Purdue Feline 2022.pptx

Feline Dentistry: Common Diseases and Updated Therapies Matthew Lemmons, DVM, DAVDC MedVet Medical and Cancer Center for Pets Indianapolis, IN Compared to Canine Dentistry Most disease processes seen in the dog are also seen in the cat with exceptions Caries CUPS/CCUS Diseases seen more frequently o...

Feline Dentistry: Common Diseases and Updated Therapies Matthew Lemmons, DVM, DAVDC MedVet Medical and Cancer Center for Pets Indianapolis, IN Compared to Canine Dentistry Most disease processes seen in the dog are also seen in the cat with exceptions Caries CUPS/CCUS Diseases seen more frequently or exclusively in cats Tooth Resorption Chronic Gingivitis and Stomatitis Squamous Cell Carcinoma Malocclusion After Extraction Pyogenic Granuloma Tooth Extrusion MRONJ/BRONJ Anatomic differences are relevant Short infraorbital canal Relationship of masticatory muscles with maxillary artery Maxillary Artery Relationship to Coronoid Process and Masticatory Muscles The blood supply to the feline brain is through branches of the maxillary artery The branches form an arterial rete are located near the coronoid process and between the masseter and pterygoid muscles Stretching of these muscles may compress the arterial rete Spring loaded speculums may cause this and thus use is contraindicated in cats Stiles et. al. Veterinary Journal 193(2) Martin-Flores et. al. J Vet Dent 200(1) Tooth Resorption Synonyms Feline Odontoclastic Resorptive Lesions (FORL) Neck Lesions Cervical Lesions Hard tissue loss of the tooth leading to pain and loss of tooth structure Tooth Resorption Pathogenesis Inciting factor is unknown Mononuclear cells migrate to the periodontal ligament and become odontoclasts Odontoclasts migrate into cementum, then to dentin resorbing hard tissue Enamel may be undermined and lost May be related to vitamin D levels in diet Potential pain once dentin exposed Up to 60% of cats are affected http://cro.sagepub.com/cgi/content-nw/full/15/2/115/ Findings with Cats with Tooth Resorption Am J Vet Res. August 2005;66(8):1446-52. Increased serum levels of 25-hydroxyvitamin D Lower urine SG Higher blood urea nitrogen Cats with tooth resorption are at a higher risk for developing resorption in the future J Vet Dent. 2010 Fall;27(3):142-7. Did not support the same findings Tooth Resorption Types Type I Periodontal ligament is intact Roots are complete Type II Periodontal ligament is absent Roots are replaced by bone Type III Multi-rooted tooth with both type I and II characteristics Tooth Resorption Diagnosis Clinical Signs Dropping food Chattering Turning head while eating Examination Roughness or cavitation near or below the gingival margin Missing teeth Focal gingivitis Pink spot within tooth May see super-eruption of the canine teeth; extrusion Diagnostics Exploration with dental explorer Full mouth dental radiographs Tooth Resorption Treatment Type I resorption or if unsure which type of resorption is present: Complete extraction of complete root and apposition of soft tissue Type II resorption: Crown amputation Remaining dental tissue is removed Newly formed bone (replacing roots) is not removed This treatment may be controversial Inability to visualize the periodontal ligament space alone is not adequate criteria to justify crown amputation Result of Crown Amputation on Tooth with Type I Resorption Alveolar Bone Expansion Expansile inflammation of the alveolar bone, usually found around the maxillary canine teeth May lead to lipping or cupping of the alveolar bone and infrabony pockets (vertical bone loss) Inflamed bone should be removed at time of extraction Extrusion often present Feline Chronic Gingivitis and Stomatitis Chronic and painful inflammatory disease affecting the one or more of the following Gingiva Caudal oral pharynx (not technically faucitis) Mucosa Tongue Infiltrate of lymphocytes and plasma cells Reversal in circulating CD8 and CD4 population ratio Unknown etiology but may be secondary to calicivirus Clinical Findings and Diagnostics +/- Mandibular lymphadenopathy +/- Hyperglobulinemia If atypical appearance, biopsy recommended Full mouth radiographs and full oral examination even if medical therapy is to be considered Available Treatment Options Selective extractions or full mouth extraction Cyclosporine Omega interferon Pentoxifylline Steroids Stem cell transfusion currently being researched Extractions J Vet Dent. March 1997;14(1):15-21. 