Feline dentistry and oral medicine

1. Feline dentistry and oral medicine

2. CATS • Several oral diseases and lesions are specific to cats • Buccal bone expansion • Tooth resorptions/Resorptive lesions • Viral-induced oral disease • Lymphocytic-Plasmacytic Gingivostomatitis • Eosinophilic granuloma complex • Often idiopathic • Oral neoplasia is relatively uncommon but highly aggressive

3. Buccal bone expansion • Expression of periodontal disease in cats • Most commonly affecting the maxillary canines • Mandibular canines may also be affected to a lesser degree • Histologically, granulation tissue intercalated within the alveolar bone • May see some horizontal and vertical bone loss as well • Granulation tissue tends to form apically and extrudes canine teeth • Mistakenly referred to as “supereruption”

4. Buccal bone expansion

5. Buccal bone expansion • Treatment • If >50% attachment loss, extract tooth SURGICALLY • Debride disease buccal bone • **Close the extraction site** • If <50% attachment loss, meticulous subgingival scaling • Prevention • Good home dental care

6. Tooth Resorptions • Etiology unknown • Does not seem to be an inflammatory process • No infectious process has been found • Hypervitaminosis from commercial diets suggested • Pathogenesis unknown • Suspected to be an imbalance between odontoblasts and odontoclasts • Similar to osteoporosis? • Nomenclature changes frequently • Resorptive lesions/FORLs • Neck lesions • Cat cavities • Cat caries

7. Tooth Resorptions • Lesions are staged according to the dental tissues affected • Stage 1 – Enamel or cementum • Diagnosed with explorer tip • Stage 2 – Enamel or cementum and dentin • First stage that can be detected radiographically • Stage 3 – Enamel/cementum, dentin, and pulp • Stage 4 – Major loss of tooth substance • Stage 4a – Crown and roots equally affected • Stage 4b – Crown affected more than roots • Stage 4c – Roots affected more than crown • Stage 5 – End stage resorption

8. Tooth Resorptions • Clinical signs • Often see severe focal gingivitis or gingival hyperplasia over the lesion • Teeth that have excessive calculus accumulation should also raise suspicion • “Pink teeth” in cats usually indicate advanced resorption covered by gingiva • Lesions are painful • Lesions progress without treatment

9. Tooth Resorptions • Treatment • Only definitive treatment is extraction or coronectomy • Extraction is the gold standard treatment • Advanced resorptions cannot be extracted completely • Coronectomy is acceptable in this case unless the cat has stomatitis

10. Tooth Resorptions

11. Tooth Resorptions • Prevention • None as etiology is still unknown • Pamidronates(?)

12. Viral-induced Oral Disease • FCV is a common disease in cats • 10% to 40% of the domestic and feral cat population affected • Can occur in all breeds, ages, sexes • Frequently seen in high-density populations • Disease is often self-limiting • Many cats will remain chronic carriers • ssRNA structure of the virus means mutation is common • Vaccines do not always provide protection

13. Viral-induced Oral Disease • FCV • Oral manifestations are common expressions of FCV • Vesiculation • Ulceration of the tongue and palate • Acute but self-limiting type of stomatitis

14. Viral-induced Oral Disease • Treatment • Usually none needed • Viral diseases usually self-limiting • Viruses do not respond to antibiotics • Supportive care • Secondary infections • Can occur if immunosuppressed • Antibiotics may help with secondary BACTERIAL infections

15. Viral-induced Oral Disease • Prevention • Environmental disinfection • Quarantine new cats in the household • Good hygiene

16. Lymphocytic-Plasmacytic Gingivostomatitis (LGPS) • Characterized by clinical signs and presence of lymphocytes and plasma cells on histopathologic examination • NOT FCV-induced stomatitis • Etiology unknown • Thought to be a hyperimmune response to plaque components or plaque bacteria • Bartonella henselae has been postulated as an etiologic agent but no positive correlation found • One study actually found a negative correlation • FHV, FCV, FeLV, and FIV have NOT been shown to have a causal relationship

17. Lymphocytic-Plasmacytic Gingivostomatitis (LGPS) • Clinical signs • Severe inflammation of the oral cavity extending beyond the mucogingival junction • Often focused on the caudal oropharynx in the area lateral to the palatoglossal folds • “Faucitis” is a misnomer – this region is NOT the fauces • 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. • May have concurrent periodontal disease and/or tooth resorptions but not always the case

18. Lymphocytic-Plasmacytic Gingivostomatitis (LGPS) • Clinical signs • Most other clinical signs are associated with oral pain • Ptyalism • Bleeding from the mouth • Pawing at the mouth • Running from the food bowl • Poor haircoat from reluctance to groom • Often see hyperproteinemia with severe hyperglobulinemia and reflex hypoalbuminemia • Often no other changes on CBC/Chem panel

