Welcome, welcome to this presentation. My name is Doctor David Clark. I'm a veterinary dental specialist based in Australia with a referral practise, and I also teach at Melbourne University and also across the Tasman in New Zealand at at Massey University.
So today's presentation is on feline dentistry. I think this is an interesting topic because there's not really, and as you'll find over the next 45 minutes to an hour, we really don't know a lot about cats, to be honest, dental wise in cats. Quite a few topics I guess that I'm gonna bring up extrapolated from human dentistry.
Some are really just, we've tried it over a few years and it seems to work, and others, we've just got no idea, to be honest. Anyway, we'll motor on and we'll see what the topic brings up. So, what I thought we'd do initially is have a look at the normal cats or the healthy cat's mouth initially.
And maybe why we would take a radiograph. And then I've divided the presentation into, I guess ages is probably the best way to describe it. And looking at some of the oral conditions, between, say, the juveniles and then the middle-aged cats, and then older cats.
In particular, some of the juvenile conditions such as gingivitis and periodontitis. I then wanted to have a look, I guess just briefly at periodontal disease because we already know heaps about periodontal disease, but I just thought I'd give you a couple of things that we can do, with a cat with periodontal disease and how you can treat some of those conditions. They wanted to look at tooth resorptions, which in all honesty, we don't really know a huge amount about.
And then at the end, we'll just touch on, have a look at some of the stomatitis that we, that we see as well. So, normal, what's normal? Well, when we look in a cat's mouth, we should have a healthy oral cavity.
And that means, as you can see on the right hand side here, we have white teeth, canines and premolars and molars, incisors, as we can see here. There shouldn't be any plaque or calculus on the tooth surface, and the gum should be nice and pink and actually adhere tightly to the tooth surface. So inflammation is disease, so we should have nice white teeth and nice pink gums.
Now, when a cat comes into your clinic and they actually have some disease, or you're gonna anaesthetize them to clean their teeth, I would advise you, to take a radiograph. In fact, I would advise you to take full mouth radiographs on all cats that come into the, into the clinic for a, for a surgery. In fact, Even if they're not coming in for a dental procedure.
So, in theory, and what we've taught our technicians in the practise, is to take full mouthed radiographs on the radiographs on the cats when they come in, for a procedure when they're young. So when they're even 6 months of age for desexing, it probably adds about 5 minutes literally to your procedure. You then have a baseline for that particular cat.
You don't then have to take radiographs on every cat every single time it comes into the clinic. You could just then use a probe in your eyes. But it's a really good idea to, take radiographs at the start and then radiographs, when they come in for a dental procedure.
So this is just a slide just showing you what normal is. We can see that the, there's a crown and there's a root, the opp canals in the middle. And I'll let you, just digest that, yourself as well.
But that's essentially what, what normal is. And why would we take radiographs? Well, there's a few studies out now.
And while we say at the first visit every cat should have full mouth radiographs, I think when this was actually published, Frank Pastrati published this just over 20 years now. He meant the first dental visit, meaning that when your cat came in and it had a dental problem, you should take full mouth radiographs on the cat. But I would encourage you to actually go one step further and actually take full mouth radiographs on the cat that comes in before they have a dental problem, so you actually have a baseline.
And why would you take full mouth radiographs? Because it yields so much information and it is highly justifiable. And from their studies, what they found was that tooth resorptions are often missed on clinical examination and were diagnosed in 8.7% of cats.
So that's about, you know, 1 in 12 cats, give or take, that will actually have tooth resorptions that you can't actually see just on your clinical examination. And many other clinical, clinical lesions as well. So I'd encourage you if you've got access to that particular study, to, to read it.
Because it actually is, is really interesting and it just shows, you know, how much additional information, clinical additional information you'll get by taking, veterinary dental, radiographs. So, What I thought we'd do is split up this presentation based on age. So the first group of cats that I actually wanted to look at was the juvenile cat.
And this is really cats that are 12 months of age, give or take 12 months of age. And we often see they have various viral infections. The two most common dental problems they they actually suffer is a juvenile onset gingivitis and a juvenile onset periodontitis.
The other conditions there like gingivostomatitis, tooth resorptions, maocclusions, and crowding do occur, but at a much significantly lower, lower level. So I thought what we'd do is look at gingivitis first. So, unfortunately, this is my cat.
