In Search of Compassionate Care #DrDonDeForge~No. 36

Donald H DeForge, VMD

17 Seemans Lane

Milford, CT 06460

P-203-877-3221

Tri-state Oral Consultant in Advanced Oral Medicine and Oral Surgery
E-Mail DoctorDeForge@yahoo.com

DonDeForge100@gmail.com

www.SilverSandsVeterinary.com

www.AnimalDentistrySolutions.com

Fellow of the Academy of Veterinary Dentistry
Practice Limited to Dentistry

Immediate Past President of the Society for Veterinary Medical Ethics

No.36-- www.AnimalDentistrySolutions.com

In Search of Compassionate Care

Donald H. DeForge, VMD

 Human medicine, veterinary medicine, and other allied medical fields have reached epic levels of sophistication and specialization!

There is no upper limit! Top researchers and clinicians combine to find answers to cancer; diabetes; Alzheimer’s; Parkinson’s disease; and a plethora of painful conditions.  Organ transplants and cloning continue to advance to extend our years, on planet Earth, with quality of life.

With a plethora of specialists in veterinary medicine, our companion animal population continues to recover more quickly from serious disease; life expectancy continues to increase; and more pets have quality pain-free lives.  Surgical teams with criticalists in consultation with animal internists lighten the pathway to recovery.

What is lacking in the New Millennium in all areas of medicine is COMPASSION!

 Medicine is synonymous with multi-taskers.  Veterinarians are burdened by clinics; surgery; urgent care; critical care; and ER patients. They live in a framework of management bureaucracy.  Somewhere in the mass of this struggle the word COMPASSION has been forgotten.  This is not just a veterinary problem but also a major problem in human medicine.  Too many patients and not enough time leads to “impersonal” care.

The day of the human general practitioner visiting your home has decreased by 90%.  There are communities with local clinics and home visits but they are few and far between.  At one time, the human physician examined all systems and treated all problems.  With specialization, the orthopedist does not want to hear about a prostate problem.  The hand surgeon does not want to hear about your back pain…..etc. etc. etc.

Articles have been written on burnout, suicide, and compassion fatigue.  None have proven answers. The fact that we continue to write about these issues can hopefully encourage human physicians, human dentists, other health care professionals and veterinarians to seek help before it is too late.

We must not forget that COMPASSIONATE patient-care considerations are linked to treating others the way we would want to be treated. We owe it to our patients to never abandon them with a lack of COMPASSION.

When Doc visited my Dad who was a stroke victim, he sat and chatted and had a cup of coffee before leaving.  When the dentist came to our home to remove an abscessed tooth from my Dad, he did not just walk away but sat with my Dad and joked and told stories about what it was like “in the day” when they were growing up.  Compassion to the stroke victim isn’t as common today within the “sterility” of corporate practices.

Technical, biomedical, and financial issues are areas in which physicians and veterinarians find a comfort zone.  COMPASSION and other emotional care problems have become ”major discomfort areas”! They are intangible entities and take time to solve.  These issues decrease the amount of patients seen each day.  They are “not for profit” areas of care and that bothers medical facility management.

The intangible must become tangible.  Compassion does not belong on a multi-task list.  COMPASSION is a uni-task or a mono-task.   Years ago and even today, the veterinarian sought the multi-tasker and was the ultimate multi-tasker. In the New Millennium, the veterinarian must transition from a multi-tasker to a mono-tasker. Searching for COMPASSION is a mono-task.

Before anyone can mono-task, they must temporarily each day disconnect from the electronic world and initiate focus tasking:

1] First and foremost shut off the Smart Phone

2] Walk away from your desk-top and the other multi-problems sitting on your desk for completion

3] Put a pause on answering messages; writing E-Mails; consulting with your head technician or physician’s assistant; or meeting with your practice manager

4] Set COMPASSION goals.  Review these goals weekly with staff to see if any or all of the goals have been achieved.

All of this is to strengthen the meaning of the doctor-patient relationship. Separating oneself from an anxiety centered multi-tasking world and mono-tasking can lead to harmony and initiate feelings of compassion. Finding compassion in meditation has been found helpful.

A recent study by Northeastern University’s David DeSteno confirmed what Buddhist theologians have long believed---meditation can lead you to more compassion, love, and a commitment to end suffering for oneself and others. 

