Feline Orofacial Pain-Cat Stomatitis Syndrome

 

Feline Orofacial Pain 

Cat Stomatitis Syndrome 

Guided Bone Regeneration 

An Innovative Treatment

Donald H DeForge, VMD

Fellow of the Academy of Veterinary Dentistry
Practice Limited to Dentistry
AnimalDentistrySolutions.blogspot.com
E-Mail DonDeForge100@gmail.com

A Primer: The Special Journey to RECOVERY 

Feline Orofacial Pain---- linked to Cat Stomatitis Syndrome---- is a complex extremely painful oral condition in cats which is one of the most frustrating oral conditions that the general practitioner will encounter in their cat clinical oral examinations.  The answer is now here!  Feline orofacial pain caused by cat stomatitis can be removed permanently.

This web log will review Dr. DeForge's hallmark surgery summarizing all aspects of the journey in the Cat Stomatitis Surgical Protocol.  This life changing journey is detailed and reviewed from beginning to completion containing all steps which culminate in a pain free quality of life.!

Guided Bone Regeneration [GBR] 

 This report includes pre-anesthesia testing requirements; Esophagostomy Tube placement two weeks prior to surgery for enteral support and for medicine administration; a brief discussion of GBR Stomatitis surgery; and post surgical care essentials.

Dr. DeForge knows of no university; private referral practice; or veterinary dentist utilizing this surgery to date.

Dr. DeForge is accepting referrals nationwide after the above criteria are met.  He realizes the pain of cat stomatitis and will work with generalist and specialist who are involved in the referral of any cat with stomatitis.

While initiating pre-anesthesia testing, the patient is placed on a specific medicine protocol to make sure the patient is comfortable.  This medicine is not a substitution for surgery.  It is a series of prescriptions that will temporarily remove pain and discomfort while being scrutinized with the pre-anesthesia testing mentioned in this report.  

For local referrals, Dr. DeForge requests a Consultation appointment to give his non-definitive assessment of your cat's oral problems.  The definitive testing for cat stomatitis is by biopsy-histopathology only.  See below Pre-Anesthesia Testing and Referring Doctor Consultation.  

If you live a distance from Dr. DeForge and cannot complete an assessment with him, personally, to initiate a Doctor-Client-Patient Relationship, Dr. DeForge will not be able to provide written prescriptions for these important medicines.  

He will speak to your local LDVM and ADVISE certain medicines be initiated.  Advising is not prescribing! It is your doctor's final decision to prescribe these medicines after consultation with Dr. DeForge.

Once seen by Dr. DeForge the oral pain that has been daily will be gone.

From pre-anesthesia testing; to Esophagostomy tube placement; to oral surgery; and during recovery there is no pain!  Life is quality and your cat is pain free forever!

Part One: Help is on the Way!

Pre-Anesthesia Testing and the  Referring Doctor Consultation

Ruling out Comorbidities in the Stomatitis Feline and preparation for surgery

All pre-anesthesia testing must be completed no later than thirty days prior to referral!

• Referring Doctor must fill out Doctor's Referral Form on SilverSandsVeterinary.com
• Please perform a Comprehensive Chemistry Profile and CBC with Urinalysis 
• All cats, 5 years or older, must have a Thyroid Profile-including a Total T4 and a Free T4
• The following tests are sent to the National Veterinary Lab-William Hardy, VMD-Director; Feline Leukemia [FeLeuk IFA]; Western Blot FIV testing; Western Blot Bartonella Testing. [Call 201-891-2992 for a Test Supplies Order Form.  All tests are directly mailed USPS to the National Veterinary Lab.] A test submission form may be downloaded as a PDF file at natvetlab.com. Click on the RED test submission form button.
• Chest Radiographs must be completed and read by a radiologist
• EKG/ECG and ECHOCARDIOGRAM are completed and reviewed by a cardiologist
• An Abdominal Ultrasound is completed to rule out lymphoma and other comorbidities.  Many times an internist will need to complete a biopsy to scrutinize findings noted on ultrasonography for a definitive diagnosis
• Oral Biopsy is essential-including gingiva, oral mucosa, bone, and dental tissue. If uncomfortable with deep tissue biopsies, please ask Dr. DeForge to complete this procedure.
• Full mouth Oral Photography is completed
• Full mouth Oral Radiology is completed
• A Video Telemedicine Conference is initiated with Dr. DeForge and the Generalist referring the Cat Stomatitis patient
• A list must be provided from the Referring Doctor of any and all comorbidities, already diagnosed, in the stomatitis patient
• A history of any allergy to medicine[s]; or adverse reactions to any sedative; tranquilizer; analgesic; or other drug utilized in this patient in the past must be provided
• After all pre-anesthesia testing is completed, a Letter of Clearance for Anesthesia must be provided by the Referring LDVM or the Internal Medicine Doctor/and Cardiologist performing the pre-anesthesia assessment.
• If any of the above testing cannot be completed by the LDVM, the client must visit an Internal Medicine Doctor for testing.  Local referrals can have all testing performed by Dr. DeForge if the LDVM is not able to complete the testing.

