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Bright Eyes' Journey Back From Stomatitis
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Case Study: Bright Eyes
11yo MN DSH
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Referred by:
Hilltop Veterinary Clinic
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History:
Bright Eyes is an 11-year-old neutered, male domestic shorthair referred to the Dentistry department at The COVE by Hilltop Veterinary Clinic for evaluation of oral pain and stomatitis. Bright Eyes has had oral inflammation since his adoption two years prior to presentation. He had a dental cleaning shortly after his adoption, which improved his oral pain for several months. When the pain and inflammation recurred, antibiotics, long-acting steroids, and opioid medications were administered. These treatments, again, gave some initial relief, but Bright Eyes continued to lose weight and exhibit signs of pain when eating.
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Presentation
A conscious oral exam revealed severe caudal mucositis bilaterally and severe bilateral alveolar mucositis, which extended mesially to the maxillary canine teeth. The maxillary canine teeth were extruded, indicative of periodontal disease in that location. Bilateral mandibular third premolars were missing, with no history of previous extraction.
Bright Eyes was underweight and appeared to be in pain. He was subjectively euhydrated and was normothermic. A new heart murmur was detected, and his blood pressure was elevated at 170mmHg. The remainder of his physical exam was unremarkable.
Diagnostics, Diagnosis, and Treatment
The referring veterinarian's diagnosis of stomatitis was confirmed, and anesthesia for intra-oral radiographs and full-mouth extractions was recommended. Further investigation of the hypertension and new heart murmur was recommended prior to anesthesia. The pet owner was reluctant to pursue full mouth extractions and needed some time to review the options. In the meantime, Gabapentin was added to the previously prescribed medications for additional pain control.
One month later, Bright Eyes was evaluated by the Cardiology department at The COVE. He was eating less than before and was no longer tolerating oral medication. He had lost >0.25 pounds and was dehydrated and subdued. He was diagnosed with right bundle branch block, ventricular premature beats, and a possible patent ductus arteriosus. Pre-anesthetic lab work, including a thyroid level and a urinalysis, was performed and revealed non-regenerative anemia and thrombocytopenia. The decision was made to place an esophageal feeding tube prior to dental surgery, so that Bright Eyes would be a more stable anesthetic candidate.
When Bright Eyes was better hydrated and a more stable anesthetic candidate, he was scheduled for full mouth extractions. A fentanyl, lidocaine, and ketamine CRI was initiated and dental nerve blocks were utilized for pain control. Pre- and post-extraction radiographs were performed to ensure that all dental material was completely removed. The diseased gingival tissue was excised prior to closure of the surgical flaps and care was taken to ensure that the alveolar bone was smooth and free of inflammatory tissue.
Bright Eyes was discharged the following day with buprenorphine, gabapentin, prednisolone, clindamycin, and continued tube feedings.
Outcome and Follow-up
Bright Eyes was evaluated 2 weeks post-op. His extraction sites had healed well, and his owners reported that he was quite comfortable and eating voraciously on his own. The esophageal feeding tube was removed. His prednisolone was tapered and then discontinued by six weeks post-op.
A recent phone re-check at eight months post-op revealed that Bright Eyes continues to be asymptomatic for stomatitis.
Discussion
Feline chronic gingivo-stomatitis (FCGS) is a common, frustrating, and painful condition whose etiology remains elusive. A number of bacterial, viral, and allergic causes have been hypothesized, but thus far there has been no evidence to support them. The only known fact about FCGS is that it is an abnormal local immune-system response of unknown origin.
A committee of board-certified veterinary dentists recently formed to create a consensus statement on the appropriate treatment for FCGS. They agreed that the first step in treating cats suffering from FCGS, in addition to pain management, is anesthesia for full mouth radiographs and extraction of any teeth with either tooth resorption or periodontal disease.
After that first step, there was no longer any agreement, which likely speaks to the wide range in severity of FCGS that is presented. Depending on the level of inflammation present, the owner's ability and willingness to provide home care, and the chronicity of the disease, treatment options range from selective extractions as described above, to caudal mouth extractions or full mouth extractions. Thirty percent of cats with FCGS have resolution of clinical signs following caudal mouth extractions if no inflammation or disease is present on the canine teeth or incisors.
For cats who do not experience resolution of clinical signs following caudal mouth extractions, full mouth extractions are recommended. Eighty-five percent of cats respond well to full mouth extractions and do not require long-term medical management. The longer the inflammation is present prior to surgical intervention, the longer it is expected to persist following extractions.
Medical management for cats who fail radiographically-confirmed full mouth extractions is controversial. Unfortunately, there is no treatment that consistently provides good results, and many options have significant associated side effects. Treatments that may be tried with various levels of success include immuno-suppressive steroids, cyclosporine, interferon alpha, lactoferrin, hypoallergenic diets, CO2laser ablation, and fatty acid supplementation.
