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Dentistry Case Study: Contact Mucositis
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History: Edgar is a seven-year-old MN Scottish Terrier who was referred from Western Branch Veterinary Hospital for evaluation of oral pain. Edgar had a history of a stick stuck across his hard palate three months prior. Western Branch treated Edgar with an anesthetized oral exam, a professional dental cleaning, Tramadol, Carprofen, and Clindamycin, all of which helped with his comfort level, and then referred him to The COVE for further treatment.
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Edgar did not allow a conscious oral exam at The COVE because of his pain level and his mandibular lymph nodes were enlarged bilaterally. The other portions of his physical exam were unremarkable. With the information provided by the pcDVM and Edgar's response to a professional cleaning, a tentative diagnosis of Contact Mucositis (previously known as Chronic Ulcerative Paradental Stomatitis or "CUPS") was made.
Diagnostics, Diagnosis, and Treatment:
Edgar was anesthetized for a complete oral exam and intra-oral radiographs. A Fentanyl/Ketamine/Lidocaine CRI was initiated several hours pre-op to aid with wind-up pain. End-stage periodontal disease (>50% attachment loss) was identified on the maxillary and mandibular carnassial teeth and molars. Bilateral caudal mucositis, severe bilateral buccal mucositis associated with the caudal teeth, severe mucositis at bilateral commissures, and palatitis associated with the maxillary fourth premolars were noted.
Bilateral maxillary and inferior alveolar nerve blocks were performed prior to thorough super- and subgingival scaling and polishing. Surgical extraction of 108, 109, 110, 208, 209, 210, 309, 310, 311, 409, 410 and 411 was performed and post-extraction radiographs confirmed complete extraction. Edgar was discharged the following day after transitioning from CRI to acetaminophen-codeine, Gabapentin, and Deracoxib.
A recheck exam two weeks later showed significant improvement in both comfort and oral inflammation. The pain medications were decreased and a recheck one month post-op showed continued improvement. At that time, he tolerated a complete oral exam, which demonstrated complete healing of the surgical sites as well as resolution of the oral ulcerations. Pain medications were again decreased and the family was able to initiate home care.
Follow-up exams for Edgar have been extended to every six months with annual anesthetized exams (we are now two years into his treatment) and he continues to be quite comfortable between professional cleanings. At his most recent evaluation, the caudal mucositis was absent but mild contact mucositis was present over the first and second maxillary premolars, which were subsequently extracted.
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Photos from the initial procedure showing palatitis, mucositis at commissure, gingival recession, and mandibular bone exposure
Photos from the most recent procedure (two years after initial)
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Discussion:
Contact mucositis can be a frustrating disease for veterinarians, owners, and pets. It is very important to distinguish it from periodontal disease in terms of its prognosis and in order to establish a proper treatment plan. The paradental tissues include the oral mucosa, the palatal mucosa, the lining of the buccal pouch, the margins of the lips, and the epithelium of the tongue. In many patients, these paradental tissues can remain relatively healthy even in the face of chronic and advanced disease of the periodontal tissues. A patient may, however, have severe mucositis with relatively good periodontal health. They really are two separate conditions that may be present by themselves or concurrently.
The presenting complaints of contact mucositis are typically severe halitosis, excessive drooling of thick ropey saliva, lip fold dermatitis, oral pain, and difficulty eating. The only laboratory findings typically associated with this condition are hypergammaglobulinemia and mild neutrophilic leukocytosis.
While the specific pathogenesis of contact mucositis remains unknown, dogs with the condition are unable to tolerate the presence of bacterial plaque on the crowns of their teeth. Even fairly minor plaque accumulation results in an excessive, painful ulcerative inflammatory response. For this reason, management of the condition is focused on plaque control.
Brushing is essential to disrupt the biolayer which forms on the tooth surface within minutes of professional cleaning. Water additives, a dental diet, and dental chews, etc., should be considered adjunctive care to brushing, but these adjuncts alone will not be enough to provide the necessary plaque control. Daily, or even twice-daily care and attention requires a strong commitment from an owner and should be implemented early in the disease process if appropriate. If plaque cannot be
controlled
, the next option is to remove the surfaces where plaque can develop. This means extractions.
Removing the teeth that are difficult to care for, i.e., the molars, or that are adjacent to an ulcerative lesion, may be an initial step. Owners should be warned that even if teeth opposite an ulcer are removed, the lips may then lie against other teeth that they were previously not in contact with, and that the lesions may migrate. For this reason, more extensive extractions are often recommended right from the beginning.