60% achieved complete cure 20% required no further treatment but had occasional minor relapse 13% still required some medical management 7% received no benefit J Am Vet Med Assoc. March 2015;246(6):654-60. 39% substantial improvement 28.4% complete resolution 26.3% little improvement 6.3% no improvement 68.8% of the substantial or complete improvement group required finite medical management Edenutulous cats will often still eat dry food Feline dentition designed for shearing/tearing not grinding May need smaller kibble Cyclosporine J Vet Dent. 2013 Spring;30(1):8-17. If used after full mouth extraction at 2.5 mg/kg BID >50% improvement in inflammatory score at six weeks >75% of patients showed at least 40% improvement Cats who had previous corticosteroid treatment showed less to no response Modulates immune response via T-helper cells 4-8 weeks to complete effect Omega Interferon Recombinant feline omega interferon Labeled to treat FIV and FeLV Stomatitis Daily oral administration for 100 days May improve clinical signs in 70% of patients Can not get through US distributors MOA unclear Pentoxifylline 5 mg/kg PO once daily May inhibit TNF and neutrophil function/chemotaxis Steroids May be last resort Prednisolone PO 2 mg/kg once daily Stem Cell Therapy IV transfusion of placenta derived allogenic stem cells Currently experimental treatment showing benefit in cats who do not respond to extractions ~70% response rate if patients do not respond to extractions Reduced CD8 lymphocytes Does not appear to be effective as stand alone therapy Neoplasia Squamous cell carcinoma is the most common malignancy of the oral cavity in cats, ~70% Fibrosarcoma is the second most common Odontogenic tumors are rare, but do occur Squamous Cell Carcinoma Overall poor prognosis Locally invasive and slow to metastasize Painful Median survival rates past one year are rare Most successful treatment seems to be for rostral mandible lesions with mandibulectomy followed by curative intent radiation therapy Surgical intervention often leads to acute postoperative morbidity with common long term effects Photo and radiograph courtesy Don Beebe Occlusal Trauma After Extraction Can occur when extracting mandibular molar and maxillary fourth premolar occludes against soft tissue traumatically Extrusion of canine teeth may contribute Treatment is by taking offending tooth out of occlusion and removing mass Crown reduction with restoration +/- endodontic therapy Extraction Can cause pyogenic granuloma Benign inflammatory lesion Confirm with biopsy Pyogenic Granuloma Typically located in the vestibule adjacent to the mandibular first molar Can occur after extraction of the mandibular first molar or due to congenital malocclusion (brachycephalic breeds more often) Hyperplastic and inflamed lesion. Pathologist may read as FCGS. Assess occlusion Tooth Extrusion Super eruption of the canine teeth in cats Extruded teeth have more cementum at the base May be associated with tooth resorption but not necessarily of the extruded tooth. J Vet Dent. June 2008;25(2):8695. Can lead to malocclusion if severe and luxation of the tooth if periodontitis is present Bisphosphonate Related Osteonecrosis of the Jaws (BRONJ) Bisphosphonates are commonly used to treat conditions such as osteoporosis Bisphosphonates have gained popularity in the veterinary community Bone sarcoma related pain Hypercalcemia of malignancy Idiopathic hypercalcemia Representative medications Alendronate Zolendronate Pamridonate Induce apoptosis of osteoclasts Some favor terminology Medication Related Osteonecrosis of the Jaws (MRONJ) BRONJ Necrosis of the jaws resulting in exposed bone May occur after dental surgery Theoretically due to reduced ability for the bone to remodel after trauma BRONJ Treatment In humans, treatment may be conservative (antibiotic therapy) or aggressive resection Best course of treatment in cats is unknown Questions?