Anatomy. CATS ARE NOT DOGS WHEN IT COMES TO DENTISTRY-applying Oral Assessment, Treatment, and Prevention to your Feline patients

Transcription

1 CATS ARE NOT DOGS WHEN IT COMES TO DENTISTRY-applying Oral Assessment, Treatment, and Prevention to your Feline patients Jan Bellows DVM, Dipl. AVDC, ABVP Fellow Academy of Veterinary Dentistry ALL PETS DENTAL, Weston 1 Anatomy Location, location, location The fauces are defined as the lateral walls of the oropharynx that are located medial to the palatoglossal folds. The areas lateral to the palatoglossal fold, commonly involved in feline stomatitis, are not the fauces.

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3 Pathology-The 3 Biggies Periodontal Disease Tooth Resorption Oropharyngeal Inflammation 8 Gingivitis-Periodontal Disease 9

4 Stage 1 Gingivitis Plaque turns to Rough Tartar Stage 2 Early Periodontal Dz 12 12

5 Stage 3 Moderate Periodontal Dz g Stage 4 Advanced Periodontal Dz Furcation Exposure

6 Tooth Resorption Tooth resorption Stage 1 (TR 1): Mild dental hard tissue loss (cementum or cementum and enamel). Stage 2 (TR 2): Moderate dental hard tissue loss (cementum or cementum and enamel with loss of dentin that does not extend to the pulp cavity). Stage 3 (TR 3): Deep dental hard tissue loss (cementum or cementum and enamel with loss of dentin that extends to the pulp cavity); most of the tooth retains its integrity. Stage 4 (TR 4): Extensive dental hard tissue loss (cementum or cementum and enamel with loss of dentin that extends to the pulp cavity); most of the tooth has lost its integrity. (TR4a) Crown and root are equally affected; (TR4b) Crown is more severely affected than the root; (TR4c) Root is more severely affected than the crown. Stage 5 (TR 5): Remnants of dental hard tissue are visible only as irregular radiopacities, and gingival covering is complete.. Stage 1 lesion extending into cementum or cementum and enamel

7 Stage 2 moderate hard tissue loss affecting the cementum and dentin, and may involve enamel Stage 3 deep dental hard tissue loss extending into the pulp Stage 4 extensive hard tissue (Cementum or cementum and enamel with loss of dentin that extends to the pulp cavity); most of the tooth has lost its integrity.

8 4 a Crown and root equally affected 4 b Crown more affected than root 4 c Root more affected than crown

9 Stage 5 Remnants of dental hard tissue are visible only as irregular radiopacities, and gingival covering is complete. Therapy for all feline root resorption other that non-inflamed stage 5 EXTRACTION Type 1 Tooth resorption types Type 2 Type 1 lesions arise in the cervical area of the tooth and extend inward and/or up and down the root. Type I lesions are inflammatory in nature. Radiographically type I lesions have relatively normal root structure. The more common Type 2 lesion begins subgingivally. Radiographically the roots appear to be resorbing. The periodontal ligament will not be readily recognizable due to ankylosis in Type II lesions. Type 3 Both Type 1 and 2

10 Type 3 Therapy for Type 2 Crown amputation and gingival closure

11 Oropharyngeal Inflammation stomatitis? stomatitis?

12 stomatitis? stomatitis? stomatitis?

13 stomatitis? Stomatitis? Oropharyngeal Inflammation Oropharyngeal inflammation is classifiedby locationas: 1. Gingivitis inflammationof gingiva 2. Periodontitis: inflammation of non-gingival periodontal tissues (i.e., the periodontal ligament andalveolar bone) 3. Alveolar mucositis:inflammation of alveolar mucosa (i.e., mucosa overlying the alveolar process and extending from the mucogingival junction without obvious demarcation to the vestibular sulcus and to the floor of the mouth) 4. Sublingual mucositis:inflammation of mucosa on the floor of the mouth 5. Labial/buccal mucositis: inflammation of lip/cheek mucosa 6. Caudal mucositis: inflammation of mucosa of the caudal oral cavity, bordered medially by the palatoglossal folds and fauces, dorsally by the hard and soft palate, and rostrally by alveolar and buccal mucosa 7. Palatitis: inflammation of mucosacovering the hard and/or soft palate 8. Glossitis: inflammation of mucosa of the dorsal and/or ventral tongue surface 9. Cheilitis: inflammation of the lip (including the mucocutaneous junction area and skin of the lip) 10. Osteomyelitis: inflammation ofthe bone and bone marrow 11. Stomatitis: inflammation of the mucous lining of any of the structures in the mouth; in clinical use the term should be reserved to describe wide-spread oral inflammation (beyond gingivitis and periodontitis) that may also extend into submucosal tissues (e.g., marked caudal mucositis extending into submucosal tissues may be termed caudal stomatitis) 12. Tonsillitis: inflammation of the palatine tonsil 13. Pharyngitis:inflammation of the pharynx

14 Cheilitis: inflammation of the lip (including the mucocutaneous junction area and skin of the lip) Glossitis:inflammation of mucosa of the dorsal and/or ventral tongue surface Tonsillitis:inflammation of the palatine tonsil