Always has to be the veterinarian's cat, doesn't it? And, he came in, his name's Ziggy, and he came in, and we actually, he came from a breeder, and he, my wife was actually the one that picked it up and found that he had really, really bad halitosis. So, being the veterinarian, you know, she calls me and says, you better have a look at the cat's mouth.
And I opened his mouth, and this is what I saw. So, I thought, Oh my lord. Anyway, he had juvenile gingivitis, and juvenile gingivitis normally occurs about the time of teething.
It often occurs in Burmese, Siamese, Abyssinians, Persians, and we, we can also have Maine Coons, we could probably add to that list as well. We, as I said, we don't really know what causes it. I think it would be probably related to teething and also maybe plaque buildup on the tooth surface in the cat's immune response to that particular disease.
The thing to note about this versus periodontitis, which I'll show you in a minute. Is that when you take radiographs of the cat's mouth, so obviously you're gonna anaesthetize the cat first. The cat here is anaesthetized, and I've taken a photograph of him.
We then tube him and put him on fluids, etc. Etc. But when you take radiographs of the cat's mouth, what you'll find is that there's no loss of bone, there's no deepening of the periodontal pockets, so there's no loss of attachment.
So you literally have a, a hyperemia and a hyperplasia of the ginger in gingivitis. So you take your probe and you measure around the tooth, and the attachment is in the, in the normal spot, in the correct anatomical position. So you, the way you treat this is gingivoplasty.
I would use a scalpel blade rather than quartery or, I suppose you could use laser, but I haven't actually used laser. I've always used a scalpel blade. But I wouldn't use quarterri, cause you don't want to cook the tooth and, and you don't want to cut the gum.
Cause you wanna actually cut the gum and resect it, so you leave about 1 millimetre of gingiva left. So just below the, you go gingival line. You want to leave about 1 millimetre of, of gum.
You then need really good home care. I personally like a product called Maxigard. It's a vitamin C and zinc, based product.
I think it's available in most, most countries, now. Also an abrasive diet, like one of the abrasive diets, you know, like Hill's TD, for example, or Royal Canon Dental Food, or any of the others that have like dental properties as well. Those two I mentioned because they've got the VOHC, seal of approval.
There's others, available as well. Those two are just available, here in Australia. You could use a finger cloth as well, maybe a zinc impregnated finger cloth or just a, a plain finger cloth with some water or a toothbrush, just to continue to keep the plaque off.
And hopefully, with some anti-inflammatories, as well, you might find using, you know, one of the, one of the non-steroidals like a meloxicam, you'll also get that under control. The other condition which is also seen in, in really young cats is juvenile periodontitis. So this is essentially the same as gingivitis, except the disease extends into the surrounding tissues.
So into the alveolar bone, into the periodontal ligament, and into the surrounding, tissues of the teeth as well. And I guess the big difference here is that you can see that the inflammation extends beyond the mucogingival line. You've also got some gingival recession of that canine tooth in the top picture.
And on radiograph, You can see you've got tooth resorptions, you've got loss of alveola bone, like the 3rd, pre-molar there on the right-hand side of that radiograph has got significant bone loss. It's got urcation exposure, and slight loss of the, of the mesial root as well. The difference between gingivitis and periodontitis, I guess, is the extent of the disease, as well.
Same as before, general anaesthetic, radiographs, clean the teeth. In this case, you'd need to do extractions. I would extract, both the molar and the third pre-molar in this case, as they've got significant bone loss and also resorptions.
Pain control is really important, so anti-inflammatories, home care, as, as we discussed a minute ago. If the person can actually brush their cat's teeth, that's, that's magnificent, and then, feeding an abrasive diet, as well. The middle-aged cats get similar diseases, to the, to the juveniles, but we see a lot more adult periodontitis.
And we also seem to see in our practise, a lot of tooth resorptions, in these cats as well. And some gingivos dermatitis. Occasionally, FIV is seen in these cats, so it'll make the other diseases worse.
And also we see some eoinophilic granulomas and occasionally some neoplastic conditions as well. So I thought I'd briefly just touch on adult periodontitis and just show you how we could treat a couple of these, these conditions. So as you're aware, and I don't really need to tell you all about periodontitis and periodontal disease because you've probably had that from numerous sources before, but one thing to note is that it's a multifactorial disease.
So it requires more than just plaque. The primary cause is plaque, so once you get bacteria and the glycoproteins attaching to the two surface and gingivitis occurring, it can obviously then extend into the deeper. Tissues when we'll then call it periodontitis.
