Full Mouth Extractions for FCGS: Is It the Only Option? with Dr. Maria Soltero Rivera

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Welcome everyone to the Positive Veterinary Dentistry Podcast, a podcast dedicated to helping veterinary professionals like you elevate patient care to better dentistry, better diagnostics, and better dyssions.
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I'm your host, Benita Altheer, licensed veteran, tech specialist in dentistry, and the creator and founder of Positive Dental Education.
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Whether you're listening in a general practice setting, specialty academia as a student, or just beginning your career in veterinary medicine, this podcast is intended for you to give you practical real-world insights.
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Today's episode focuses on a disease that many of us in practice find both heartbreaking and challenging to manage, chronic feline gendivostomatitis, or FCGS.
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This is a debilitating and painful condition for cats, and it can be equally frustrating for veterinary teams and cat caregivers who are trying to help these pets find relief.
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For many years, FCGS was thought to be simply a severe response to plaque or dental disease, but more recent research has shown that this condition is far more complex, involving an immune-mediated response, possibly chronic viral infection, and even changes in the oral microbiome.
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To help us better understand this disease and how we can help these patients, I'm excited today to be joined by Dr.
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Maria Soltera Rivera.
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Dr.
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Soltera Rivera has been involved in advancing our understanding of feline chronic gendivostomatitis through both clinical work and research.
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She is also the co-author of a review article that explores the current science behind this disease, including its immune-mediated nature, the role of the oral microbiome, and emerging treatment options for refractory cases.
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This article, published in the Journal of Feline Medicine and Surgery in 2023 by Dr.
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Soltero Riveras, Dr.
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Stephanie Goldschmidt, and Dr.
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Boaz Arzey, will be referenced in this podcast today.
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All three are professors at the University of California at Davis and work together on these types of research projects.
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In this episode, we're going to talk about what we currently know about FCGS, why full mouth extractions are still considered the mainstay of treatment, and what new therapies may be on the horizon for our patients who don't respond to surgery alone.
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Before we jump into this podcast, I want to welcome you, my guest, Dr.
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Maria.
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I really appreciate you being here.
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Thank you for allowing me.
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Yes, I have really enjoyed working with you, teaching DVMs around the country.
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Your level of expertise and scientific understanding has just really impressed me because knowing the why behind what we do, I feel is so important.
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And I know as I've been out in the world going to lectures on this particular topic, we're all looking for new information and what the research is telling us so that we can make better clinical decisions for these animals.
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So I'm really excited that you're here today and that you can help us with understanding this a little bit more thoroughly.
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Before we dive into this episode, my last guest, Dr.
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Chris Bannon, left you a question.
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Yeah.
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And that question wasn't specifically directed at you, but it's a good one.
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And I think it does apply somewhat to this episode.
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Okay.
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So her question was if you have a nickel for every time a client says to you, Oh my gosh, you have to extract how many teeth and how will my pet ever eat again?
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How rich would you be?
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I would be a billionaire by now.
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One nickel at a time.
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Absolutely.
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It's such a common question that we get.
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And it and it's very nice to see then their reaction on the other side once their animal feels better, has recovered.
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And then that's when we get the typical comment of they're acting like a puppy and a kitten again, despite their age.
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And they might eat you out of house and home, actually.
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They're going to eat way better because they've been struggling.
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So this definitely applies a lot to these types of patients where we are seeing them losing body weight and not thriving because they literally are struggling to get the nutrition that they need.
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Even their relationship with the owner struggles, right?
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Because they're so painful, it's hard to pet them.
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They don't receive the interaction as well as they would if they were comfortable.
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Exactly.
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And we could talk about that because the human-animal bond is so important.
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And when something significant like this could interrupt that human-animal bond where the pet's not wanting to be interactive with their owner, that can really affect their quality of life, both human and animal, right?
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So let's start with the big picture.
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So many of us were taught early on in our careers that feline gendivostomatitis was essentially an extreme response to plaque or potentially related to severe periodontal disease.
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But your research and other recent work in the field suggests that this disease is far more complex.
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Can you help us understand what we currently know about the pathophysiology of chronic feline gendivostomatitis and what's actually happening in these patients?
