Feline Dentistry and Oral Medicine

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Feline Dentistry and Oral Medicine

  1. 1. Feline dentistry and oral medicine
  2. 2. CATS <ul><li>Several oral diseases and lesions are specific to cats </li></ul><ul><ul><li>Buccal bone expansion </li></ul></ul><ul><ul><li>Tooth resorptions/Resorptive lesions </li></ul></ul><ul><ul><li>Viral-induced oral disease </li></ul></ul><ul><ul><li>Lymphocytic-Plasmacytic Gingivostomatitis </li></ul></ul><ul><ul><li>Eosinophilic granuloma complex </li></ul></ul><ul><li>Often idiopathic </li></ul><ul><li>Oral neoplasia is relatively uncommon but highly aggressive </li></ul>
  3. 3. Buccal bone expansion <ul><li>Expression of periodontal disease in cats </li></ul><ul><li>Most commonly affecting the maxillary canines </li></ul><ul><li>Mandibular canines may also be affected to a lesser degree </li></ul><ul><li>Histologically, granulation tissue intercalated within the alveolar bone </li></ul><ul><ul><li>May see some horizontal and vertical bone loss as well </li></ul></ul><ul><ul><li>Granulation tissue tends to form apically and extrudes canine teeth </li></ul></ul><ul><ul><li>Mistakenly referred to as “supereruption” </li></ul></ul>
  4. 4. Buccal bone expansion
  5. 5. Buccal bone expansion <ul><li>Treatment </li></ul><ul><ul><li>If >50% attachment loss, extract tooth SURGICALLY </li></ul></ul><ul><ul><ul><li>Debride disease buccal bone </li></ul></ul></ul><ul><ul><ul><li>**Close the extraction site** </li></ul></ul></ul><ul><ul><li>If <50% attachment loss, meticulous subgingival scaling </li></ul></ul><ul><li>Prevention </li></ul><ul><ul><li>Good home dental care </li></ul></ul>
  6. 6. Tooth Resorptions <ul><li>Etiology unknown </li></ul><ul><ul><li>Does not seem to be an inflammatory process </li></ul></ul><ul><ul><li>No infectious process has been found </li></ul></ul><ul><ul><li>Hypervitaminosis from commercial diets suggested </li></ul></ul><ul><li>Pathogenesis unknown </li></ul><ul><ul><li>Suspected to be an imbalance between odontoblasts and odontoclasts </li></ul></ul><ul><ul><li>Similar to osteoporosis? </li></ul></ul><ul><li>Nomenclature changes frequently </li></ul><ul><ul><li>Resorptive lesions/FORLs </li></ul></ul><ul><ul><li>Neck lesions </li></ul></ul><ul><ul><li>Cat cavities </li></ul></ul><ul><ul><li>Cat caries </li></ul></ul>
  7. 7. Tooth Resorptions <ul><li>Lesions are staged according to the dental tissues affected </li></ul><ul><ul><li>Stage 1 – Enamel or cementum </li></ul></ul><ul><ul><ul><li>Diagnosed with explorer tip </li></ul></ul></ul><ul><ul><li>Stage 2 – Enamel or cementum and dentin </li></ul></ul><ul><ul><ul><li>First stage that can be detected radiographically </li></ul></ul></ul><ul><ul><li>Stage 3 – Enamel/cementum, dentin, and pulp </li></ul></ul><ul><ul><li>Stage 4 – Major loss of tooth substance </li></ul></ul><ul><ul><ul><li>Stage 4a – Crown and roots equally affected </li></ul></ul></ul><ul><ul><ul><li>Stage 4b – Crown affected more than roots </li></ul></ul></ul><ul><ul><ul><li>Stage 4c – Roots affected more than crown </li></ul></ul></ul><ul><ul><li>Stage 5 – End stage resorption </li></ul></ul>
  8. 8. Tooth Resorptions <ul><li>Clinical signs </li></ul><ul><ul><li>Often see severe focal gingivitis or gingival hyperplasia over the lesion </li></ul></ul><ul><ul><li>Teeth that have excessive calculus accumulation should also raise suspicion </li></ul></ul><ul><ul><li>“Pink teeth” in cats usually indicate advanced resorption covered by gingiva </li></ul></ul><ul><ul><li>Lesions are painful </li></ul></ul><ul><ul><li>Lesions progress without treatment </li></ul></ul>
  9. 9. Tooth Resorptions <ul><li>Treatment </li></ul><ul><ul><li>Only definitive treatment is extraction or coronectomy </li></ul></ul><ul><ul><ul><li>Extraction is the gold standard treatment </li></ul></ul></ul><ul><ul><ul><li>Advanced resorptions cannot be extracted completely </li></ul></ul></ul><ul><ul><ul><li>Coronectomy is acceptable in this case unless the cat has stomatitis </li></ul></ul></ul>
  10. 10. Tooth Resorptions