But you need other things to occur as well. So you might need some hair caught around the teeth, you might need some stress, as well. You might need some overcrowding.
Do you need other factors as well for periodontal disease to actually extend from gingivitis, into more severe, periodontitis. So we can see two, photographs here. The left-hand side is a cat with straight adult, adult onset, slow, periodontal disease, and it's got gingivitis.
We can see that the gingiva, is inflamed there. And then on the right hand side, we can see that the disease is like extended, as well. And you can see this is the same picture as the cat with the really severe, juvenile periodontitis as well, because essentially it looks a very similar.
You've got inflammation into the mucosa, you've got recession of, of the gum, as well. We diagnose adult periodontitis by radiographs and using a periodontal probe. So here is a cat, using, using, a periodontal probe to determine the extent of the periodontal disease.
So the probe is placed into the gingival sulcus. A sulcus is a normal depth of, space around the tooth, and in a cat, it's normally up to about 1 millimetre deep. If it becomes a pocket, meaning we've actually lost epithelial attachment, and we're now getting infection and inflammation into the surrounding tissues like the cementum and the alveolar bone, then we'll have a much deeper pocket, so 2 millimetres or greater, as well.
Measurement is taken by using a steel or a metal periodontal probe, generally speaking, it has markings on it. As we can see by the clinical picture on the upper right-hand side, the probe is placed underneath the gum. Into the periodontal sulcus or into the periodontal pocket, down the side of the tooth, until you get resistance where the epithelial attachment is, and you then take a measurement from the depth of the periodontal space, sulcus or pocket to the free gingival margin.
And that will give you the, the depth of the sulcus or the pocket. As I said, sulcus up to 1 millimetre, pocket greater than 2 millimetres. And then, you know, you've got severe disease if you've got a periodontal pocket.
So we normally record these measurements on a dental chart adjacent to where the tooth position is. There's various paper dental charts around. There's some electronic dental charts around there as well.
I've put one of the websites for the electronic dental charts. But legally, I think it's a great idea. And also from a historical, Reason, so when you actually go back and actually look at your records, you'll actually be able to look and say, ah, that particular cat last time had a pocket of 6 or 7 millimetres.
Now it's got a pocket of 9 millimetres, so the disease is obviously getting worse. Or the disease used to be 5 millimetres, now it's 2 millimetres, so that's, that's a reason why you would measure using your periodontal probe. So from a treatment point of view, if a cat came in, for example, there's products on the market that can help treat periodontal disease or periodontitis.
So I thought I'd just show you, one. So what we see commonly in, in the cats here in Australia, and I assume worldwide, is we get palatal pockets on the maxillary canine teeth, as you can see on the left hand, picture here. It's a palatal pocket that elevator is just pushing the gum across to the, to the palatal side and there's a deep pocket running down the palatal side of the of the canine tooth.
And when you take a radiograph, we can see the same, area there. The actual canine tooth has a small void or a small radiolucent area on the palatal side, which is on the right hand side in this particular radiograph. You can see there's a radiolucent area where the cat has actually lost bone around that, that canine tooth.
And moving across, you can see that there's 6 incisors. There's the 6, teeth on the lower right-hand side of that radiograph. And the one closest to the canine tooth, you can see actually has a fracture.
So, that, that particular incisor tooth would be extracted. But if we've got a deep pocket like on that canine tooth, you wouldn't need to extract that. You could actually use, a product like one of the doxycycline gels, for example, which I'll show you, show you now.
So here's the same picture, and I've put some lines and some circles there just to demonstrate exactly what I'm, I'm talking about. So the yellow line, shows, loss of the periodontal ligaments along the buck or root surface with little or no bone loss. So you've actually got a little periodontal pocket.
So if you were to place your probe down that side of the tooth, you would actually get a deeper periodontal pocket. So in this case, about 5 to 6 millimetres on the buckle side of that particular canine tooth, which is where the yellow, yellow line is. And you can actually see that the periodontal ligament is slightly wider on that side of the tooth.
Then in the purple circle, which is on the palatal side of that canine tooth, we can see that there's a radiolucent area there, which has loss of both the periodontal ligament, but we've also lost a reasonable amount of the alveolar bone. So there's a physical, area of void there or a defect there, which is then gonna fill up with hair and food and, and whatever else the cat is, is chewing on. And the infection and the bacteria that are then inside that pocket, are going to use like the anaerobes are gonna use up all of the oxygen in the pocket, which creates a magnificent, or a magnificent environment for the anaerobic bacteria to, to grow and, and multiply.
