Tuesday, February 4, 2020

CERTIFIED ORAL PAIN FREE~The Answer to Cat Stomatitis~ Number #48

Certified Oral Pain Free
The Answer to Cat Stomatitis

Donald H DeForge, VMD
Fellow of the Academy of Veterinary Dentistry
Practice Limited to Dentistry
E-Mail DonDeForge100@gmail.com
Web Log #48

                                      Normal                                                        Not Normal


                                                               Advanced Stomatitis


Feline Stomatitis [FS]
Introducing StomaSurg~

No pet owner wants their cat in pain!  Yet each 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-


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!

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

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