  11. 11. Tooth Resorptions <ul><li>Prevention </li></ul><ul><ul><li>None as etiology is still unknown </li></ul></ul><ul><ul><li>Pamidronates(?) </li></ul></ul>
  12. 12. Viral-induced Oral Disease <ul><li>FCV is a common disease in cats </li></ul><ul><ul><li>10% to 40% of the domestic and feral cat population affected </li></ul></ul><ul><ul><li>Can occur in all breeds, ages, sexes </li></ul></ul><ul><ul><li>Frequently seen in high-density populations </li></ul></ul><ul><ul><li>Disease is often self-limiting </li></ul></ul><ul><ul><li>Many cats will remain chronic carriers </li></ul></ul><ul><ul><ul><li>ssRNA structure of the virus means mutation is common </li></ul></ul></ul><ul><ul><ul><li>Vaccines do not always provide protection </li></ul></ul></ul>
  13. 13. Viral-induced Oral Disease <ul><li>FCV </li></ul><ul><ul><li>Oral manifestations are common expressions of FCV </li></ul></ul><ul><ul><ul><li>Vesiculation </li></ul></ul></ul><ul><ul><ul><li>Ulceration of the tongue and palate </li></ul></ul></ul><ul><ul><ul><li>Acute but self-limiting type of stomatitis </li></ul></ul></ul>
  14. 14. Viral-induced Oral Disease <ul><li>Treatment </li></ul><ul><ul><li>Usually none needed </li></ul></ul><ul><ul><ul><li>Viral diseases usually self-limiting </li></ul></ul></ul><ul><ul><ul><li>Viruses do not respond to antibiotics </li></ul></ul></ul><ul><ul><li>Supportive care </li></ul></ul><ul><ul><li>Secondary infections </li></ul></ul><ul><ul><ul><li>Can occur if immunosuppressed </li></ul></ul></ul><ul><ul><ul><li>Antibiotics may help with secondary BACTERIAL infections </li></ul></ul></ul>
  15. 15. Viral-induced Oral Disease <ul><li>Prevention </li></ul><ul><ul><li>Environmental disinfection </li></ul></ul><ul><ul><li>Quarantine new cats in the household </li></ul></ul><ul><ul><li>Good hygiene </li></ul></ul>
  16. 16. Lymphocytic-Plasmacytic Gingivostomatitis (LGPS) <ul><li>Characterized by clinical signs and presence of lymphocytes and plasma cells on histopathologic examination </li></ul><ul><li>NOT FCV-induced stomatitis </li></ul><ul><li>Etiology unknown </li></ul><ul><ul><li>Thought to be a hyperimmune response to plaque components or plaque bacteria </li></ul></ul><ul><ul><li>Bartonella henselae has been postulated as an etiologic agent but no positive correlation found </li></ul></ul><ul><ul><ul><li>One study actually found a negative correlation </li></ul></ul></ul><ul><ul><li>FHV, FCV, FeLV, and FIV have NOT been shown to have a causal relationship </li></ul></ul>
  17. 17. Lymphocytic-Plasmacytic Gingivostomatitis (LGPS) <ul><li>Clinical signs </li></ul><ul><ul><li>Severe inflammation of the oral cavity extending beyond the mucogingival junction </li></ul></ul><ul><ul><li>Often focused on the caudal oropharynx in the area lateral to the palatoglossal folds </li></ul></ul><ul><ul><ul><li>“ Faucitis” is a misnomer – this region is NOT the fauces </li></ul></ul></ul><ul><ul><ul><li>Fauces - The passage from the back of the mouth to the pharynx, bounded by the soft palate, the base of the tongue, and the palatine arches. </li></ul></ul></ul><ul><ul><li>May have concurrent periodontal disease and/or tooth resorptions but not always the case </li></ul></ul>
  18. 18. Lymphocytic-Plasmacytic Gingivostomatitis (LGPS) <ul><li>Clinical signs </li></ul><ul><ul><li>Most other clinical signs are associated with oral pain </li></ul></ul><ul><ul><ul><li>Ptyalism </li></ul></ul></ul><ul><ul><ul><li>Bleeding from the mouth </li></ul></ul></ul><ul><ul><ul><li>Pawing at the mouth </li></ul></ul></ul><ul><ul><ul><li>Running from the food bowl </li></ul></ul></ul><ul><ul><ul><li>Poor haircoat from reluctance to groom </li></ul></ul></ul><ul><ul><li>Often see hyperproteinemia with severe hyperglobulinemia and reflex hypoalbuminemia </li></ul></ul><ul><ul><li>Often no other changes on CBC/Chem panel </li></ul></ul>
  19. 19. Lymphocytic-Plasmacytic Gingivostomatitis (LGPS)
