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Veterinary Forum December 2008 (Vol 25, No 12)

Dental Dilemma — Shock's Surprise

by Jan Bellows

    Shock, a 13-year-old, 6-kg, neutered, indoor, domestic shorthaired cat, was referred with a 1-year history of stomatitis in the caudal portion of the oral cavity. Five months before presentation, the referring veterinarian had extracted the left mandibular third premolar and both mandibular molars. One month before referral presentation, the referring veterinarian had prescribed 5 mg of prednisolone PO q24h for 3 weeks, then q48h during the fourth week with little improvement of the stomatitis (Figure 1).

    The cat had a good appetite for commercial food but had lost 0.5 kg during the previous month. The owner also reported increased water consumption and urination frequency.

    The referring veterinarian provided results from a recent complete blood count (CBC) and serum chemistry profile as well as test results for feline heartworm, FeLV, and feline immunodeficiency virus.

    All tests were within normal limits except for mild hyperglobulinemia, with a globulin count of 5.5 g/dl (normal: 2.3-5.3), and absolute eosinophilia, with an eosinophil count of 21% at 2,200/µl (normal: 0-1,000) at 5 months and 18% at 1,674/µl at 3 months before presentation. In addition, glucose test results from 5 months earlier (before surgery) and 3 months earlier (before oral prednisolone had been prescribed) were normal.

    On referral, physical examination revealed a stout, well-fleshed cat with a body score of 4 out of 5. The examination findings were within normal limits.

    Oral examination revealed marked inflammation and hyperplasia involving primarily the areas of the previously extracted mandibular molars extending caudal, rostral, and dorsal (Figure 2).

    A CBC, serum chemistry profile, and coagulation testing were conducted. Abnormalities included creatinine at 3.0 mg/dl (normal: 0.6-2.4), calcium at 11.1 mg/dl (normal: 8.2-10.8), glucose at 445 mg/dl (normal: 64-140), eosinophils at 1,620/µl (normal: 0-1,000), and urine specific gravity of 1.021 with 4+ glucose without ketones.

    Based on the laboratory findings, a diagnosis of nonketonuric diabetes mellitus was made. The initial treatment plan approved by the owner included preanesthetic medication, general anesthesia, and a tooth-by-tooth clinical and radiographic examination. An updated treatment plan would be designed after the initial assessment.

    Buprenorphine at 0.01 mg/kg IM was given as premedication. For induction, diazepam at 0.15 mg/kg was administered IV, followed by propofol at 2 mg/kg. A 3.5-mm endotracheal tube was used to maintain 2% isoflurane and oxygen. The patient's temperature was supported with the Hot Dog Patient Warming System (Augustine Biomedical + Design) with radiant heat.

    Intraoral survey films revealed a first-molar tooth fragment and stage 5 tooth resorption (TR5) of the third premolar in the left mandible (see Classification of Tooth Resorption). Films of the right mandible revealed a prominent molar mesial root fragment as well as stage 5 tooth resorption of the third premolar (Figure 3). Films of the rostral mandible revealed marked bone loss around most of the incisors, which were in stage 3/4 periodontal disease on examination.

    The second treatment plan, which was formulated while the cat was anesthetized and approved by the owner, included biopsy of the lesions overlying the caudal mandibles, extraction of the right and left mandibular cheek teeth, as well as extraction of the maxillary fourth premolars. Maxillary and mandibular regional nerve blocks were performed by injecting 0.1 ml of bupivacaine bilaterally to achieve regional anesthesia of the maxilla and mandible.

    Envelope gingival flaps were created with a No. 15 scalpel blade and Freer periosteal elevator exposing the underlying maxillary and mandibular buccal alveoli. A sterile saline-irrigated, high-speed handpiece with a No. 2 round carbide bur was used to expose the underlying roots. The double-rooted mandibular teeth and triple-rooted maxillary fourth premolars were sectioned to create single-rooted segments. Freshly sharpened wing-tipped elevators were gently rotated perpendicular to the alveolar margin to create sufficient mobility to deliver the tooth segments from the oral cavity using extraction forceps.

    The coronal extent of the lateral alveolus overlying the retained roots in the left mandibular cheek teeth was removed to allow extraction of the root fragments. Intraoral radiographs confirmed extraction (Figure 4). Alveoloplasty using a No. 2 carbide round bur loaded on a sterile saline water-cooled, high-speed handpiece was performed in all exposed areas to smooth the coronal extent of the alveoli before closure. The incised gingiva was closed with 4-0 monocryl suture using a continuous pattern. During the 3-hour operation, blood glucose levels were monitored hourly (490 mg/dl at hour 1, 525 mg/dl at hour 2, and 430 mg/dl at hour 3).

    The cat made an uneventful recovery. For pain relief, buprenorphine at 0.075 mg/kg q12h sublingually was dispensed for 3 days. To control postoperative infection, clindamycin at 10 mg/kg PO was dispensed.

    Management of the elevated blood glucose was left to the referring veterinarian, who had initially administered insulin twice daily and recommended feeding a high-protein, low-carbohydrate diet. Several glucose curves were conducted for 2 weeks after surgery. At the third postoperative week, the insulin dosage was decreased to once daily. Two weeks later, the cat was taken off insulin.

    Biopsy results revealed numerous plasma cells and lymphocytes consistent with gingivostomatitis. There was no evidence of neoplasia.

    At the 2-week postoperative examination, minimal inflammation remained (Figure 5). Clinically the cat was doing well, as reflected by a 0.5-kg weight gain.

    One month later (6 weeks after surgery), examination revealed moderate inflammation dorsal to the mandibular molars (Figure 6). The cat was anesthetized using the same protocol as previously followed. A carbon dioxide laser was used at 4-watt power with a 1.4-mm tip in continuous wave mode to "paint" (raster) the entire inflamed tissue areas (Figure 7). At reexamination both 2 weeks and 1 month after the laser procedure, the inflammation had not returned, and subsequent follow-up likewise showed no signs of inflammation (Figure 8).