The concept is that the mono-task meditation exercise improves attention and the ability to focus one’s attention to specific areas of the work environment…..i.e. COMPASSIONATE CARE!  

In humans medicine, this is a reflection concerning ALL patients [i.e. the well insured and those without insurance] and in veterinary medicine to all members of the Animal Kingdom!

The ultimate question is:  Can compassion be trained and learned in adults?

One researcher compares it to flexing our “compassion muscles” every day.

We build up the “compassion muscle” and respond to our patient’s suffering with greater care and desire to help.  

Veterinarians find themselves holding their patients with loving care and talking to their patients after surgery or a medical test and not just returning them to the medical-surgical wards.

Veterinarians have to accept a TOTAL commitment to becoming “Voices of the Voiceless” and finding creative ways to help clients who love their pets but have financial difficulties.  This is not easy!  A team member can be assigned to this important task under the supervision of the hospital manager.

Human physicians MUST find ways to stop double and triple booking by adding new doctors and physician assistants to their group.  They MUST report abnormal lab tests compassionately with a personal phone call to their patients and not relegate this task to one of the nurse assistants at their practice.

Human physicians must take on a GREATER ROLE working with insurance companies to have testing approved that is relative to diagnosis and patient care.  This is time consuming but it is essential in returning COMPASSIONATE CARE to medicine.  Insurance obstacles should not become a problem in providing care.  Everyone is entitled to excellent diagnostic care and appropriate treatment without insurance restriction.

The positive extension of leadership compassion is that it grows!  It is embellished by all nurses, assistants; technicians; and client service representatives as it is exemplified by practice management.

This same model will be successful in any workplace.....not just human or veterinary medicine!  Consider bringing compassion to your workplace; to your school; to those that you meet and greet each day!

Leadership compassion originates from mono-tasking and focus-tasking in compassionate care.  It is the answer!  “Only when we give joyfully, without hesitation or thought of gain, can we truly know what love means.” Dr. Leo Buscaglia

Let The Animal Dentist Come to You! #DrDonDeForge #MobileVetSilverSandsVeterinary~No.35

#DrDonDeForge
#AnimalDentistSilverSands
#SilverSandsVeterinaryNetwork
#MobileVetSilverSands
#MobileDentalServicesSilverSands
www.SilverSandsVeterinary.com
No. 35-www.AnimalDentistrySolutions.com


Dental Exams in your home!

Can't make a visit to a Veterinary Hospital?
Is your pet anxious?
#DrDonDeForge has you covered!

• Physical Exam
• Oral Exam

All in the comfort of your home!

Our unique medical/dental practice was among the first in the country established to care for patients who are unable to be treated in a traditional veterinary office setting. For over 40 years, we have been working to remove barriers to access to care by delivering premium dental care to patients with unique challenges at an affordable fee!!!  Is your dog stressed coming to the veterinary hospital?  Does your cat hate being put in a carrier?
Dr. DeForge administers a safe sedative for the inital oral check-up right in your home.  If your cat or small dog needs oral care there is a no fee to transport to #DrDonDeForge Dental Center at #SilverSandsVeterinary in Milford, CT.[find out more at www.SilverSandsVeterinary.com]
If your dog is medium; large; or extra large in size and has anxiety, Dr. DeForge administers at no charge a sedative for you to transport your dog to #SilverSandsVeterinary
Dental Operatory at Milford Veterinary Hospital which is part of the Silver Sands Veterinary Network.
Your pet is happy to come to our hospital without any stress or anxiety! 

#MOBILEVETSILVERSANDS 
House Calls for Pets
VMD Home Calls
Let the Doctor Come to You!

Dr. Don DeForge

1-800-838-3368

DonDeForge100@yahoo.com

www.SilverSandsVeterinary.com

A Part of the Silver Sands Veterinary Network

House Calls

House Calls for Pets provide a unique perspective on patients' environment and health problems. The demand for house calls is expected to increase considerably in future decades as the U.S. pet population increases.

With early intervention, house calls involving multidisciplinary care may reduce in hospital admissions and long-term care can decrease

Dr. DeForge’s House Calls for Pets allows observation of the patient performing daily activities, reconciling medication discrepancies, and evaluating home care.