Part Two:

The Esophagostomy Tube

* A nutritional support system

* A medicine transport system

There is a protective neck bandage that must be changed weekly to clean the entrance point [stoma] of the tube into the neck.  This can be done by your doctor or one of their veterinary nurses.

The Esophagostomy tube is a very important part of pre- and post-surgical care.  This tube is needed for medicine administration and for the nutritional needs of the patient. The tube is placed two weeks prior to Oral Surgery Part One. This two week period allows the E-Tube usage technique to be mastered by the client before surgery is scheduled.    

If traveling from out of state, this Esophagostomy tube maintenance is completed by Dr. DeForge's nursing team. Many veterinarians are not comfortable placing an esophagostomy tube.  In those instances, Dr. DeForge asks this tube be placed by a Board Certified Internal Medicine doctor or Surgeon in a specialty center near your home.  Local referral patients can have the tube placed by Dr. DeForge and his team.

You must set up, at home, a 4 foot x 4 foot giant breed crate to keep the cat you love confined after the Esophagostomy tube has been placed. It is a home of love and concern for one month!  You must have a comfortable bed in the crate along with gravity food and water bowls--elevated about six inches off the floor of the crate-- so that the Elizabethan Collar does not interfere with eating or drinking. Your pet is not allowed to run through the home and run the risk of dislodging the tube.  The Elizabethan Collar is placed to further protect dislodgment of the Esophagostomy tube.  There are a multitude of comfortable Elizabethan Collars that you can purchase from Pet Centers or your veterinarian.  Your cat can come out of the crate if you wish to hold the cat in your lap or have the cat sit beside you as you relax.  Once you can no longer be with your cat to directly monitor, you must return your cat to the crate.  Not following these instructions may lead to Esophagostomy tube dislodgment with a delay in scheduling surgery or a delay in healing.

The Esophagostomy Tube-The question is not WHY?

This simple procedure ensures adequate nutrition for postsurgical feline patients-which can speed recovery time and minimize hospitalization. Adequate nutritional support is an essential, yet often overlooked, aspect of postsurgical care. Ill patients frequently present with decreased appetite, anorexia or weight loss related to their underlying condition. These signs may be related to pain; structural disease; oral disease in the mouth-i.e. cat stomatitis; or generalized feelings of illness due to systemic disease (e.g. lymphoma, renal disease).

The negative effects of malnutrition are well-established and include decreased wound and fracture healing, decreased immune response and organ dysfunction. Enteral nutrition can hasten recovery time, decrease hospitalization stays and avoid unwanted sequela such as hepatic lipidosis.

Esophagostomy tube placement in cats is a technically simple procedure, requiring minimal anesthetic time, and it carries a low risk of complications. Furthermore, esophagostomy tubes have a larger diameter than nasoesophageal or nasogastric tubes, allowing for administration of blenderized diets and medications. Compared to gastrostomy or jejunostomy tubes, esophagostomy tubes can be easily removed at any point.

Part Three:

Post-Surgical Care

Post-surgical care is THE most important part of Dr. DeForge's Guided Bone Regeneration Stomatitis surgery.  

The surgery itself is broken into two parts.  One half of the mouth is treated; there is a two week resting period; and then the remaining areas are  treated.  

After each surgery, Dr. DeForge utilizes Low Level Laser Therapy to reduce oral swelling and pain.  This therapeutic cold laser treatment is very effective.

Intensive nursing  care initiates at the time of discharge from Oral Surgery Part One until one month after the completion of Oral Surgery Part Two!  A medicine treatment sheet will be provided by Dr. DeForge.  This treatment sheet shows the medicines that need to be given with their periodicity; and the special formulas to be fed through the Esophagostomy tube with detailed time and volume descriptions.

The return to a pain free quality of life will occur within days after surgery.  The bone grafting response takes much longer as new bone replaces the diseased bone that was removed by Dr. DeForge.  Working together as a team will allow your pet to have expedited healing.

Each patient because of the Esophagostomy Tube placement must be kept in a 4 ft x 4 ft  transport cage.  This cage is a home for 30 days and it must have within: a comfortable bed; elevated gravity food and water dishes; and be placed in a room away from other pets with sunlight and ventilation.  Remember and Elizabethan Collar must be on your cat to protect the Esophagostomy Tube until the Esophagostomy Tube is removed.

Pheromone plug-ins should be placed in the same room to bring an atmosphere of calmness to the recovering patient.

There must be daily Chat Room Messages sent to Dr. DeForge through the Silver Sands Veterinary APP!  In those messages, you must include statements about pet disposition; any sign of discomfort; medicine administration; Esophagostomy tube usage; bowel movements; and urinations. In this Chat Room, you can also send pictures of your pet to Dr. DeForge.  The mouth should be kept clean using wash cloths dampened in luke warm water.

Do not scrub the face.  Gently massage the face with a dampened  wash cloth to clean away any saliva and blood tinged fluids.  

The Elizabethan Collar must stay on 24/7 and be kept clean.  

Your LDVM or Dr. DeForge should change the Esophagostomy tube dressing once weekly to be sure no infection is occurring at the stoma entrance into the neck.  If your LDVM is changing the dressing be sure to have them gently clean the site and apply Aquaphor healing ointment to the site before reapplying the dressing.