So you're gonna get a much higher number of anaerobes, and the anaerobes then are going to produce coaginases and various other tumour necrosis factor and various other, toxins that are going to destroy the peridontal ligament, which is made up of collagen and also the alveola bone. So then it becomes a progressive, progressive disease. So we can then, if we take a radiograph, because if we're thinking we need to treat this tooth, we want to make sure that we haven't got other disease like an endodontic disease, for example, or damage around the perapical area.
So we want to look at the perapical area and just make sure that it's healthy. In this case, where the red arrow is pointing, we've got a normal peri periapical area. So this would be an ideal cat, for treatment where we could clean the roots surface with a, with a cure.
And then place a, a medication into that particular, into that space. So what we do is we use a curette, which is a hand instrument, and you place that down into the space, into the periodontal pocket. And with a sharp blade, you scrape all of the exposed root surface, removing all of the endotoxins, all of the food, all the debris, all the hair, everything else that's in the pocket.
So you're left with a clean void around the surface of the, of the tooth. I think in my hands, I could successfully Treat this using a paraceutical, in this case we'd use Doxyro, which is a doxycycline based product. And I think I could successfully do it if I'd lost up to about 40 to 50% of the length of the root, as in lost the bone and support, as long as the tooth isn't like really mobile and, and really wobbly.
So after the area is cleaned out, we then inject the doxy robe, the doxycycline. It's a gel. It comes as a gel.
And once it becomes wetted and warm inside the, the actual patient's body, it actually becomes hard, so it sets rock hard like a cement. And you can see on the, the right-hand side, That, we've then got replacement of the tissues back onto the, the tooth again. So if you were to then go back in about 3 to 4 months' time and actually take your probe, and often we can do this in the consulting room, if the cat will sit there, we'll get replacement or reattachment, I guess.
I guess you'd call it, rejuvenation of, of the, of the tissues and reattachment of the The, the bone and, and the soft tissue back onto the tooth, you can actually take your probe and run it around the tooth, and you should have normal, normal sulcus depths, as well. The important, I guess, caveat here is though that you need a client that's actually willing to keep the teeth clean, and brush the teeth, as well, because there's no point just putting it in there and, and hoping that, you know, the disease will just disappear and go away, because that's probably why it started in the first place. So that's actually quite a, a, a novel way and a, and a good way to help clean and, and fix some of the periodontal issues.
Older cats or senior cats, we'll call 8 years or older, they get, a completely different set of, of diseases as well. So they get periodontal disease, as you're well aware, which we just discussed. They also get, tooth resorptions.
Cats over about 6 years of age get tooth resorptions. We also see, oral tumours in, in older cats. And stomatitis, as well, and some of the systemic diseases that sometimes can manifest as, as oral diseases.
But the two I thought we would, have a look at now is, in particular, tooth resorptions, which in honest, honesty, we don't really know a large, amount about. We don't know why they occur yet, and we really don't have a solution, to actually fix them. But, We, we, we'll have a look at those and then we'll have a look at stomatitis, after that.
So, the clinical presentation of tooth resorptions, which you'd all be well aware of, is essentially the cat that comes in, either because it, it won't eat, it can't eat, it's too sore around its mouth, or it has like halitosis, or sometimes we even have owners who will tell us that the cat has got like a jittery sort of jaw shattering sort of appearance, I guess. Or sometimes the cat will be pouring in its mouth or rubbing its head along the ground, as well. When you look inside the cat's mouth, it all looks similar to this.
This is quite severe, but you can see on this photograph on the right hand side, if you look at the mandible, you've got the molar tooth on the left hand side, which has quite a severe, tooth resorption in the distal root. Then you have a focation exposure in the pre-molar adjacent to it with a focation in there as well. In the upper jaw, we have tooth resorptions in both of those pre-molars with gingiva, growing into them.
And then we have some gingival recession on the, on the canine tooth. We often find these lesions are hidden. They're often covered in plaque or calculus.
The gum, often the gingiv will often, become really hyperemic and hyperplastic and actually grow into the, the physical lesions. So sometimes it's difficult to see, the lesion. It does have an appearance.