Dr. DeForge can offer house calls integrated into his general practice-Milford Veterinary Hospital at Silver Sands Veterinary in Milford, CT with careful planning, including clustering house calls by geographic location. 

Patients that need extensive imaging, urgent care, and specialist intervention must be seen at Milford Veterinary Hospital-Silver Sands Veterinary. [just across the street from Dan Perkins Subaru in Milford, CT at the intersection of Bridgeport Av. and the Boston Post Rd.] Find out more at www.SilverSandsVeterinary.com

Dr. DeForge offers at Milford Veterinary Hospital- Internal Medicine consults; Radiology-Special Imaging; Ultrasound Imaging; Echocardiograms; and specialized Surgery along with advanced oral care at Milford Veterinary Hospital-Silver Sands Veterinary.  www.SilverSandsVeterinary.com  Dr. DeForge is a Fellow of the Academy of Veterinary Dentistry.

House calls were standard practice for physicians in 1930, when approximately 40 percent of patient encounters occurred in the patient's home. By 1950, this had fallen to around 10 percent, and by 1980, only about 1 percent of patient encounters were house calls. 

House calls can provide a unique perspective on a patient's life that is not available in an office visit or during hospitalization. A house call can foster the physician-patient-client relationship, and enhance the veterinarians understanding of the patient's environment and support system

 

 

 

Dr. DeForge leads the way with compassionate animal house calls.  He will sit with you and review your pet’s health problems and set up a plan of health care just as the physicians did in the 1950’s in the United States. No anxiousness......just tender loving care with mobile animal nurses that want to bring love and compassionate care to your home!
Call 203-877-3221 with questions or write to #DrDonDeForge at DonDeForge100@gmail.com Do it today for the pet you love! You can schedule on-line at www.SilverSandsVeterinary.com Just state you want a house call-mobile visit!

Vital Pulpotomy in the Dog and Cat~ No.34

DrDonDeForge
Advanced Veterinary Dentistry
1-800-838-3368
DonDeForge100@gmail.com

DH DeForge, VMD
Fellow of the Academy of Veterinary Dentistry
[Practice Limited to Dentistry]

Treatment of the Recent Fracture
Vital Pulpotomy

Vital Pulpotomy-Saving Teeth!

The vital pulpotomy is a  procedure used most often in immature teeth in young dogs with a  recent fracture. It can be used in older dogs, with recent crown fractures, if dental x-rays show no radicular [root] pathology. 

The client must be told that all dogs undergoing Vital Pulpotomy treatment must have a post-treatment endodontic x-ray in 12  months post-care. 

If the apex of the tooth is abnormal, the patient will need a conventional root canal at that time.  The pulpotomy, in young patients, is recommended because it keeps the tooth vital allowing for tooth maturation.

If there is radicular [root] pathology, then the patient must undergo conventional root canal therapy. 

Besides vital pulpotomy and or root canal therapy the only other option for a tooth with an open pulp canal is extraction.  A patient should never be left with an open pulp canal.  It is painful and can lead to a very poor quality of life.

 For the large canine teeth in dogs and cats, and the large chewing (carnassial) teeth in dogs, the extraction procedure can be traumatic and painful due to the size of the roots in our animal patients. The root of the canine tooth is longer and wider than the crown (the part of the tooth you can see above the gums). Extraction of these teeth involves major oral surgery, comparable to removing impacted wisdom teeth in human patients. The patient also loses the function of the tooth, which can be very important in working dogs.

Dr. DeForge tries to avoid extraction of fractured but otherwise healthy teeth.

After any endodontic procedure a restoration is utilized to close the treatment site.

There are exceptionally strong enamel shaded restoratives available to animal dentists from human dentistry. Amalgam is another very safe alternative in restorative dentistry.  No restoration is permanent in the dog.

Dog's can dislodge restorations quite easily if chew behavior is not modified.

The restoration that has the least chance of being dislodged by our animal patients is a full jacket crown.

Comments from Dr. DeForge:

The most important single aspect of successful vital pulp treatment is a correct diagnosis.  The clinician must ascertain the tooth to be vital! This determination is made through a thorough workup  including the clinical examination and radiographic appearance of the tooth.--all performed under general inhalation anesthesia. 