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You are correct.
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And that was the previous knowledge.
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And that's not entirely wrong.
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It's just that there's a more complex picture than just that happening.
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So what we know so far is that this seems to be an immune-mediated disease where the not only the oral cavity is affected, but this is the whole system is showing signs of this happening, and that it's driven by chronic antigenic stimulation where the plaque plays a role.
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Definitely the bacteria, the oral cavity, play a role.
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But there's also other things that happen in these cats very commonly that could serve as a chronic antigenic stimulation, like for example, viral infections.
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A lot of them have prinker and chaleci virus infection, FIV or FELV.
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And so that plays a role too.
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So what we know from targeted studies is that C D8 positive T cells, meaning the lymphocytes that are cytotoxic, play a big role in this disease, and that there is a mixture of cytokine profiles that don't necessarily fit the hypersensitivity reaction alone.
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There's a mix there.
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That's why we don't necessarily think it's an allergy anymore.
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And lymphocytes are raining here, like they are the ones that drive everything, but neutrophils can be in there too, depending on if there's ulceration or how acute this is.
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Definitely the bacteria in the oral cavity in FCGS is different than what you typically see in health.
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And it's different in multiple locations in the oral cavity, not just the areas that are inflamed, it's everywhere in the different specific locations that you can see.
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If you compare the dorsal tongue microbiome in health versus FCGS, it's going to be different.
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And then if you compare the microbiome and the dorsal tongue within a cat with FCGS to the cheek pouch, they're going to be different.
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So there's a dysbiosis that's happening that's part of this process.
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But also there's a host response that seems to be uncontrolled.
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And so untargeted studies that have come out recently support the fact that there could be a genetic component in these patients that is making them respond in this exaggerated way, and has been an interesting finding with the upregulation of these cytokines, especially IL6 and 17A, and the fact that we're talking about lymphocytes, but really this study also showed that those cells that usually take care of the immediate immune response could also be playing a role in the disease.
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So it involves the immune system acutely and chronically, the innate and the adaptive immune system.
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It involves bacterial and viral infections.
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It's it's a very complex disease.
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And I think that the more we learn about it, we think we're gonna find the one thing to blame, and that's not happening.
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Yeah, it seems like we learn more and it becomes more complicated and makes that even more challenging for a general practitioner to figure out how do we actually combat this besides just aggressive treatment.
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With the research, can you explain a little bit more how this research was conducted to come to some of these conclusions so that we can better understand how this was investigated thus far to get us better information?
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Yeah, I think you can think about it as layers.
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The first layer was that first retrospective study that reported on the clinical findings of these cats and what it looked like on oral examination.
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And then we started digging deeper and said, okay, what do biopsies from these cats look like?
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And then there was the explanation of what these biopsies look like in histopathology, but then there was also the explanation of how cats responded to certain treatments, including antibiotics and maybe like steroids.
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Then there was also, and these happen in different timelines, the explanation of what do we see on the dental radiarest of these cats.
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And so that kind of helped come complete the picture of yes, it's not only the soft tissues that are affected, the heart tissues are also affected, the teeth are affected, because we see that these cats, all of them have periodontal disease, usually more moderate or severe, and 50% of them will have tooth restoration or root tips.
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So now we're better understanding what's happening at the soft tissue level, at the heart tissue level.
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How do we go about the treatment and what the clinical behavior of the disease is?
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And then people started taking it further, saying, okay, now we take the biopsy and now we're going to look for specific things.
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We're going to look at CD4 positive cells, CDA positive cells, what are the cytokines that are there?
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What are the tall-like receptors?
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And then somebody said, Oh, wait, but what happens in the blood?
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And so then the blood was looked at.
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And then we found out that they are, and this was some of the early work, but the hyperglobulinemia that we typically see on these cases, it was confirmed.
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And then people said, Oh, but wait, there's molecular studies that we can do that are untargeted, meaning we don't choose to look for certain things.
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We let all the genetic information in there tell us the story.
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And so that's when we started looking at DNA sequencing and RNA sequencing for these patients, trying to figure out what's their and infectious disease is in terms of infectious diseases, which has had been done before with targeted studies with BCR and things like that.
