Friday, December 27, 2019

CERTIFIED ORAL PAIN FREE-FELINE STOMATITIS [FS] Web Log #41


Donald H DeForge, VMD
Fellow of the Academy of Veterinary Dentistry
Practice Limited to Dentistry
AnimalDentistrySolutions.blogspot.com
1-800-838-3368
E-Mail DonDeForge100@gmail.com
Web Log #41





                                      Normal                                                        Not Normal


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                                                               Advanced Stomatitis





CERTIFIED ORAL PAIN FREE

Feline Stomatitis [FS]
Introducing StomaSurg~

No Pet Owner wants their cat in pain!  Yet every day 1000's of cats wake up each day in pain thinking that a life of pain is normal.........believing that life is constant pain.  As veterinary professionals and pet advocates there now is a way to remove oral pain in stomatitis cats permanently.  The answer is Stomasurg~

A Discussion of the Past and the Present~

A Breakthrough Surgery for the Treatment of Feline Stomatitis [FS]

Removing Pain Permanently-Certified Pain Free- with STOMASURG~

Feline Radiosurgery with Guided Bone Regeneration STOMASURG~
 
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 cat. 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 25 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.

 Unfortunately, approximately, only about, one-half of the cats 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. 

Dr. DeForge creates breakthrough Surgery for the treatment of Cat Stomatitis-STOMASURG~

As a treatment alternative, a Radiosurgery-Guided Bone Regeneration technique 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
.

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.

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] Comments on the report in which the laser was utilized 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].


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.  All Bartonella positive cats should be treated because cat Bartonella is a zoonosis.

Bartonella Infection and Feline Stomatitis: 
Special Comments from Dr. DeForge
It must be emphasized that this author does not feel that Bartonella is the etiologic agent of 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, confirmed with histopathology, treatment with Azithromycin does NOT 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.

Some patients with long-term FS are very aggressive, when presented, because of the long-term chronic 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 were gentle and well socialized before developing FS. It is not uncommon to also see in advanced FS patients: dehydration, cachexia, and anorexia. After FS Radiosurgery with Guided Bone Regeneration, it is common to see happy playful cats back in the home again post-surgery.
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 soft tissue; dental; and bone biopsy specimens be sent to an oral histopathologist for examination.

These areas are not easy to biopsy and significant bleeding can occur when performing surgery and/or biopsies in these sites. It is recommended to perform all soft tissue biopsies with 4.0MHz Radiosurgery. An understanding of Indirect Radiowave Radiosurgery Coagulation [IRRC] is recommended. 

Pre-Anesthetic Testing: 
All suspect FS cats should be scrutinized for other existing non-related medical problems.[i.e. co-morbidities]  This is done by Dr. DeForge; your LDVM; or an Internal Medicine Specialist. Feline Leukemia IFA 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 [IFA] test at National Veterinary Labs. Surgery is not recommended in Leukemia + felines. 

If there is a question of ANY complicating health issue [co-morbidity] have Dr. DeForge or your LDVM request an Internal Medicine Specialist consult prior to 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 Feline Stomatitis!

It is recommended to test ALL suspect FS cats at the National Veterinary Lab and treat the Bartonella positives, with Azithromycin. 

Because of the public health significance of a Feline Bartonella positive cat's presence in the home with oral oozing sores and ulcers in the mouth, treatment is encouraged.  

As earlier stated, there is a subset of Bartonella POSITIVE cats under a year of age with A SIMILAR APPEARING oral inflammatory disease that may resolve with Azithromycin therapy.  Never treat oral pathology with Azithromycin without a positive test for Cat Bartonella from the National Veterinary Lab.
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.


 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.

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 extraction of all teeth with a complete and permanent resolution of the inflammation.