Vital Pulpotomry is only performed on recently fractured teeth.
It is commonly performed in young patients.  It can be used in any age patient as long as the clinician is sure that the tooth in question was recently traumatized and endodontic x-rays are within normal limits.

Subjective and objective pain determination is quite difficult to determine in the dog an cat. Clinically, the tooth must be free of soft-tissue symptoms of gingival swelling and pathologic mobility. Radiographs should not show any periapical radiolucency. There should be no radiographically demonstrable external or internal resorption.

 

Pulpotomy:

Following the induction and maintenance of the patient with gas inhalation anesthesia the technique of pulpotomy, regardless of agent used, is exactly the same up to the application of the pulpal medicaments.  

MTA and Calcium Hydroxide are the most common medicants for the pulpotomy in the dog. Either is applied as a paste that remains over the pulp. Dr. DeForge uses the most up-to-date materials to assure a successful pain-free outcome.

The second most important aspect of pulpotomy assuring a successful outcome is the placement of a start of the art  base; primer-resin adhesive and a composite restoration. 

There is no guarantee that Vital Pulpotomy will be successful. If bacteria have reached a point below the treatment site, infection can continue into the pulp necessitating a root canal.  

The Vital Pulpotomy is an important first step in care that may need no further treatment. It decreases anesthesia time; removes pain; and allows maturation of the tooth.  

The root canal is reserved as a last resort.  Once a root canal is performed the tooth is now non-vital.  The advantage of the root canal is that it is also non-invasive and the patient has a remarkable return to normalcy without pain.

Extraction is invasive and requires surgical cutting of mucosa and bone and is never recommended by Dr. DeForge as first choice of care in recently traumatized teeth.

Post treatment x-rays in 12 months is the key! If these x-rays show an abnormal apex after Vital Pulpotomy, root canal therapy is then advised.

Follow-up oral radiology in 6-12 months is imperative.

Questions?
E-Mail DonDeForge100@gmail.com

INTRODUCING STOMASURG No. 33

Donald H. DeForge, VMD
Fellow of the Academy of Veterinary Dentistry
Practice Limited to Dentistry
www.SilverSandsVeterinary.com
1-800-838-3368
Milford Veterinary Hospital at Silver Sands
House Calls for Pets Silver Sands

#DrDonDeForge

Introducing: StomaSurg➽ No. 33

Removing Oral Pain One Patient at a Time!

Gingivostomatitis in the Cat

The pathology of gingivostomatitis can affect gingiva, mucosa, tongue, palate, and the pharyngeal area. The salient clinical signs of gingivostomatitis are: swollen, ulcerated, and bleeding gums; lack of appetite or the inability to eat; consequent weight loss; cachexia; excessive salivation; blood in the saliva; halitosis; pawing at the mouth and SEVERE ORAL PAIN! 

Introducing StomaSurg➽
A Surgery for Gingivostomatitis in the Cat using
Guided Bone Regeneration

StomaSurg➽ is the first oral surgery that completely removes Gingivostomatitis in CATS. It is now available in CT and NY.

CT Location-Milford Veterinary Hospital at Silver Sands-17 Seemans Lane, Milford, CT 06460

NY Location-Gold Coast Center for Veterinary Care
770 W. Jericho Tpke-Huntington, NY 11743

For appointments at either location:
E-Mail DonDeForge100@gmail.com or call
1-800-838-3368
Dr. DeForge will come directly to the phone, if you call, to discuss this breakthrough surgery, StomaSurg➽, the only oral surgery treatment to date that COMPLETELY removes Gingivostomatits in the cat.


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➽

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 the referring FDVM; LDVM; or RDVM

Some 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➽

Pre-Surigcal Consultation is fully credited to StomaSurg➽ surgical fees if you decide to have your cat treated with StomaSurg➽ after consultation with Dr. DeForge

Cat Stomatitis: A Cure! No. 32

www.SilverSandsVeterinary.com
P 1-800-838-3368
E-Mail: DonDeForge100@gmail.com
Centers for Oral Care
The New York and New England Animal Dental Health Services
Donald H DeForge, VMD
Fellow of the Academy of Veterinary Dentistry
President of the Society for Veterinary Medical Ethics
No. 32

CAT STOMATITIS!

THERE IS A CURE!