It looks like a tooth resorption though. This is obviously super gingerly. And if you were to get an explorer probe, you'd be very, a brave person to actually do it in a white cat in the consulting room, cause the cat would probably jump up and scratch and bite and go absolutely crazy.
But if the cat was anaesthetized, one of the things you can do is just touch the, the tooth resorption with an explorer probe, and often the jaw will chatter because of the, the, the pain, not pathonemonic, but, but sometimes can be a good indicator that there's something going on there. We also find that there's a significant number of tooth resorptions, sub gingerly, which you may not see if you just look inside the cat's mouth, as well. And that's the benefit of taking a, a radiograph as well.
So I've written a bit of a list here. We see them more commonly, in this part of the world in Oriental breed cats. So the Burmese would have to be really high up on that list.
Abyssinians, Siamese are also up there, but Burmese would be my number one, cat that we see tooth resorptions in. There's no sex predisposition or no breed predisposition. They certainly do increase with age.
I'm sure we do see quite a large number of them in younger cats that may be, early, tooth resorptions, but we certainly see a lot more from 6 or 8 years of age, onwards. We see them in, wild cats, like tigers and lions as well, so they're not, just limited to household, household cats. They're found in every tooth.
Everyone says they're low numbers in incisors, but I sometimes wonder whether the incisors being so small, is that we just don't see them or we just don't pick them up. We do see a large number in, pre-molars, especially the third mandibular premolar. That would be like my number one tooth, I guess, that we see the, the first ones occurring.
Majority, I find a buckle, probably 90%, 91% are on the buckle surface. Very few are on the lingual surface. And we can also stage, them as well.
Sometimes it's academic to stage them. But certainly we should look at the different types. So we can stage them.
And they're numbered 1 through 5, as you can see, see here. So these pictures come from the American, Veterinary Dental College. Thank you for, for providing the pictures, for this presentation, in this particular circumstance where we're looking at the stages.
So stage one, you can see just at the cemento enamel junction, there's a minor, resorption there. Stage 2 is a little bit deeper and also in the ocation. We're now basically going into the, the dentine in, in stage 2.
Stage 3 now takes you into the pulp, and obviously, it's becoming, more painful. And there's multiple, groupings of, of stage 4, which then goes into the pulp and you're starting to get resorption. Of the root.
And then stage 5, you've pretty much lost the entire tooth and it's completely, completely resorbed. So when you look at the types, of lesions, and we look at how we're going to treat them, staging them is, is interesting and it, and it can be, can, can be quite useful, but it really doesn't provide the same amount of information that, that typing, typing them does, that's for sure. So I like to type.
The tooth resorptions for one main reason, and that is how am I gonna actually treat the tooth? Rather than just saying, well, let's type it because it's, it's academic. We really want to know how we're gonna treat these particular teeth.
And pretty much at the moment, 100% of teeth that have tooth resorptions need to be extracted. There's really no treatment available at the moment that actually is successful. I will tell you about type 1 lesions, in a minute, which we did a, we did a study, but it wasn't successful.
But there may be some, some promise because it's actually successful in people, but I'll, I'll get to that in a minute. So we typed the teeth, and we call them Type 1, or type 2. So a type 1 tooth resorption is on the left-hand side, and we can see that the periodontal ligament is intact.
So we can see that the resorption is through the crown and the root of the tooth. But the thing to note is that there is an intact periodontal ligament versus the type 2 lesion, which is on the right hand side of this slide. And what we can see is that there's significant, resorption of the, the tooth.
But the main thing to note is that we've lost the periodontal ligament. We actually have the tooth being replaced by bone. So there's, there's a replacement of the actual physical tooth by bone, and we've got ankylosis of the tooth within the actual jaw itself.
So that's the important thing, to note about the different types of, of lesions. So here's an example of, of type one. We can see that we've got on the right-hand radiograph, the arrows are pointing to on the upper side, the molar tooth, and we have a, a lesion, a resorption in the distal root of that particular tooth.
But you'll know that the periodontal ligament is intact in that particular tooth. And the same with the third premolar, which is on the right-hand side of that radiograph. You can see that there's a small, apart from the fact you've got bone, loss, alveolar bone height loss there.
You can see on the medial aspect of, of that route, you've got a small amount of, of recession, sorry, resorption, there as well. So that's a typical type one lesion. A type 2 lesion, you can see by this radiograph is that there's no periodontal ligaments around the majority of that tooth.