Feline Stomatitis Radiosurgery with Guided Bone Regeneration~

StomaSurg~ is THE ANSWER to making all cats with FS-

CERTIFIED PAIN FREE

Feline Stomatitis 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.  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, Radiosurgery is utilized to incise all soft tissues and expose the pathology, identified earlier with digital radiology. Using the fully filtered rectified waveform, 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 and produces the least amount of lateral heat and tissue shrinkage. This waveform 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 with Guided Tissue Regeneration are the important keys unlocking a pain free state in Stomasurg.

There is an antibiotic protocol after surgery to eliminate infection that cannot be surgically treated because of proximity to vital anatomy. 

Pain Control:
Pain control is paramount intra-operatory and post-operatory to Dr. DeForge.
This is accomplished with injectable opiates; Periodontal Ligament Blocks; and other safe pain medicines to be prescribed as part of a home treatment pain management program after surgery. 
The pain presence is not, primarily, from the surgery itself but is from the oral inflammation and ulcerations present pre-surgery. The inflammation, in soft tissue, quickly resolves once the osseous surgery is completed.

Any cat 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 Cat StomaSurg~ This proves that FS is not a dental disease but a bone disease. What remains to be shown is the suspected identity of the proposed polymicrobial system in the bone initiating the immune-related oral inflammation.

Pre-Testing Prior to Surgery

Dr. DeForge, your LDVM, or an Internal Medicine doctor must examine your cat and clear your cat for General Inhalation Anesthesia for StomaSurg~ Cats with cachexia who are not eating may need an esophagostomy tube placement prior to surgery for nutritional supplemenattion and medicine administration. 

Introducing StomaSurg➽
This new surgery by Dr. DeForge is a bone-treatment centered treatment not the tooth
extraction surgery being used for the last 25 years.  No one knows the cause of cat stomatitis.

Dr. DeForge has found the cure with Guided Bone Regeneration Surgery.


What is StomaSurg➽?

Dr. DeForge's breakthrough surgery has three components:

1] Biopsy to confirm Gingivostomatitis is present


2] Intraoral Radiology to review bone pathology present


3] Radiosurgery, Osteoplasty, and Guided Bone Regeneration Treatment of pathological bone sites


Gingivostomatis is THE MOST Painful Oral Disease in Cats!

Dr. DeForge with StomaSurg~ can make the cat you love~ Certified Pain Free!

Gingivostomatitis is NOT a dental disease it is a bone centered pathology!

Dr. DeForge can treat any cat that has all of the teeth removed, i.e. edentulous, with no successful resolution of the stomatitis state........ and completely return the patient to a pain free quality of life with StomaSurg➽

The Answer:

Radiosurgery and Guided Bone Regeneration are the keys. Radiosurgery is utilized to create full thickness mucoperiosteal surgical flaps and to expose the diseased bone.
  • Oral radiology identifies the osseous pathology
  • Osteoplasty is aggressive and is utilized to remove all diseased osseous tissue after PDL Nerve blocks
  • Guided Bone Regeneration with bone alloplast is utilized to create a bone matrix that allows osteoblasts to reconstruct the alveolar ridge and reconstitute the bone

Pre-Anesthesia testing and Clearance for Anesthesia is
completed by Dr. DeForge or the referring FDVM; LDVM; or RDVM

Some eery advanced and very ill FS patients will need esophagostomy tubes for alimentation if presented in the advanced cachexia state

All cats return to a pain free quality of life after StomaSurg➽ Certified Pain Free


Contact Dr. DeForge with questions at DonDeForge100@gmail.com


Friday, December 20, 2019

CERTIFIED ORAL PAIN FREE-A Prescription for Happiness~Number #40

Advanced Veterinary Dentistry
Donald H DeForge, VMD
Fellow of the Academy of Veterinary Dentistry
Practice Limited to Dentistry
1-800-838-3368
DonDeForge100@gmail.com
AnimalDentistrySolutions.blogspot.com
www.SilverSandsVeterinary.com


A Prescription for Happiness:

CERTIFIED ORAL PAIN FREE


Image result for Picture of a pet being hugged


Is My Pet in Oral Pain? 