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But those are inevitably, they will have false positives or false negatives.
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Whereas when you're getting all this genetic data and processing it, you're gonna be able to have a more holistic view of what's happening.
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And so you look at it and you can remove all the genetic data from the cats and only look at infectious diseases.
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And we've done that and looked at that only.
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And we have done the opposite where we remove all the infectious diseases and we look at the cat only.
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And that has been done at the RNA level.
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And so that tells you not only which genes are there, but which ones are actively playing a role there.
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And then we've looked at what does the saliva look like there?
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Well, how the how do the proteins change in the saliva when you have FCGS?
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And then as we learn more and more, then at the same time, the medications and their research increase.
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So then you're like, oh, this is happening.
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So maybe this medication can do a good job.
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So let's look at cyclosporin and a clinical trial was done for that.
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Or let's look at telign recombinant interferon omega and a clinical trial was done on that and see how that changes the other findings that we've seen as baseline for this disease.
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And so that's how the research has gone in this particular disease, which is pretty amazing.
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And I use it as a poster child of how we should go about researching anything really in oral medicine because we've done a pretty good job over the last three decades trying to figure out this disease and how to improve the quality of life of these patients.
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Wow.
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Three decades of research, and it's brought us to this point and answered some questions that were really unanswered for years and years and years for these kitties, right?
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We were very confused about this.
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So when we think about gene expression or these specific cats, you talked a little bit about potentially familiar lines having higher incidence of this condition.
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What have we learned from that in regards to cats that are genetically related?
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Good question.
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So, in order to determine that, we would need to do genetic studies and populations of cats of the same breed, affected and unaffected.
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And those studies are not out yet.
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We we've had suggestions of cat breeds that are typically seen more commonly in these studies of FCGS that could potentially then lead you to think that there's a familial predisposition.
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Usually, when you see common breeds being represented, you can't help but think there has to be some sort of genetic link.
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I think the strongest genetic suggestion that we have found so far is this last study looking at the host response at the RNA level with that upregulation of IL6 and 17A and the myeloid lineage cells.
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That was pretty strong evidence that we may have cats that are genetically predisposed to having these dysregulated immune responses in response to chronic antigenic stimulation, which could be viral or it could just be anything that's in the oral cavity microbiome-wise.
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So um, so I think that's a pretty those two things are pretty strong suggestions.
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And I think the next step would be to do genome studies where again you compare the population of interest with and without the disease and see if there's any genetic variations that are picked up and that could explain the biology behind the disease, too, because it could be something random, right?
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And it might not be related to the biology of the disease.
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So you have to make sense of that in the context of what we know about the disease already.
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Right.
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Is there specific breeds that we know of now that we feel could potentially be on that list of genetically predisposed to this condition?
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Well, I don't I don't think that we can necessarily say particular breeds, but I do think that in general we tend to see more severe disease, dental disease, and pure breeds of cats.
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Um, so I wouldn't hang my hat on any specific breed being more affected with FCGS or not, but to say that when the studies are done, the definitely the breeds will have to be considered as a covariate or a potentially confounding variable.
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Okay.
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All right.
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What about the evidence when it comes to cats in the same household?
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Because they obviously are sharing their saliva with each other and viruses and they're on potentially similar foods.
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What have we learned about cats in the same household having a higher incidence, if that's true, of chronic feline gendomostomatitis?
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Yeah, that's a great question.
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So we have learned from a study evaluating cohabiting cats that that does represent a risk factor for FCGS.
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And you do get an increased odds of having FCGS if you have, as compared to households with just a single cat.
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The study showed it's pretty remarkable that for each additional cat in the household, there's an increased odds of FCGS by more than 70%.
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Wow.
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That's tremendous.
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Well, that's a real number.
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Yeah.
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Yeah.
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And that's what I understood as well, because we it's unusual, but when you have multi-cat households and then you find one where they seem to just be having a rash of this same condition amongst their cats, it just makes you wonder.
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And then we're having to consult with these clients about some pretty significant treatment to make these cats comfortable and in improve their quality of life.
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And if it's affecting more than one of their cats, that can be quite significant for them, especially financially, trying to deal with more than one having a similar issue.