The tooth is essentially looking like a ghost. It's almost blending in with the bone. You can look at the hard palate bone there, and you can look at what used to be the maxillary canine.
Tooth. And it's really difficult in this particular situation to really distinguish where is the root of the tooth and where is the alveolar bone. Because essentially, you're getting, tooth replacement by bone, and you've essentially lost most of the periodontal ligament, around that tooth as well.
So the treatment is based on the lesion type. So, type 1, lesions, like in the early stages, so grade 1 to 2. So if we, if we, looked at the stages.
And we did a study with, a gentleman, a endodontist, specialist, human endodontist, here in Australia, called Jeff Hitheray, and he published an article in humans and found that he treated those teeth with 90% trichloroacetic acid. And what he did was he used a micro brush, and he then he placed that against the tooth into the actual physical resorption. It killed the, I guess you'd call them adontoclasts that were actually causing the, the resorption.
And then he placed a glass ionoma over that, and he found that to be very successful. So we tried that in, you know, in our cases, in the cats, in probably 10 to 15 years ago, and we didn't find it actually to be successful at all. And the teeth continued to resolve using essentially the same technique that Dr.
Heathera used as well. So we, I put that there just to There's a, a point of, you know, it is worth trying things, but sometimes if you have a particular treatment that works in people, it doesn't necessarily mean that it's gonna work in, in your cat as well. So I would now.
Class grade ones and twos exactly the way I would class threes and fours. So in threes and fours and fives, you've got lesion into the pulp and loss of the crown, and I would extract the tooth completely and then suture over the gingera. So as you can see by the radiographs, on the bottom here, the same cat again.
Missing a part of the distal root of the molar and the meal root of the pre-molar, and the teeth have been completely extracted. And then you've got the, the middle, pre-molar there, which is, which is healthy. Type 2 lesions, you need to either extract the whole tooth like and block, take out the whole tooth and root.
But there was a paper that was published by Greg DuPont in 1995 in the Journal of Andrew Dentistry, where he suggested and recommended if there was no, periapical or root pathology, that you could actually perform crown amputation, which means taking the crown off the top of the tooth and then lowering the height of the alveolar bone, and then suturing the gingiva over the roots. And the concept here. Is that once you remove the crown and you've placed the gingiva over the, the remaining root, if you're not gonna have infection in the area and the tooth will continue to resolve and eventually, it'll disappear and just become bone.
And that's quite a successful treatment. But the caveat there is that you have to take a radiograph of the tooth. You cannot do this particular procedure if you have any, pathology of the root, any, any, osteomyelitis or pathology, of the periaical area that's suggestive of an abscess, or infection.
So the, the tooth root needs to be, quite, quite, resorbed without any osteomyelitis. The other area which I thought we might touch on in this presentation is just talk about stomatitis and where we're at, in the mouth of cats with, with stomatitis. And I guess, you know, what's, what's our approach to the stomatitis as well.
And unfortunately, once again, it sounds like I'm not really the guy with all the answers, during this presentation, because unfortunately, we don't really know a lot about stomatitis either. So I think you're getting the idea that cat dentistry, is, is, you know, really out there. There needs to be a lot more research and a lot more time, put into what's actually causing, the problems in these cats, cats' mouths, cause Currently, we are, we're trying lots of different, procedures and we're getting a lot of the cats to be healthy, but we're either taking a lot of teeth out, at the moment, or, you know, obviously medicating them and, and keeping them happy for long periods of time.
So, Stomattitis and forsitis are essentially inflammations of the mouth, that have extended past and are much worse than just gingivitis and, and periodontitis. We do see them in very young cats. Interestingly, we did have a Burmese cat in today in the clinic.
Which was only 14 months of age, and it had quite severe, stomatitis, and it also had, you know, quite severe, periodontitis as well. So we do see it in young cats. But generally, I see most of our stomatitis, being older cats.
There is an initial aetiology, that can be camouflaged. Often we don't know the aetiology in this particular, these particular situations. And often the gross appearance, may only demonstrate inflammation, but when you take radiographs and do a complete workup, you actually see, a completely different picture.
So, that's what I think we should have a look at some of the, some of the ideologies and then maybe our approach to, to treatment. So the cats that tend to come into our, our practise, turn up like this. They have quite severe, stomatitis, gingivitis, extending way into the, the buckle folds, and into the lips.