It can be difficult to tell when a dog or cat is suffering from a painful oral condition. Being able to identify the signs and symptoms that your dog or cat is in pain is a very important part of being a pet owner.
  
Many animal dentists and oral care professionals have described "bad" oral pain! This is a form of pain that is hidden or occult at times in the pet you love!

Your pet can be living in chronic pain....... thinking that pain is normal while suffering from that pain!
  
STOP and consider the tragedy of living in pain and not being able to communicate that pain to others.  It is impossible to capture this thought without becoming emotional about your pet's constant discomfort.
  
As pet advocates, guided by animal dentists and trained oral care professionals......this hidden pain can be removed!

Causes of Bad Pain in Dogs and Cats:
Periodontal Disease [Gum Disease]

Cracked, Worn, or Completely Fractured Teeth

Cavities

Masses in the mouth

Open Pulp Canals-Diseases of the Endodontic System

Damage to the Pulp and Root Canal by Trauma

Overgrowth of the gums

Disease of the lips, tongue, and sinuses

Stomatitis-Severe Oral Inflammation in dogs and cats

Hidden Jaw Fractures caused by Advancing Oral Disease

Oral Infections and Abscessation

Signs of Oral Disease and Bad Pain in Dogs and Cats:
 Unusual Drooling
 Dropping food and being unable to chew on the food
 Thrusting food into the back of the mouth to swallow
 Bad Breath in Dogs
 Bleeding gums
 Loss of Appetite
 Toy Avoidance
 Lethargy and Laziness
 Restless and Not Sleeping Well at Night
 Sneezing and Nasal Discharge
 Weight loss
 Avoiding dry foods and only eating canned or soft table food
 Chewing on One Side of the Mouth Only
 Sudden Shyness and/or Behavioral Changes
 Physical Changes in Your Dog's Mouth-swollen lips, cheeks,
 gums, etc.

Decreased Appetite

Not interacting with other pets or family members

Sleeping more

Not using litter box-eliminating in home

Decreased grooming in cats

Aggressive behavior in an otherwise friendly pet

Vocalization when touching the mouth

Spontaneous howling in dogs

Screeching when attempting to eat
Sometimes you may be able to tell there's something wrong in your dog or cat's mouth just by looking at or in their mouths.  Never force a mouth open if you suspect an oral problem or oral pain [see signs above]! 

Have your veterinarian or an animal dentist give a mild sedative to look into the mouth and make a non-definitive diagnosis.... without your pet experiencing pain. A definitive diagnosis is only possible under light analgesia-Gas Inhalation Anesthesia with oral x-rays.  A biopsy is needed, in many patients, to establish a diagnosis after screening dental x-rays evidence an abnormal radiology finding.

 In the healthy pet, oral checks at home should be done monthly to allow you to pick up any abnormal finding. Call your doctor for an exam and confirmation of these findings.  Your doctor will then decide if they wish to handle the problem or refer to an animal dentist.

Quality oral exams by pet advocates is something that should be done regularly to ensure good oral health.  Other times, the cause is not readily visible and will require a visit to your doctor or an animal dentist for oral x-rays.

You may notice one side of your pet's mouth is swollen; inflamed; or bleeding gums are present. There can be fractured or missing teeth. A bad malodor in the mouth is always sign of  oral pathology.


How to become a 

Certified Oral Pain Free Health Care Professional

Veterinary advocacy for this purpose~~~~~ a Certified Oral Pain Free Professional~~~~ is defined as involvement and leadership in the educational........... locally, regionally, and nationally.......... occupational activities that, directly and indirectly promote a pain free quality of life for all members of the Animal Kingdom.


