The main characteristics of all age groups are advanced oral inflammation and severe pain. No veterinarian should rely on corticosteroids and antibiotics as the treatment protocol for these felines. It is non-productive, does not help the patient in the long-term, and most importantly can predispose the patient to systemic pathology. This author sees many cases of FS that have been treated for years with corticosteroid therapy with adrenal disease, liver disease, kidney disease, and transient diabetes. Others present with septic oral pathology that has been influenced by the immune system being suppressed by glucocorticoids.
The main characteristics of all age groups are advanced oral inflammation and severe pain. No veterinarian should rely on corticosteroids and antibiotics as the treatment protocol for these felines. It is non-productive, does not help the patient in the long-term, and most importantly can predispose the patient to systemic pathology. This author sees many cases of FS that have been treated for years with corticosteroid therapy with adrenal disease, liver disease, kidney disease, and transient diabetes. Others present with septic oral pathology that has been influenced by the immune system being suppressed by glucocorticoids.
Some patients with long-term FS are very
aggressive, when presented, because of the long-term pain that they have
experienced. The owners comment that not only mouth pain aggression is present
but relate that they can be attacked by their cat at home at any moment. Many
of these cats had been gentle and well socialized before developing FS. It is
not uncommon to also see in advanced FS patients: dehydration, cachexia, and
anorexia.
Diagnosis
of FS:
Diagnosis of FS is accomplished with biopsy and histopathology. The practitioner must never confuse FS with Squamous Cell Carcinoma [SCC] or any other oral neoplasia in the feline. Biopsy must be deep and representative of the pathology. Superficial biopsies are useless to the histopathologist. This author recommends both soft tissue and bone biopsy specimens be sent to an oral histopathologist for examination.
Diagnosis of FS is accomplished with biopsy and histopathology. The practitioner must never confuse FS with Squamous Cell Carcinoma [SCC] or any other oral neoplasia in the feline. Biopsy must be deep and representative of the pathology. Superficial biopsies are useless to the histopathologist. This author recommends both soft tissue and bone biopsy specimens be sent to an oral histopathologist for examination.
These areas are not easy to biopsy and
significant bleeding can occur. It is recommended to perform all soft tissue
biopsies with Radiowave Radiosurgery [RWRS]. An understanding of Indirect
Radiowave Radiosurgery Coagulation [IRRC] is recommended. See on-line The Journal of Veterinary Radiowave
Radiosurgery-www.RadiowaveRadiosurgery.com
Pre-Anesthetic Testing:
Whether for biopsy or for surgical treatment, all FS felines should be scrutinized for other existing non-related medical problems. This is done by an Internal Medicine Specialist. Feline Leukemia testing should be repeated if not performed within the last year in all age groups. A Feline Immunodeficiency Virus test-i.e. Western Blot at National Veterinary Labs is recommended. The owner must be warned that recovery from stomatitis surgery is delayed in FIV+ Felines.
Whether for biopsy or for surgical treatment, all FS felines should be scrutinized for other existing non-related medical problems. This is done by an Internal Medicine Specialist. Feline Leukemia testing should be repeated if not performed within the last year in all age groups. A Feline Immunodeficiency Virus test-i.e. Western Blot at National Veterinary Labs is recommended. The owner must be warned that recovery from stomatitis surgery is delayed in FIV+ Felines.
Feline Leukemia Elisa positive cats should
be evaluated with a Fluorescent Antibody test by an Internal Medicine
Specialist. Surgery is not recommended in Leukemia + felines. If there is a
question of ANY complicating health issue, contact an Internal Medicine
Specialist before proceeding.
A Feline Bartonella test is accomplished
prior to surgery for all felines-Dr. DeForge recommends the Western Blot
Bartonella Test at National Veterinary Labs. As stated earlier, it is this
author's opinion, Bartonella disease is not the cause of FS and FS patients
cannot be successfully treated with Azithromycin. It is recommended to test FS
cats and treat the Bartonella positives, with Azithromycin. Because of the
public health significance of a Feline Bartonella positive feline’s presence in
the home, with oral oozing sores and ulcers in the mouth, treatment is
encouraged.
Mixed Pathology and FS:
Mixed pathology is found in the FS patient. Feline Eosinophilic Granuloma Complex, external and internal root resorption, root ankylosis, and bone changes can all be present. The soft tissue changes are the most extreme with ulcerated sites that bleed readily when being examined. In many FS patients, the attached gingiva, under general inhalation anesthesia, can be peeled back from the tooth and bone as easily as peeling a banana.