There are encouraging early results out of UC Davis and Cornell University using allogenic adipose-derived mesenchymal stem cells for their potent immuno-modulating properties. Recent studies have shown substantial improvement or complete resolution in 70 percent of cats who had previously failed full mouth extractions and immunosuppressive drugs. The effects of stem cell therapy earlier in the disease process, prior to dental extractions, is currently being studied. In addition to providing additional treatment options with fewer systemic side effects, these studies may provide additional insight into the etiology of this frustrating disease process.
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Rostral view of the incisors and canines.
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Severe gingivitis and alveolar mucositis on the maxilla, moderate gingivitis on the mandible.
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Moderate gingivitis on the maxilla and mandible, tooth resorption on the maxilla
fourth premolar.
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TECH TIP:
Esophagostomy Tube Placement in the Stomatitis Patient
By Danielle Martin, LVT
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In some cases, esophagostomy tubes are indicated in dentistry patients. If a patient is exhibiting trouble eating, hissing at food, or running away from food, a feeding tube is almost always recommended. They can also be placed in patients that are non-compliant with oral medications to allow medication administration in the post-operative period. In most cases, these tubes are placed after the extractions have been performed but under one anesthesia. In rare instances, when a dentistry procedure cannot be performed urgently, and the patient is not eating at all, a feeding tube can be placed under a separate anesthetic event to provide nutritional and pain support prior to surgery. In Bright Eyes' case, an esophagostomy tube was placed one week prior to his procedure to provide proper nutrition and fluid administration pre-op.
We provide a demonstration picture to the clients during the consultation to judge whether a tube feeding is something the client can do for their pet. Because a bandage is in place around the insertion site, even the most squeamish clients
can understand what they would need to do
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Placement of the Tube
After the entire left side of the neck is clipped and prepped
aseptically
by the technician, the esophagostomy tube placement is started by inserting a closed long Kelly or Carmalt
forceps into
the oral cavity and into the cervical esophagus on the left side with the tips facing outward. The technician will apply pressure to the forceps, pressing the esophagus outward and dorsal to the jugular vein. While applying pressure over the tips of the forceps with their nondominant hand to push the jugular, artery, and other neurovascular structures aside to prevent trauma, the doctor will make an incision over the tips of the forceps using a scalpel blade. The technician applying pressure to the forceps then opens them to grasp the feeding tube, pulling the tube end rostrally through the neck and out through the oral cavity. Leave a few centimeters of the proximal tube end protruding from the incision to secure to the patient. At this point, the doctor will redirect the distal end of the tube through the oropharynx, gently advancing the tube as far as possible into the esophagus. The technician can then secure the tube to the skin using 0 or 2-0 nylon in a finger trap pattern. The tube position needs to be then verified by a radiograph.
The final step is to place a bandage around the neck to cover the stoma site. I have found that wrapping the tube in the bandage and looping the tube so that the cap end comes out of the bandage rostrally allows easier access for the owners to provide feedings.
This keeps the tube safe inside the Elizabethan collar. The neck needs to be completely clean and dry before this is placed. The bandage around the tube requires weekly changing and once the patient returns to eating normally on their own three weeks after surgery, the tube can be removed. This is done at a medical progress examination and involves no pain or sedation.
For tube information and care, click here.
If you have access to Clinician's Brief, you can find photos
here.
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DID YOU KNOW?
Have You Heard About Our New Tooth Pics?
We have a new X-ray unit!
The dentistry team recently upgraded to a new X-ray unit called the IM3-CR7. It is a CR unit that has helped us achieve better quality radiographs. Now, we can more easily view the periodontal and endodontic disease present in each patient. Since we now have a larger size film, we are able to obtain full mouth radiographs more efficiently, therefore reducing time under anesthesia. This increase in diagnostic efficiency has led to a heightened level of oral health in our patients.
Enhanced clarity of the IM3-CR7 allows Dr. Fox to more readily
diagnose periodontal disease radiographically.
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DID YOU KNOW?
We Love Being Out and About In The Community!
By Kelsey Eure, Veterinary Assistant / Veterinary Technician Student
Did you know that The COVE is regularly involved in community events? There are several events coming up in the next few months where you will find our dedicated team members volunteering their time in support of the community.
Our team members can be found at The COVE booth handing out promotional items and answering any questions about the services we provide. Our upcoming events are: Cause for Paws (Saturday, April 27th), and Mutt Strut (Sunday, May 5th). Please feel free to stop by and ask any questions you may have about The COVE. We hope to see you!
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SAVE THE DATES!
May 28-31, 2019: The COVE Seaside CE Event in Virginia Beach
Enjoy the salty air, let down your hair and join us for a complimentary continuing education event for doctors, technicians, and managers featuring topics in cardiology, surgery, critical care, and dentistry. Attend one or attend them all - a unique opportunity to earn up to 9 CE credits.
Look for registration information in a few months.
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24/7 Emergency and Critical Care | Surgery | Cardiology | Dentistry
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6550 Hampton Roads Pkwy, #113 | Suffolk, VA 23435
P: 757.935.9111 | F: 757.935.9110 |
thecovevets.com
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