Be vigilant and follow all directions outlined by Dr. DeForge.  If something appears not correct in the healing process call Dr. DeForge; email him; or use our Chat Room within the APP to leave a message.  

If there is a bad odor from the mouth; bleeding from the mouth after 72 hours; or inappetence contact Dr. DeForge.  

Do not stop prescribed medicines if your cat seems normal.  Use all medicines prescribed by Dr. DeForge until he tells you they can be discontinued.!

To REPEAT: please do not stop any of the medicines prescribed until Dr. DeForge gives you permission to discontinue the medicines.  

All medicines are flavored syrups from a compounding pharmacy and are started two weeks before surgery and continued for one month after Oral Surgery Part Two.  Pick up the Probiotic in packet form-Culturelle for Kids-give one packet twice daily two hours after each antibiotic treatment.  When using the Esophagostomy tube, you must mix this probiotic in 10 mls of Vanilla Ensure or Vanilla Boost-mix well-and then flush the Esophagostomy tube with 10mls of room temperature bottled water.  If this is not done the tube can become occluded.  Once your cat is eating, the Culturelle for Kids Probiotic in the packet form can be mixed into baby food and fed from a bowl. [Available over the counter in drug stores and super markets]

Cats will eat from a bowl within 3-5 days after the oral surgery [Part One and Part Two]  The Esophagostomy tube is still utilized for medicine administration and caloric supplementation with Vanilla Boost,  Vanilla Ensure, Vanilla Glucerna., and/or Royal Canin Recovery Liquid. 

Your first recheck is in 30 days post-Part Two of the Oral Surgery.

The History of Past Failed Stomatitis Treatment 

The Future: Guided Bone Regeneration Surgery

                                      Normal                                                        Not Normal

                                                 Advanced Stomatitis

Feline Stomatitis [FS]

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

Feline Stomatitis has been investigated by animal dentists for over thirty 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 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.  Full recovery is uncommon.

Veterinarians are forced to return to immunosuppressive and/or glucocorticoid therapy after surgery to control inflammation and pain.

The Answer is here: Guided Bone Regeneration Surgery

As a treatment alternative, Dr. DeForge's Guided Bone Regeneration Surgery is being used to completely and permanently reverse the oral inflammatory state and remove the 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 past three decades 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 areas; the glosso-pharyngeal arches; the commissures; and at times the entire pharynx. Depending on the feline, all mentioned above or site-specific pathology centers can be identified.

Historically Non-Productive Treatments: 
Historical medical treatments have been completely non-productive and useless to feline patients.. 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, only, offer short term pain relief and discomfort quickly returns.

Surgical ablative 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 be non-productive; lead to respiratory embarrassment; and even loss of life. [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 also 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: 

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 they are experiencing. 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 Surgery with Guided Bone Regeneration, it is common to see the return of  happy playful cats back into the home!

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.  When referring a suspect stomatitis patient to Dr. DeForge, please include:

• Full mouth oral photography 
• Full mouth dental imaging 
• Histopathology reports.  

If the referring doctor cannot perform these evaluations, they will be completed by Dr. DeForge, prior to FS GBR Surgery initiation.

Stomatitis pathology sites are not easy to biopsy and significant bleeding can occur when performing surgery biopsies in these areas. Dr. DeForge performs all  biopsies with 4.0MHz Radiosurgery. An understanding of Indirect Radiowave Radiosurgery Coagulation [IRRC] is recommended. This technology allowing cutting and coagulation to be completed with minimal to no bleeding.

Mixed Pathology and FS:

 
Mixed pathology is found in the FS patient. Feline Eosinophilic Granuloma Complex, external and internal root resorption, root ankylosis, and bony 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
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 identify FS etiology.

Feline Stomatitis-Oral Radiology and Histopathology: 

The pathologist in FS soft tissue biopsies describes 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  favorably with full mouth exodontia.  Others respond and then re-develop oral inflammatory pathology within 6-18 months.

Feline Stomatitis Surgery with Guided Bone Regeneration assures that the patient has a permanent pain free quality of life. Dr. DeForge has proven this is a bone pathology and not a dental pathology. 

FS GBR Surgery 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 radiographically, osteoplasty techniques are utilized to removed petrological bone before initiating GBR techniques.

Pain Control:
Pain control is paramount pre-operatory; intra-operatory; and post-operatory.  There is no pain in any stomatitis cat from the moment Dr. DeForge meets your special friend until the stomatitis post-operative period is completed.

Pain control is accomplished with injectable opiates; Periodontal Ligament Blocks; and other safe pain medicines to be prescribed as part of a home treatment pain management plan after surgery.

 
Verification of Bone-Centered Etiology

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 Stomatitis Guided Bone Regeneration Surgery. 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.

The Future is Now!

Dr. DeForge continues his efforts to establish the etiology of cat stomatitis.  He hopes one day there may be a vaccine to prevent this disease.  Until that time, Guided Bone Regeneration Surgery is returning cats to a complete pain-free quality of life.