Mixed pathology is found in the FS patient. Feline Eosinophilic Granuloma Complex, external and internal root resorption, root ankylosis, and bone changes can all be present. The soft tissue changes are the most extreme with ulcerated sites that bleed readily when being examined. In many FS patients, the attached gingiva, under general inhalation anesthesia, can be peeled back from the tooth and bone as easily as peeling a banana.
Feline Stomatitis: A Disease of Bone-Not a Dental
Disease
Dr. DeForge’s studies have confirmed that FS is not a disease of the dentition but is a disease of bone. A polymicrobial bone pathology is suspected. A grant for bone culture and tissue culture is being sought to confirm FS etiology.
Dr. DeForge’s studies have confirmed that FS is not a disease of the dentition but is a disease of bone. A polymicrobial bone pathology is suspected. A grant for bone culture and tissue culture is being sought to confirm FS etiology.
Feline
Stomatitis-Oral Radiology and Histopathology: Characteristic changes
are noted in the bone, utilizing digital oral radiology, in all age groups of
FS patients. The pathologist in FS soft tissue biopsies will describe an
inflammatory infiltrate composed primarily of plasma cells, neutrophils, and
lymphocytes. The fact that all patients respond to aggressive osseous surgery
sheds new light on a bone origin of FS. If FS pathology was of a dental origin,
ALL patients would fully respond to whole mouth exodontia. This is not the
case. Only half of the FS patients respond fully to exodontia with a complete
and permanent resolution of the inflammation.
Feline Stomatitis Radiowave
Radiosurgery [FSRWRS-GBR ] with
Guided Bone Regeneration is THE ANSWER to Feline Stomatitis
Feline Stomatitis Radiowave Radiosurgery coupled with Guided Bone Regeneration can successfully treat any feline with FS and reverse the pathology so that the patient has a pain free quality of life. FSRWRS-GBR is a surgery of bone. It utilizes oral digital radiology to identify areas of sclerosing osteomyelitis, condensing osteitis, sclerotic alveolar crestal bone loss, and hypertrophic bone reaction with resorption. Once the pathology is identified, Radiowave Radiosurgery [Ellman International-www.ellman.com] is utilized, to incise all soft tissue and expose the pathology, identified earlier with digital radiology. Using the fully filtered rectified waveform, Radiowave Radiosurgery produces a blood-free atraumatic surgical field that allows visualization of the bone pathology to be treated.
Feline Stomatitis Radiowave Radiosurgery coupled with Guided Bone Regeneration can successfully treat any feline with FS and reverse the pathology so that the patient has a pain free quality of life. FSRWRS-GBR is a surgery of bone. It utilizes oral digital radiology to identify areas of sclerosing osteomyelitis, condensing osteitis, sclerotic alveolar crestal bone loss, and hypertrophic bone reaction with resorption. Once the pathology is identified, Radiowave Radiosurgery [Ellman International-www.ellman.com] is utilized, to incise all soft tissue and expose the pathology, identified earlier with digital radiology. Using the fully filtered rectified waveform, Radiowave Radiosurgery produces a blood-free atraumatic surgical field that allows visualization of the bone pathology to be treated.
The fully rectified filtered waveform is a
pure continuous flow of high-frequency energy. The fully rectified filtered
waveform produces the least amount of lateral heat and tissue shrinkage. The
fully filtered waveform resembles the scalpel incision most and is the only
waveform that allows cutting in close proximity to the bone, due to the minimal
amount of lateral heat produced. [Sherman J, Waveform Types and Properties,
Oral Radiosurgery-3 rd Edition, Chap. 2, p.9;Taylor and Francis-2005.] Osseous Surgery and Guided Tissue
Regeneration are the important keys to the completion of Feline Stomatitis
Radiowave Radiosurgery [FSRWRS]
There is an antibiotic protocol after
surgery to eliminate the osteomyelitis that cannot be surgically treated
because of proximity to vital anatomy. Pain control is paramount
intra-operatory and post-operatory. The pain presence is not, primarily, from
the surgery itself but is from the oral inflammation and ulcerations present
pre-surgery. Contrary to past belief, this new surgery technique has shown that
all abnormal soft tissue does not need to be removed at the time of surgery.
The inflammation, in soft tissue, quickly resolves once the osseous surgery is
completed.