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Does and we maybe don't know, but if they are a multicat household and they are related genetically, that could be even more increase in the incidence of it.
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The increased risk in shared households brings up the question of could it be that there's enough stress that makes for opportunistic infections to happen, or is it like a shared infectious disease that everybody has left?
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Or is it that the antigen is there and the susceptibility depends on the cat, on the cat, but if you have enough of them, you're gonna find the susceptibility.
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So, anyway, those are things that that have come to mind when we talk about the results of these studies.
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I've often wondered if a vaccine could be developed to prevent this condition.
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Good question.
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I think in the context of the role of feline caleci virus and with disease, that could be something to be thought about.
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Also, in general, a vaccine for viral infections could go a long way, but we would need to see the clinical trials because I don't think we've been able to firmly say that those are a needed to elicit the disease or if they just have disease modifying properties and affect the prognosis of the patient.
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It's a standing, lingering question.
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Okay, that would be amazing if that would be because we're always looking for the quick fix or the preventative, right?
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Because we never want them to get into this situation.
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Yeah, exactly.
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So if we can prevent it all together, that would be ideal.
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And that could be something in the future with cat breeding programs for these purebred kitties.
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If there was some sort of genetic marker, which forgive me for not understanding genetics, no dad, you're at the at the research.
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The right the right way, absolutely that we could you could check with yeah, right, prevent breeding ones that would be more likely to pass that genetic marker on to their offspring.
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Correct, correct.
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That would be the goal, but even it's so that's super early on.
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If we take it a little bit later, what are the things that we need to look at in cats that could give us a clue that this is where they're trending?
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That's another question that we I've aimed to try and answer with some of my research is what comes before FCGS?
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Because it it's hard to believe that something that affects the heart tissues that way would be coming up acutely of acute onset, right?
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To have an effect on heart tissues, you have to be there for a little while.
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So, what comes before FCGS?
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And I think we've starting, we're starting to to figure out what that is.
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And in one study that we did here looking at aggressive periodontitis in young cats, we found that a certain percentage of them, um, minority nonetheless, but still will go on to develop FCGS like lesions.
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And so, so my question is do you have aggressive periodontitis before you have FCGS?
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And so that is, we have to do further studies on that to see, because then you are gonna want to be more proactive about the treatment of aggressive periodontitis and follow it up more closely and make sure that we don't get to that point of uncontrolled, more diffuse inflammation because aggressive periodontitis is only affecting the periodontal tissues.
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But if with FCGS, you have that extension of the inflammation beyond the muco gingival mind to affect the other non-kerotinized tissues of the oral cavity.
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Right.
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That brings up two questions I have for you.
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One is that I think there's still a lot of confusion out there when a general practitioner is observing clinical signs in the mouth of a cat that they want to call it stomatitis or chronic feline gingivostomatitis when we're just dealing with something like gingivitis.
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Could you best define for us the how a general practitioner can discern the difference between what we would call gingivitis versus no, it's actually chronic feline gingivostomatitis and the things we need to look for.
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Oh, absolutely.
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So I think the the thing to know is that gingivitis and periodontitis is confined to the periodontal tissues, right?
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So gingiva, alveolar bones, the periodontal ligament, those are the periodontal tissues.
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But in feline chronic gingival stomatitis, the term stomatitis is there because we're extending beyond the periodontrum, and now other soft tissues are affected.
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So you're thinking about inflammation that involves the periodontal tissues, but then extends beyond that mucogingival line to affect alveolar, buccal mucosa, caudal mucosa, sublingual tissues, linguomolar glands, the commissures of the lips, there's more diffuse inflammation.
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Interestingly, the heart palate doesn't seem to be affected in these cats.
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So, and we do sometimes see that the soft palate being affected, but it's not to be.
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So when we see that pattern of inflammation that's more diffuse, and there is that inflammation present in the back of the mouth, lateral to the palatoglossal arches, that anatomical structure that is a fold of tissue that connects the palate to the tongue, lateral to that, that inflammation extending to the front, affecting the areas around the teeth, that is pretty typical of these cases.
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And that can be ulcerative, proliferative, or both.