It extends all the way into the forces in the back of the mouth, into the arches as well. We see a lot of ulceration. It's very painful.
Sometimes there's plaque and calcu accumulation, sometimes there's not. It's not really a hallmark of stomatitis. We do, though, see a large number of fracture and missing teeth, and quite a large number of tooth resorptions, as well, which indicates or suggests that maybe that is one of the causes or one of the major causes of, of stomatitis we see.
But as you'll see by the list that I've put there, there's a significant number of Proposed ideologies is probably the way I, I would describe it, because we, we're not sure, you know, what causes the actual stomatitis at the moment. So any of these in any particular cat, certainly could cause, could cause the issue. So we've got bacterial infections, we've got viral infections that could, exacerbate some other problems.
We certainly see quite a number of fractured, crown. Sounds with exposed pulps, tooth resorptions, or oral resorptive lesions, as they were called, incompletely performed extractions, or retained roots that might have fractured off from a tooth, resorption as well. Sometimes systemic diseases will cause stomatitis, like renal insufficiency, for example.
I don't really think we see a lot of food allergies. We do see eosinophilic granulomas from with fleas, as well, which can masquerade a stomatitis and some of the oral neoplasms, as well, and obviously immune-related, diseases. But we don't see as many of those in cats as we do in, in dogs.
But there is a large list, but to be honest, we don't have the exact cause and, and effect of stomatitis at this point in time. So I think if we had a standard approach to treatment, we could rule out quite a large number of problems, and we find that quite a few cats do, do, do really well. So what we do is a complete examination.
We take blood, we check for FIV T4, and, and eu and do a urine profile. I've put question marks as to whether we should do, PCR swabs for Calei and herpes virus. I'd have to say that I did do that, I guess almost routinely up until many years ago, but I found that that doesn't really help our, our treatment process now, because we find that there's other things that actually cause the, the stomatitis, as well, and I guess more frequently.
We thoroughly examine the oral cavity under anaesthesia. The animal has to be anaesthetized. And I like to do a full dental examination and chart the, the process.
We use a probe and measure periodontal pockets, look for tooth resorptions, fractured teeth, we expose pole. And any retained, roots and record that on the dental chart. And then, as I said right at the start, we radiograph, the whole mouth with the idea that we're really looking for sub gingival tooth resorptions and retained roots.
Anything, I guess that's gonna cause inflammation in the, in the cat's mouth. Here's a cat we saw not too long ago that presented with severe stomatitis, as you can see on the left-hand side, there's quite severe hyperemic and, and hyperplastic gingiva with severe inflammation. And what we found was radiographing the mouth.
It was just a significant number, as you can see there, of retained tooth roots. Most likely from tooth resorptions. The cat hadn't had previous dentistry done, so it's, it's, it's not possible that they were left behind roots.
So they were most likely from, tooth resorptions and the crown had fractured off and left all these jagged pieces of, of root. And then as you can see from the right-hand side, the teeth were extracted, and then the ginger is, is sutured back over as well. So the first thing we need to do is take radiographs and just make sure that we don't have, you know, something which is which is really obvious that's causing the problem.
So, my recommendation is to extract, any of the teeth with with advanced periodontal disease, and advanced periodontal disease means teeth that have pocket depths that are greater than 50% of the root, root length. You could use doxy, cycline, in the, in the teeth that have the shorter periodontal pocket depths in the short term and see whether that improves the situation. If there's any retained tooth roots that are causing, irritation, inflammation, or are sitting there, you need to take those out.
Any tooth resorptions, you need to extract those teeth. And I would extract any teeth with exposed pulps rather than performing root canal or any other endodontic procedure on, on the teeth as well. I think the important thing in my hands is that after I've extracted the teeth, I like to reduce the height of the alveolar bone, generally by at least 1 millimetre, sometimes 2 millimetres, so the actual, The surface of the alveola bone is low enough so that all the bonypiles have gone, all the rough edges have gone.
And if I just take my glove and rub it over the bone surface, it's nice and smooth, like glassy smooth as well. If there's sockets where I've taken teeth out, retained roots or tooth resorptions, I'll take a hand curette and just cure out the cementum and the, and the, and the perontal ligament from those, sockets as well. I tend not to, even though others have recommended, I tend not to get a high speed burr and place it down into the socket and burr away the cementum and any periodontal ligament.