Any Feline Stomatitis edentulous feline who
has experienced complete exodontia by a qualified surgeon or animal dentist
with return of the oral inflammatory disease can be successfully treated with
Feline Stomatitis Radiowave Radiosurgery-GBR .
This proves that FS is not a dental disease but a bone disease. What remains to
be shown is the identity of the proposed polymicrobial system in the bone
initiating the immune-related oral inflammation.
Pre-Testing Prior to Surgery
An Internal Medicine doctor must examine
your cat and clear your cat for General Inhalation Anesthesia for Stomatitis
Surgery. That same Internal Medicine doctor must place a feeding tube-i.e.
Esophagostomy tube- two weeks prior to
Part One of the Stomatitis Surgery at the time of your pre-anesthesia
testing. Alternative pre-anesthesia
testing can be performed by Dr. DeForge. If pre-anesthesia testing is performed
by your LDVM, a Clearance for Anesthesia letter must be signed and provided by
your LDVM to Dr. DeForge. All chest
x-rays must be reviewed by a radiologist.
All sonograms, if indicated, must be performed by a specialist. All ECG’s must be computer interpreted or
reviewed by a specialist prior to anesthesia.
The Surgery with bone grafting is completed
in two parts each two weeks apart. Dr.
DeForge works on ½ of the mouth in each visit.
Each surgery is 2 hours long.
The patient is discharged the same day of
the surgery. There must be a caretaker
that is able to follow the instructions on the usage of the E-Tube for feeding
formula after surgery and giving medicines to the patient after surgery. All medicines are given in the E-Tube until
about one week after the second surgery.
The E-Tube flushing-maintenance is essential to prevent the tube
becoming clogged. Medicines and
Histopathology Biopsy Lab fees are additional to the above estimate.
You must purchase an E-Collar and a vest
harness for your cat prior to the surgery and bring it with you to our center
the day of surgery. We zip-tie the E-Collar to the harness to protect the
E-Tube and to stop the patient from traumatizing the surgery after it is
completed.
You must have a large breed dog crate to
keep the patient confined in while the surgery period is active. After the E-Tube is removed.[i.e. two weeks
after the second surgery the large breed dog crate is discontinued] A cat with an E-Tube can dislodge the E-Tube
even with an E-Collar in place if given free roam of the home.
A veterinarian must change the dressing
covering the E-Tube weekly. The E-Collar
must be kept clean daily. It is
especially important to clean after eating-this will be explained on
discharge. All foods are
blenderized. No blenderized foods can be
given for 72 hours after each surgery.
That is a time ONLY for
Tube Feeding with Ensure Vanilla Formula to allow the mouth to heal.
There will be a complete set of discharge
instruction post-surgery. All medicines
are compounded by RoadRunner Pharmacy into a triple tuna liquid. These are first given by E-Tube. When the E-Tube is removed they are able to
be mixed in Fancy Feast Primavera or Florentine canned food varieties-tuna or
salmon. Schedule a pre-surgery consult
with Dr. DeForge. He will order the
prescriptions for you at that time. For
this consult there must be a 12 hour food fast and a 6 hour water fast in case
Dr. DeForge wants to give a mild sedative to examine the mouth.
After the first month post-surgery,
antibiotics are pulsed two weeks out of each month for 6 months. This is to reduce residual infection in the
oral cavity. After that time no medicines
are needed.
Thank you for allowing me to help in the
removal of Cat Stomatitis from the member of your family that you love.
In conclusion, Guided Bone Regeneration Stomatitis Surgery in the
cat is not for everyone. The care of an E-Tube must
be meticulous. Medicines are given for
90 days post surgery. A large/giant
breed dog crate must be established for confinement during this period. It is a comfortable home and not an isolation
unit for 90 days. You must visit, hold,
and show love to your pet during this important 3 month post-surgery
period. Cat GBR Stomatitis Surgery is
not a surgery for outdoor cats. It is
not a surgery for cats with other medical problems that may have secondary and
not primary cat stomatitis. It is a
journey. A journey well worth the
completion……. but a journey that is positive ONLY
with a hope and belief in a positive outcome.
With attendance to all that is recommended, your cat will have a
wonderful life. Do not go into the
surgery without realizing it requires effort and work on your part to be
successful. Dr. DeForge is the surgeon
but the family and Dr. DeForge are the primary pet advocates. Without listening, communicating, and working
together success and pain relief will not occur.
DH DEFORGE, VMD-Fellow of the Academy of
Veterinary Dentistry
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