Attention: Doctors,Veterinary Nurses, and Stomatitis Cat advocates.

Today’s Topic in Animal Dentistry outlines my oral surgery using GBR to cure cats from stomatitis.  It is the only surgery to date that can bring complete resolution without remission.

Questions can be directed to DonDeForge100@gmail.com or you can call me at 1-800-838-3368.

 Introduction:  Topic In Animal Dentistry #1

The classic treatment of feline Stomatitis with whole mouth extraction or extraction of the teeth distal to the canine teeth has proven to be non-productive in half of the patients treated.

Any where between 50-65% of these felines have only short term improvement with a return of the oral inflammatory condition in 6 to 18 months.  On the other hand, the alternative surgery, herein described, utilizing Guided Bone Regeneration and radiosurgery to create full thickness mucoperiosteal flaps…… i.e. osseous surgery combined with bone augmentation has proven to be completely successful. 

 
Guided Tissue Regeneration (GTR) 
Refers to procedures that attempt to regenerate lost periodontal structures, such as bone, periodontal ligament and the connective tissue attachment that support our teeth. This is accomplished using biocompatible membranes, often in combination with bone grafts or tissue stimulating proteins. 

Guided Bone Regeneration (GBR) 
Refers to procedures that attempt to regenerate bone. This is accomplished using bone grafts and biocompatible membranes that keep out tissue and allow the bone to grow. 

In the Journal of Veterinary Dentistry, Vol 14, No. 4-Dec 1997-Evaluation of Bioglass®/PerioGlas™ [Consil®] Synthetic Bone Graft Particulate in the Dog and Cat-DH DeForge, VMD -GBR is described. 

Bioglass® Synthetic Bone Graft Particulate [PerioGlas™/Consil™] was utilized to treat osseous periodontal defects, and in post-extraction sites to maintain the vertical height and width of the alveolar ridge.  In the osseous periodontal defect treatment group, clinical probing depths deceased significantly, and there was an apparent gain in attachment level.  This synthetic bone graft particulate improves the rate of osseous growth while being resorbed and replaced with bone during the healing process.

This original work led to the utilization of Consil®/Bioglass®, synthetic bone graft particulate, in a feline stomatitis surgery technique I developed.

 When implanted in stomatitis felines, a material surface reaction results in the formation of a calcium phosphate layer that is similar in composition and structure to the hydroxyapatite found in bone mineral.  This apatite layer provides the scaffolding onto which the patient’s new bone will grow allowing repair of the bone defects in feline oral stomatitis.  Diseased bone is removed and new bone is created to allow the patient to fully recover from the inflammation and pain caused by the pre-surgical oral pathology.

  
The hypothesis that the cats affected with stomatitis suffer from a bone disease rather than a dental disease has been confirmed  with this new surgical approach to the disease. The confirmation is the actualization of complete and permanent clinical improvement after GBR surgery in the edentulous patient [i.e. patients having had earlier whole mouth extraction surgery by other surgeons prior to referral to me]. In these felines, where the whole mouth extraction technique had failed, GBR Feline Stomatitis Surgery succeeds confirming the origin of the pathology as a bone-centered pathology.

Before patients can be treated utilizing radiosurgery combined with GBR, comprehensive pre-anesthetic screening must be completed. An incisional biopsy is performed to rule out other causes of oral pathology including oral cancer.  An Esophagostomy tube must be placed two weeks prior to GBR Stomatitis Surgery.

This surgery has been utilized by me for over a decade with ONLY POSITIVE results.  After all of this time, animal oral surgeons are now starting to acknowledge in their lecturing and manuscripts in journals that cat stomatitis may have a bony component. The wheel of surgical change moves slowly!

Contact Dr. DeForge about an in gratis exam!

Dr. Don DeForge

Fellow of the Academy of Veterinary Dentistry

President of the Society for Veterinary Medical Ethics

04October2018

Cat Stomatitis Part I No. 31

Animal Dentistry Solutions

No. 31 

A BLOG by DH DeForge, VMD

Fellow of the Academy of Veterinary Dentistry

1-800-838-3368

DonDeForge100@gmail.com and DoctorDeForge@yahoo.com

Finding the Cure: CAT STOMATITIS Part I

                          

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.

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.

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] 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].

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.

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 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.

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.

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.

 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 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.

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