I think you can get yourself into a lot of trouble doing that. If you're in the mandible, you may inadvertently hit the mandibular canal, then you'll have blood everywhere. And if you're in the maxilla, you may well go into the sinus or into the nasal cavity.
So I think a hand curette is a much, much safer option there. Every, extraction site in the stomatitis cats, I think, should be sutured. It can be really difficult to suture some of these because the, the ginger is just so friable and it just tears.
But if you use a 5-0 suture, I tend to use a fast acting, suture, and I try and bury the knots. I'll often do a knot at the, cranial or the rostral. End of the end of the jaw, and then go whichever, you know, front towards the back or, or the vice versa, and just do a continuous suture if, if every simple interrupted suture is just gonna tear, and then bury the knot at the, at the, at the cranial or the, or the caudal aspect, wherever you finish as well.
And a buried knot with a, with a nice suture pattern over the top often doesn't annoy the cat, as well. In these really severe cases, I'll take a biopsy, just to make sure that we haven't got, like a, a neoplasm, as well. So you haven't got a, a, you know, a squamous cell carcinoma, for example, that's masquerading as, as stomatitis, and send that off to the, send that off to the lab as well.
If there's any teeth left, then I'll clean them, ultrasonically with my, with my scalar, and then, and polish the paste and wash it off, paying particular attention to the whole tooth and make sure you clean in the, in the gingival, sulcus as well. Afterwards, I tend to put the cats on doxycycline. I think doxycycline, works quite well in these situations, and meloxicam, as, as I said before, generally, generally for about a week, to 10 days, and then we'll get them back after about 10 days and just see how, how the cats are, are travelling.
Feeding them soft cubes of, of, of meat, you know, you can, you can boil or, or, or, Or cook, some chicken or some beef, and just, you know, make it soft, and just feed them, you know, 5 centimetre diameter cubes, for example. And then regular revisits. So don't let them drop off the radar and make sure you get them back every, you know, couple of weeks to see how they're, how they're travelling.
And a lot of them will do, will do, quite well. There's some cats that then don't respond to, the selective extractions, as I said before, and there's a whole list of, of things that you can do. You could try a novel protein, like you could try one of the commercial, foods that have like the novel protein as a trial in case it's a, it's a food, allergy.
Cylosporin has been, used by some, and there's some published, articles out of the. US, where, cyclosporin has been used, and had quite a deal of success. There was a, a paper that was published, not published, sorry, that was given, at the dental forum, a few years ago on using cyclosporin in stomatitis, and, and there was success there.
You could, you could try buprenorphine for pain and obviously the non-steroidals, as inflammatory control. I put selective prednisolone because you don't really want the animal on prednisolone for like 2 or 3 or 5 years. But you could use prednisolone in the early stages, you know, for a week or two if you wanted to, to see if you could reduce some of the inflammation.
But I don't think that's the answer for long term, solution. Interferon has been reported to be successful. There's quite a few, protocols out there.
As well, and that's possible. You could then, if you have no success with some of those things, you could try like a partial mouth extraction, like the ones that have got quite severe stomatitis, such as a cordal clearance. But cordal clearance in my hands, that would mean taking out the pre-molars and the molar teeth and leaving the cane.
9s. Unless I've got a cat with FIV or I've got a cat that's got like really severe stomatitis, and gingival recession or the canine teeth actually have some pathology, and I tend to leave the canine teeth. I find that the cats do, do much better.
But if you have to take them out, then obviously full mouth extraction, as well. I think one tip that I've found is that if you're gonna take out, say, All of the axillary teeth, and the majority of mandibular teeth, and there's one single tooth left in the quadrant, and there's no friends around it or neighbours, then I tend to take that tooth out, as well. So any of these, these could work, like, like the cordal clearance, the pre-molars, and the molars, have a good success rate.
But if owners don't want to, take out all of the teeth, I guess I would try interferon. I would try cyclosporin, initially and see, see what results you, you could get. And if you, don't have success, with those, then obviously cordial clearance would be the, the next step.
So hopefully, that's given you, some ideas and a little bit of, information about, the feline, dentistry situation we're in, as in, you know, what occurs in which age groups, how we would treat some of these, situations as well. If you have any questions or require, you know, some, some research papers, some publications, or you have a question in general, feel free to email me on the, on the email address that's there. So thanks again, for listening to the presentation.