Owners often resist the concept of extensive extractions, but this step has the greatest success rate for short-term improvement and long-term resolution. Their pets deserve a healthy, pain-free mouth, and this goal must supersede all other hopes and expectations. Pets do not need teeth to ensure food intake, and many will return to eating dry food and playing with toys. In fact, by removing the oral discomfort, these animals often eat more and play more than before surgery.
If the entire dentition has been removed and disease persists, we may need to resort to medical therapies such as cyclosporine, prednisone, azathioprine, NSAIDs, cetirizine (which also has pronounced antieosinophilic effects), a tetracycline/niacinamide combination, doxycycline, or metronidazole at an anti-inflammatory dose. It may be necessary to prescribe a hypoallergenic diet and omega fatty acids. Unfortunately, the patients that do not respond to surgical intervention tend to have an incomplete response to these interventions as well.
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TECH TIP:
Ultrasonic Scaler Tip Wear and Tear
Danielle Martin, LVT
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Did you know that your ultrasonic scaler comes with a tip wear guide? The most common types of ultrasonic scalers are pezioelectric and magnetostrictive. Both types have interchangeable tips; which one should be used is determined by how heavy the calculus buildup is and how deep you need to clean subgingivally depending on the depths of the periodontal pockets. Because of their variable uses, it is important to keep a variety of tips available. For each type of tip, a tip wear guide is available from the manufacturer. Once a tip reaches the red line, it is worn enough to reduce the scaler performance, meaning that the ultrasonic frequency will have been altered. At this point, a new tip should be ordered and the old one thrown away.
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The ultrasonic unit used at The COVE is iM3 42-12. We have multiple perio tips (designed for both supra- and subgingival scaling and great for deep pockets) and universal tips (also designed for both supra- and subgingival scaling but great for removing larger accumulations of calculus supragingivally). After each use, the ultrasonic scaling tips and rod are autoclaved so that they are sterile for each patient. We frequently consult our tip wear guide provided by iM3 and replace our tips when indicated to ensure that we are using the most effective and safe equipment available. |
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DID YOU KNOW?
We're Attending the Veterinary Dental Forum
Each year, The COVE Dentistry team goes to the Veterinary Dental Forum to expand their knowledge in veterinary dentistry. This forum consists of three days of continuing education on a variety of topics including, but not limited to, endodontics, periodontics, and anesthesia. It takes place in the fall of every year; it will be held in Dallas, Texas in October 2020. More information can be found at:
veterinarydentalforum.org.
Here is a description of what to expect at the forum, courtesy of their website: "The Veterinary Dental Forum is not only the largest veterinary dental conference but also the longest continually running meeting of its type. The Veterinary Dental Forum strives to provide the best veterinary dental program in the world with the finest lectures and labs from the top experts in the veterinary dental field."
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COVE
NEWS - Colleen Fox, DVM
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Dr. Fox has been very busy in the last year. In spring 2019, she began a program o
ffered by the European School for Advanced Veterinary Studies (ESAVS), through which she can achieve her Master's in Veterinary Dentistry. This program can last three to five years and certain prerequisite courses must be completed and passed. The ESAVS website states that
"So far, more than 500 courses in 21 clinical disciplines, with over 10,000 participants from 51 countries have been held. The ESAVS courses are taught by internationally reputed course directors and course masters, most of them Diplomates of the European or American Colleges in their specific disciplines. Thanks to the program design, the dedication of course masters and the office organisation, ESAVS has acquired a worldwide recognition for high quality post-graduate education in veterinary medicine."
Dr. Fox is very excited to be participating in this program, which will help further her knowledge of veterinary dentistry and enable her to provide the gold standard of patient care.
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COVE
NEWS - Recruiting Dogs with CVHD or DCM for New Clinical Trial
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The COVE is pleased to announce that we are currently taking part in a new clinical trial for dogs with CVHD or DCM and are looking for eligible dogs to participate and enroll. Suitable dogs must be presenting with clinical signs of pulmonary edema. Dogs may be newly diagnosed cases not currently receiving medication, or dogs previously diagnosed but not currently receiving diuretic treatment. All study activity (including consult with a cardiologist, echocardiogram, ECG, lab work, radiographs, and treatment) is supplied to your client at no cost. This may be an ideal option for those clients who struggle to afford appropriate care. Your client would be seen at our clinic for the duration of the study only (84 days / 6 visits) and then referred back to your clinic upon study completion.
For more information, please contact Dr. Small at 757.935.9111.
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SEASIDE CE - MAY CONFERENCE CANCELED
Please see new dates below
When: October 11-17, 2020
Tuesday-Thursday:
6pm-9pm
Friday: 9am-2pm
Where: Regency Royale
2760 Sandfiddler Rd.
Virginia Beach, VA 23456
Enjoy the salty air 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. Registration information coming soon.
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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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