    Discussion

    How Shock's diabetes mellitus and gingivostomatitis were diagnosed, managed, and apparently resolved created some interesting challenges. The first was determining what additional tests to conduct before anesthetizing the patient. Arguments against conducting additional testing included relatively normal blood tests 3 and 5 months before presentation, whereas arguments in favor of conducting additional testing included recent weight loss despite a normal appetite.

    The second challenge was determining the next best step for patient care. Options were (1) controlling the diabetes first, then anesthetizing the patient for thorough oral evaluation and treatment or (2) anesthetizing the patient immediately (with or without giving insulin first) to care for the marked gingival inflammation, followed by diabetes therapy. After discussing both options with the owner, oral care was elected first.

    Caudal stomatitis is a common presenting sign in cases of feline chronic gingivostomatitis. The cause is believed to be multifactorial, resulting in a hyperimmune response to plaque. In this case, the caudal stomatitis markedly decreased after removal of the adjacent teeth and underlying root fragments, as well as control of the hyperglycemia.

    The median age of cats affected by gingivostomatitis is 7 years. Patient history often includes dysphagia or anorexia causing weight loss, ptyalism, bruxism (grinding of the teeth), and facial scratching. Usually the patient resists opening its mouth when eating. The cat's hair coat is usually unkempt secondary to poor grooming behavior because of oral pain. Halitosis and bleeding within the oral cavity are common. Glossitis, cheilitis, pharyngitis, and mandibular lymphadenopathy also may be evident.

    In some cats, gingival inflammation is apparent only around the caudal cheek teeth extending past the mucogingival junction to the buccal mucosa. Other cats show marked gingivitis and periodontitis 360° around the incisors, premolars, and/or molars. Caudal stomatitis — incorrectly referred in the past as faucitis — clinically appears as cobblestone-like ulcerative, proliferative, hyperemic lesions on one or both of the lateral palatopharyngeal arches, soft palate, and oropharynx. The inflammation is largely confined to the palatoglossal folds and regions lateral to the folds.

    Caudal stomatitis is present in 85% of cats affected by feline chronic gingivostomatitis. One study found 15% of the cats only had caudal stomatitis without apparent buccal lesions. A positive diagnosis of gingivostomatitis is based on histopathology, which consists of dense infiltrations of plasma cells, primarily with lesser numbers of lymphocytes, neutrophils, and macrophages of the mucosa and submucosa.

    The gingivostomatitis was probably unrelated to Shock's diabetes because gingival inflammation was present before surgery and corticosteroid therapy. The generally accepted treatment for gingivostomatitis is extraction of the teeth in the area of inflammation (for the AVDC Position Statement on the Treatment of Tooth Resorption, go to www.avdc.org). Healing, however, was promoted by bringing the blood glucose level under control. Generally when the teeth caudal to the canines are removed, 60% of cases heal without needing additional attention, 20% need follow-up care, and 20% do not improve. In Shock's case, the mandibular molar teeth were only partially removed initially, which probably predisposed the area to marked continuing inflammation. After removal of the entire molars as well as the adjacent teeth, the inflammation decreased.

    Previously identified risk factors for diabetes in cats include above-average body weight, male gender, a history of corticosteroid or megestrol acetate use, and advanced age. In this case, daily administration of prednisolone was the most likely cause. In cats, chronic hyperglycemia is toxic to the Β” cells that are administering insulin. Therefore, removing the high glucose levels helps the Β cells start to secrete insulin again, reversing glucose toxicity. Diabetic remission often occurs when cats are treated adequately, usually within 1 month to 4 months.

    Blood tests are generally conducted to help evaluate a patient about to undergo anesthesia. When to order blood tests is largely a judgment call. In this case, blood tests were conducted both at 3 and 5 months before surgery and were essentially normal other than elevated eosinophils. Additional blood tests were conducted because of the weight loss and the prescription of steroids to the cat's treatment regimen. The cat's persistent eosinophilia could be from hypersensitivity to diet, parasites (both external and internal), or the environment. Unfortunately, follow-up CBC tests were not conducted by the referring veterinarian.

    Bibliography

    Bellows J. Small Animal Dental Equipment, Materials, and Techniques: A Primer. Oxford, U.K.: Blackwell Publishing; 2004:352-355.

    Bonello D. Feline inflammatory and infectious oral conditions. In: Tutt C, Deeprose J, Crosley DA (eds). BSAVA Manual of Canine and Feline Dentistry, ed 3. Gloucestershire, U.K.: British Small Animal Veterinary Association; 2007:137.

    Lobprise HB. Disorders prevalent in the cat. In: Blackwell's Five Minute Veterinary Consult, Small Animal Dentistry. Oxford, U.K.: Blackwell Publishing; 2007:309.

    Rand JS, Martin GJ. Management of feline diabetes mellitus. Vet Clin North Am Small Anim Pract 2001;31(5):881-913.

    Southerden P, Gorrel C. Treatment of a case of refractory feline chronic gingivostomatitis with feline recombinant interferon omega. J Small Anim Pract 2007;48(2):104-106.

    Wiggs RB. Lymphocytic plasmacytic stomatitis. In: Norsworthy GD, Crystal M, Fooshee S, Tilley LP (eds). The Feline Patient, ed 3. Oxford, U.K.: Blackwell Publishing; 2006:631.

    NEXT: Editor's Note — Poster 'child' for shelter adoptions

    didyouknow

    Did you know... While older patients have similar dental issues as younger ones, many progressive diseases, especially periodontal disease, can take a greater toll during a pet’s golden years.Read More

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