  20. 20. Lymphocytic-Plasmacytic Gingivostomatitis (LGPS) <ul><li>Treatment </li></ul><ul><ul><li>Conservative management </li></ul></ul><ul><ul><ul><li>Professional periodontal treatment to remove existing plaque and calculus </li></ul></ul></ul><ul><ul><ul><li>Extract teeth with obvious lesions </li></ul></ul></ul><ul><ul><ul><ul><li>Tooth resorptions </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Periodontitis </li></ul></ul></ul></ul><ul><ul><ul><li>Oral home care for continued plaque control </li></ul></ul></ul><ul><ul><ul><ul><li>Tooth brushing </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Antiseptic rinse </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Often very difficult because of the severity of pain </li></ul></ul></ul></ul>
  21. 21. Lymphocytic-Plasmacytic Gingivostomatitis (LGPS) <ul><li>Treatment </li></ul><ul><ul><li>Conservative management </li></ul></ul><ul><ul><ul><li>Antibiotics </li></ul></ul></ul><ul><ul><ul><ul><li>Clavamox is first choice (>90% susceptibility) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Clindamycin is second choice (~86-88% susceptibility) </li></ul></ul></ul></ul><ul><ul><ul><li>Pain management </li></ul></ul></ul><ul><ul><ul><ul><li>Buprenorphine (sublingual or buccal mucosal application) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Tramadol </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Meloxicam – if not on steroids </li></ul></ul></ul></ul><ul><ul><ul><li>Corticosteroids </li></ul></ul></ul><ul><ul><ul><li>Usually only temporarily effective </li></ul></ul></ul>
  22. 22. Lymphocytic-Plasmacytic Gingivostomatitis (LGPS) <ul><li>Treatment </li></ul><ul><ul><li>Surgical management (extractions) </li></ul></ul><ul><ul><ul><li>Start with premolars and molars </li></ul></ul></ul><ul><ul><ul><li>If stomatitis is present at the canines and incisors, extract those as well </li></ul></ul></ul><ul><ul><ul><li>Consider extractions sooner rather than later </li></ul></ul></ul><ul><ul><ul><ul><li>Long-term treatment with steroids can lead to other problems (diabetes) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Possibly increased risk of developing SCC in stomatitis cats </li></ul></ul></ul></ul><ul><ul><ul><ul><li>May take longer to see improvement in cats with prolonged medical management. </li></ul></ul></ul></ul>
  23. 23. Lymphocytic-Plasmacytic Gingivostomatitis (LGPS) <ul><li>Treatment </li></ul><ul><ul><li>Cyclosporine </li></ul></ul><ul><ul><ul><li>Cats who are refractory to treatment </li></ul></ul></ul><ul><ul><ul><li>Alternative to extractions </li></ul></ul></ul><ul><ul><ul><li>Usually compound cyclosporine into liquid suspension </li></ul></ul></ul><ul><ul><ul><li>Dose depends on formulation of cyclosporine </li></ul></ul></ul><ul><ul><ul><li>Generally 5mg/kg </li></ul></ul></ul><ul><ul><ul><li>Checking cyclosporine levels? </li></ul></ul></ul>
  24. 24. Lymphocytic-Plasmacytic Gingivostomatitis (LGPS) <ul><li>Prognosis </li></ul><ul><ul><li>Good prognosis with extractions </li></ul></ul><ul><ul><ul><li>Approximately 60% of cats are cured </li></ul></ul></ul><ul><ul><ul><li>Approximately 20% of cats are significantly improved </li></ul></ul></ul><ul><ul><ul><li>The remaining 20% show little to no improvement and will need subsequent management </li></ul></ul></ul><ul><ul><ul><ul><li>Continued conservative management </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Consider cyclosporine </li></ul></ul></ul></ul>
  25. 25. Lymphocytic-Plasmacytic Gingivostomatitis (LGPS) <ul><li>Prognosis </li></ul><ul><ul><li>Cats with concurrent FIV and/or FeLV infection tend to have a poorer prognosis </li></ul></ul><ul><ul><ul><li>Often do not improve even with complete extraction of all teeth and medical management with steroids and antibiotics </li></ul></ul></ul><ul><li>Prevention </li></ul><ul><ul><li>None known </li></ul></ul><ul><ul><li>Cannot treat disease if etiology is unknown </li></ul></ul>