15 Palatitis: inflammation of mucosacovering the hard and/or soft palate Osteomyelitis: inflammation of the bone and bone marrow The gingivaconsists of the mucosal tissue that lies over the alveolar bone surrounding the teeth and provide a seal around them

16 Gingivitis Inflammation of the gingiva Periodontium tissue that support the tooth-gingiva, periodontal ligament, cementum, alveolar bone g

17 Periodontitis: inflammation of non-gingival periodontal tissues ( the periodontal ligament and alveolar bone ) Periodontal Attachment

18 Alveolar mucositis:inflammation of alveolar mucosa ( mucosa overlying the alveolar process and extending from the mucogingival junction ) Alveolar mucositis Labial mucositis: inflammation oflip/cheek mucosa

19 Buccal mucositis Sublingual mucositis: inflammation of mucosa on the floor of the mouth

20 Caudal mucositis: inflammation of mucosa of the caudal oral cavity, bordered medially by the palatoglossal folds and fauces, dorsally by the hard and soft palate, and rostrally by alveolar and buccal mucosa Marked caudal mucositis extending into submucosal tissues may be termed caudal stomatitis Stomatitis: inflammation of the mucous lining of any of the structures in the mouth; in clinical use the term should be reserved to describe wide-spread oral inflammation (beyond gingivitis and periodontitis) that may also extend into submucosal tissues

21 Treatment? Gingivitis-Professional oral care, OraVet and home care For moderate to advanced cases of oral inflammation: Extraction of teeth in the area of inflammation Extraction of teeth caudal to the canines Extraction of all teeth 60 % cured 20% needed follow up care 20% not helped Medical options? Corticosteroids-repositol NO NO NO Non-Steroidal Anti-Inflammatory and Immune Modulating Drugs Solganol, Gold Salts (Shering): 1 mg/kg IM every week until improvement (up to 4 months), then every days Piroxicam: compounded into a liquid and administered at 1 mg/catorally every 72 hours; side effects of piroxicam include gastrointestinal ulceration. Azathioprine: A 50 mg tablet is crushed into 15 ml of liquid vitamin syrup; give 0.3 mg/kg (0.33 ml/8 lb) every 48 hours. Antimicrobials Clindamycin 3-5 mg/kg BID for days Amoxicillin/clavulanate potassium mg/kg BID for 7-10 days

22 More meds.. Chlorambucil 2 mg/kg orally every other day or 20 mg/kg every other week. Bovine lactoferrin 40 mg/kg applied to the oral mucosa. Megestrol acetate 1 mg/kg every 1-4 days consistently decreasing inflammation but predisposing the patient to weight gain, polydipsia, polyuria, and diabetes mellitus. Levamisole 2mg/kg three times per week. Doxycycline has inhibitory effects on the secretion of matrix metalloproteins by gingival PMNs resulting in a decrease in collagen destruction in the gingiva. Eicosanoids are compounds derived from C 20 fatty acids (eicosanoic acids), including prostaglandins, leukotrienes, thromboxanes, and hydroxyeicosatetraenoic acids. Lysine 250mg/cat BID (Enisyl-F dosing syringe with 250mg/ml,Vetoquinol) Cyclosporine is alters the immunological response from blocking T-helper cells. The Sandimmune (Schering-Plough) has an expected absorption rate on oral administration of about 30% and Neoral (Novartis) about 60%. Recommended dosageis 2mg/kg BID, up to 7.5 mg/kg BID. Cyclosporin should only be administered to indoor cats (outdoor cats are at higher risk of infection (especially toxoplasmosis). Interferon (Virbagen [FelFN], Virbac) has antiviral and antiproliferative effects. Use of interferon in cases of refractory chronic gingivostomatitis may decrease the calicivirus load IU orally daily or 1 IU submucosal injection into the caudal oral cavity every two weeks. The preferred method is 5 IU via submucosal administration at the junction between healthy gingiva and diseased tissues immediately post operatively when the cat is still anesthetized 1 unit/kg FelFN SC every other day for five treatments; after the fifth dose 10,000 IU in 2 mnl of isotonic saline given orally once daily for two months, then every other day for the third month. Surgery Oropharyngeal inflammation resolved following FME

23 Selective extractions Selective extractions

24 Extraction Essentials Extra sharp winged tipped elevators Cislak, Miltex, Cbidental.com Extra illumination and magnification Intraoral radiographs Sharp wing tipped elevators Illumination and Magnification

25 Intraoral Radiology

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27 Periodontal disease and alveolar mucositis

28 Buccal, caudal mucositis

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30 Not everything inflamed in the cat s mouth is benign Laser? Laser for persistent inflammation and Juvenile Alveolar Mucositis

31 Juvenile Alveolar Mucositis After tooth-by-tooth exam Intraoral radiographs Extract those teeth affected by significant periodontal support

32 After Cleaning and Polishing C02 laser over the inflamed areas right mandible

33 Therapeutic Class IV Laser post op Outpatient follow up 99

34 Plaque-Tartar Prevention 100 OraVet

35 SANOS 105

36 Plaque/Tartar Retardation-VOHC

37 109 Review Not all cases of feline oropharyngeal inflammation should be termed stomatitis Extraction generally results in a cure for marked feline oropharyngeal inflammation Laser therapy generally improves the remaining cases