Not all seek the education to be the source of a Continuing Education Program.  For those who defer from becoming an educator, the role of attending continuing education as a student must be accepted 

Whether student or teacher, a Certified Oral Pain Free Health Care Professional  must understand the importance of advances in oral care techniques through attendance at multiple continuing education programs.
  
A Certified Oral Pain Free Health Care Professional's mission includes the giving of valuable professional time and effort, on our profession’s behalf, to each patient and pet advocate seeking our care.  This care must be centered on compassion for the pain patient and empathy for the pet advocate who is stressed by the condition being treated in their pet.

Scheduling yearly, on-going, oral care continuing education is not only important and necessary for practice doctors but also for their staff........ emphasizing oral radiology and periodontology.

On the local front, it includes education of the pet advocate with oral photography and oral radiology to pin-point pain centers that may need generalist treatment or referral to an animal dentist.  

In difficult to diagnose oral x-rays, consider oral x-ray interpretation with a Telemedicine Oral X-ray Diagnostic Service. [E-Vet Diagnostics is one such service]

Becoming a Certified Oral Pain Free Health Care Professional must center on exhibiting compassion and detailed communication to all pet advocates and their companions.  It is more than producing a positive effect with a procedure.  It is providing love to the patient and a platform of trust to the pet advocate.

Inclusion of the Pet Advocate: 
Certified Oral Pain Free Pet Advocate and 
Caretaker of the Animal Kingdom

Your pet advocates can be great contributors in supplying valuable information to assure their pet is oral pain free! 

As a veterinarian or veterinary nurse, speak to your clients about the Stages of Periodontal Disease.  

In suspect oral pain patients, the pet advocates should ask their LDVM to perform a non-definitive survey oral exam in the examination room and then schedule a definitive oral exam with dental x-rays under general inhalation analgesia-anesthesia.

Prior to anesthesia for a complete dental cleaning and oral x-rays ask your veterinarian what pre-anesthesia tests they feel should be performed based on the age and health of your pet.  

Discuss with your veterinarian the anesthesia monitoring system that they utilize.  Also, review their anesthesia recovery system and post-anesthesia nursing care.

Have your doctor review post-cleaning plaque control to retard the reformation of plaque after Comprehensive Oral Diagnostics and Treatment.  Have your doctor differentiate a teeth cleaning and supportive periodontal care in cases of advanced oral disease.

Use Internet Education sources that are verifiable!

Read articles written by the American Veterinary Dental College; university animal oral care specialists; and authors with credentials in advanced oral care.

Never consider anesthesia-free or sedation-free dentistry.  It has been shown that this is completely ineffective in treating the source of oral disease which is the biofilm below the gum line.
  
Exam room or clinic cleanings without analgesia/sedation/ gas inhalation anesthesia will not only be ineffective but may cause patient pain or the creation of periodontal pockets.
  
Most importantly, make a promise to your pet today! 

You will begin each day promising that you will observe and learn something new........... about oral pain in the pet you love........... and you will return unconditional love-by having your veterinarian remove this pain...........doing this returns the unconditional love that is provided to you each day by your companion.  

This is not just in oral pain recognition but in ALL pain recognition.

As a pet advocate, you will never allow any sign of discomfort to go unnoticed in your companion.  You will seek and search out, today, a health care professional trained in oral care to describe all aspects; elements; and signs of "oral bad pain"!
  
You will be more alert to these  signs of "Bad Pain" and will seek professional help in the removal of that pain with a doctor who exhibits not only knowledge but a strong compassion with detailed communication.
  
Finally, you will reach out and hug the pet entrusted to your care with a promise to never allow ANY pain to occur in the life that you have been selected and entrusted to love....... as a pet advocate.

Leo Buscaglia stated that "Love is Life"!  

Removing ALL oral pain from the pet you LOVE........ is LIFE!

Make that LIFE meaningful....... starting today! 


It is a journey of LOVE which will allow you to find inner peace and happiness!


Questions:
E-Mail 
DonDeForge100@gmail.com

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