19. Lymphocytic-Plasmacytic Gingivostomatitis (LGPS)

20. Lymphocytic-Plasmacytic Gingivostomatitis (LGPS) • Treatment • Conservative management • Professional periodontal treatment to remove existing plaque and calculus • Extract teeth with obvious lesions • Tooth resorptions • Periodontitis • Oral home care for continued plaque control • Tooth brushing • Antiseptic rinse • Often very difficult because of the severity of pain

21. Lymphocytic-Plasmacytic Gingivostomatitis (LGPS) • Treatment • Conservative management • Antibiotics • Clavamox is first choice (>90% susceptibility) • Clindamycin is second choice (~86-88% susceptibility) • Pain management • Buprenorphine (sublingual or buccal mucosal application) • Tramadol • Meloxicam – if not on steroids • Corticosteroids • Usually only temporarily effective

22. Lymphocytic-Plasmacytic Gingivostomatitis (LGPS) • Treatment • Surgical management (extractions) • Start with premolars and molars • If stomatitis is present at the canines and incisors, extract those as well • Consider extractions sooner rather than later • Long-term treatment with steroids can lead to other problems (diabetes) • Possibly increased risk of developing SCC in stomatitis cats • May take longer to see improvement in cats with prolonged medical management.

23. Lymphocytic-Plasmacytic Gingivostomatitis (LGPS) • Treatment • Cyclosporine • Cats who are refractory to treatment • Alternative to extractions • Usually compound cyclosporine into liquid suspension • Dose depends on formulation of cyclosporine • Generally 5mg/kg • Checking cyclosporine levels?

24. Lymphocytic-Plasmacytic Gingivostomatitis (LGPS) • Prognosis • Good prognosis with extractions • Approximately 60% of cats are cured • Approximately 20% of cats are significantly improved • The remaining 20% show little to no improvement and will need subsequent management • Continued conservative management • Consider cyclosporine

25. Lymphocytic-Plasmacytic Gingivostomatitis (LGPS) • Prognosis • Cats with concurrent FIV and/or FeLV infection tend to have a poorer prognosis • Often do not improve even with complete extraction of all teeth and medical management with steroids and antibiotics • Prevention • None known • Cannot treat disease if etiology is unknown

26. Eosinophilic Granuloma Complex • Unknown etiology • Thought to be part of an allergic reaction pattern • Commonality is the presence of eosinophils • Females tend to be more affected • Young to middle-aged cats • No breed predilection • Complex consists of 3 types of lesions • Indolent Ulcer * • Eosinophilic Plaque • Eosinophilic Granuloma *

27. Eosinophilic Granuloma Complex

28. Eosinophilic Granuloma Complex • Treatment • Lesions are non-painful so may not require treatment • Eosinophilic granulomas may cause dysphagia • Immunosuppressive doses of corticosteroids • Adjunct therapy • Hypoallergenic diet • Fatty acid supplementation • Environmental modification

29. Eosinophilic Granuloma Complex • Prognosis • Good with or without treatment • Prevention • None known

30. Oral neoplasia • Oral neoplasia is relatively rare in cats • Approximately 3-8% of malignant neoplasms occur in the oral cavity • It is the 4th most common location for neoplasia • Benign neoplasms are extremely rare in the cat • Squamous cell carcinoma is the most common malignant neoplasm (60-80%) in the oral cavity • Fibrosarcoma is the second most common, followed by lymphoma, others • Acanthomatous ameloblastomas (previously called adamantinoma in the cat) are extremely uncommon but can occur

31. Oral Nesoplasia • Oral squamous cell carcinoma • Occurs mainly in older cats • No breed predisposition • Previous studies show increased risk in urban populations and smoking households • Similar to human risk factors • Environmental factors?

32. Oral Neoplasia • Oral Squamous Cell Carcinoma • Behaves differently from SCC in other locations • Extremely aggressive • Often very osteolytic • Rapid progression of disease • Variable in appearance • Ulcerative • Proliferative

33. Oral Neoplasia

34. Oral Neoplasia • Oral Squamous Cell Carcinoma • Limited treatment options • Not radiation sensitive • Resistant to most chemotherapeutic agents • Difficult to get good surgical margins • Lesions are fairly large when detected • Size of cat makes 2cm margins virtually impossible • Maybe multimodal approach? • Bisphosphonates?

35. Oral Neoplasia • Oral Squamous Cell Carcinoma • Mainly hospice-type care • Pain management • Piroxicam/Meloxicam • Buprenorphine • Supportive care • Subcutaneous fluids • Parenteral feeding • Prognosis is very poor • Survival time usually 4 – 8 weeks after diagnosis • Cats are euthanized because of quality of life issues