  26. 26. Eosinophilic Granuloma Complex <ul><li>Unknown etiology </li></ul><ul><ul><li>Thought to be part of an allergic reaction pattern </li></ul></ul><ul><ul><li>Commonality is the presence of eosinophils </li></ul></ul><ul><ul><li>Females tend to be more affected </li></ul></ul><ul><ul><li>Young to middle-aged cats </li></ul></ul><ul><ul><li>No breed predilection </li></ul></ul><ul><li>Complex consists of 3 types of lesions </li></ul><ul><ul><li>Indolent Ulcer * </li></ul></ul><ul><ul><li>Eosinophilic Plaque </li></ul></ul><ul><ul><li>Eosinophilic Granuloma * </li></ul></ul>
  27. 27. Eosinophilic Granuloma Complex
  28. 28. Eosinophilic Granuloma Complex <ul><li>Treatment </li></ul><ul><ul><li>Lesions are non-painful so may not require treatment </li></ul></ul><ul><ul><li>Eosinophilic granulomas may cause dysphagia </li></ul></ul><ul><ul><li>Immunosuppressive doses of corticosteroids </li></ul></ul><ul><ul><li>Adjunct therapy </li></ul></ul><ul><ul><ul><li>Hypoallergenic diet </li></ul></ul></ul><ul><ul><ul><li>Fatty acid supplementation </li></ul></ul></ul><ul><ul><ul><li>Environmental modification </li></ul></ul></ul>
  29. 29. Eosinophilic Granuloma Complex <ul><li>Prognosis </li></ul><ul><ul><li>Good with or without treatment </li></ul></ul><ul><li>Prevention </li></ul><ul><ul><li>None known </li></ul></ul>
  30. 30. Oral neoplasia <ul><li>Oral neoplasia is relatively rare in cats </li></ul><ul><ul><li>Approximately 3-8% of malignant neoplasms occur in the oral cavity </li></ul></ul><ul><ul><li>It is the 4 th most common location for neoplasia </li></ul></ul><ul><ul><li>Benign neoplasms are extremely rare in the cat </li></ul></ul><ul><li>Squamous cell carcinoma is the most common malignant neoplasm (60-80%) in the oral cavity </li></ul><ul><li>Fibrosarcoma is the second most common, followed by lymphoma, others </li></ul><ul><li>Acanthomatous ameloblastomas (previously called adamantinoma in the cat) are extremely uncommon but can occur </li></ul>
  31. 31. Oral Nesoplasia <ul><li>Oral squamous cell carcinoma </li></ul><ul><ul><li>Occurs mainly in older cats </li></ul></ul><ul><ul><li>No breed predisposition </li></ul></ul><ul><ul><li>Previous studies show increased risk in urban populations and smoking households </li></ul></ul><ul><ul><ul><li>Similar to human risk factors </li></ul></ul></ul><ul><ul><ul><li>Environmental factors? </li></ul></ul></ul>
  32. 32. Oral Neoplasia <ul><li>Oral Squamous Cell Carcinoma </li></ul><ul><ul><li>Behaves differently from SCC in other locations </li></ul></ul><ul><ul><li>Extremely aggressive </li></ul></ul><ul><ul><ul><li>Often very osteolytic </li></ul></ul></ul><ul><ul><ul><li>Rapid progression of disease </li></ul></ul></ul><ul><ul><li>Variable in appearance </li></ul></ul><ul><ul><ul><li>Ulcerative </li></ul></ul></ul><ul><ul><ul><li>Proliferative </li></ul></ul></ul>
  33. 33. Oral Neoplasia
  34. 34. Oral Neoplasia <ul><li>Oral Squamous Cell Carcinoma </li></ul><ul><ul><li>Limited treatment options </li></ul></ul><ul><ul><ul><li>Not radiation sensitive </li></ul></ul></ul><ul><ul><ul><li>Resistant to most chemotherapeutic agents </li></ul></ul></ul><ul><ul><ul><li>Difficult to get good surgical margins </li></ul></ul></ul><ul><ul><ul><ul><li>Lesions are fairly large when detected </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Size of cat makes 2cm margins virtually impossible </li></ul></ul></ul></ul><ul><ul><ul><li>Maybe multimodal approach? </li></ul></ul></ul><ul><ul><ul><li>Bisphosphonates? </li></ul></ul></ul>
  35. 35. Oral Neoplasia <ul><li>Oral Squamous Cell Carcinoma </li></ul><ul><ul><li>Mainly hospice-type care </li></ul></ul><ul><ul><ul><li>Pain management </li></ul></ul></ul><ul><ul><ul><ul><li>Piroxicam/Meloxicam </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Buprenorphine </li></ul></ul></ul></ul><ul><ul><ul><li>Supportive care </li></ul></ul></ul><ul><ul><ul><ul><li>Subcutaneous fluids </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Parenteral feeding </li></ul></ul></ul></ul><ul><ul><li>Prognosis is very poor </li></ul></ul><ul><ul><ul><li>Survival time usually 4 – 8 weeks after diagnosis </li></ul></ul></ul><ul><ul><ul><li>Cats are euthanized because of quality of life issues </li></ul></ul></ul>

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