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So you can have where you can have patients in which the tissues look like they've running wild and proliferating, or you can have ones that look very ulcerated and not necessarily proliferative.
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And the proliferative ones are important because you want to make sure that you biopsy and rule out any sort of more assiduous process like a cancer, uh like squamous cellcastinal mind cats is a big concern.
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So that would be something to consider.
00:21:22.960 --> 00:21:25.599
So typically speaking, that's what we notice in these patients.
00:21:25.839 --> 00:21:36.240
Yeah, and if it's strictly gendivitis or periodontitis, it's going to be confined to the attached genital tissues and the structures surrounding the teeth.
00:21:36.480 --> 00:21:46.559
And once it's outside of those defined areas, now we're dealing with something more sinister as we realize it's actually stomatitis.
00:21:46.799 --> 00:21:59.599
So the second question I had for you is how has your research shown, or I know you said it's not that common, but when we see these younger cats, they've just erupted their adult teeth.
00:22:00.319 --> 00:22:08.319
And they have inflammation of the genival tissues that does not extend beyond the mucogenival line.
00:22:08.559 --> 00:22:15.519
And we are defining that as juvenile onset gingivitis or juvenile onset periodontitis?
00:22:15.839 --> 00:22:33.359
How often are we finding that those cats, especially if left unchecked or unmitigated through anesthetized cleanings and strategic gingival surgery or extractions, even if we have loose teeth at that point?
00:22:33.599 --> 00:22:38.960
How often is it that they go on to progress to actual chronic feline gingivostomatitis?
00:22:39.200 --> 00:22:39.680
Good question.
00:22:39.839 --> 00:22:41.279
So we're talking about those cases.
00:22:41.359 --> 00:22:45.200
So let me let's define this case, uh, typical case first.
00:22:45.359 --> 00:22:55.119
So typically these cases are presenting for early onset gingivitis, and they're less than two years of age, and they've already erupted their permanent teeth.
00:22:55.279 --> 00:22:58.799
So you know it's not inflammation related to the eruption process.
00:22:58.960 --> 00:23:04.559
Um, for those that are already beyond puberty, then we probably have a real problem.
00:23:04.720 --> 00:23:09.359
And I say that because you can have gingivitis and periodontitis that's hormonally mediated.
00:23:09.440 --> 00:23:13.680
And once you get done with that exposure to the hormones, it should resolve.
00:23:13.839 --> 00:23:15.519
So we're talking about the ones that persist.
00:23:15.599 --> 00:23:19.440
So the ones that persist, um, we've actually done some studies on this.
00:23:19.599 --> 00:23:22.559
It's those are animals that should be proactively treated.
00:23:22.640 --> 00:23:33.920
And by that I mean we should put them under anaesthesia and we should take radiogas because we have found that in retrospective studies here, there's moderate to severe periodontitis in those cases in about 78% of them.
00:23:34.160 --> 00:23:38.960
So now let's rethink about the nomenclature that we've been using for this forever.
00:23:39.039 --> 00:23:41.359
We've been calling it juvenile gingivitis.
00:23:41.519 --> 00:23:48.000
But if you see moderate to severe periodontitis in 78% of the cases, can we still just call it gingivitis?
00:23:48.079 --> 00:23:51.519
And so then you go back to the human literature and you say, How did humans deal with this?
00:23:51.599 --> 00:23:53.200
Because the same thing happens with humans.
00:23:53.359 --> 00:23:58.319
And what they've done is they've realized, oh, um, we're not dealing with only gingivitis.
00:23:58.400 --> 00:24:02.160
And oh, they're not typically speaking juvenile anymore because they're done with puberty.
00:24:02.319 --> 00:24:05.279
So really what we should be calling it is aggressive periodontitis.
00:24:05.440 --> 00:24:16.240
And so that is something that we have moved towards too, is adopting that terminology of aggressive periodontitis, first of all, because it more accurately defines the disease.
00:24:16.319 --> 00:24:23.119
Um, and second of all, because it it means it doesn't confine it to an age group because we're not talking about that age group anymore.
00:24:23.279 --> 00:24:31.200
And so if you post it to the on RS juvenile gene divitis, first of all, they're gonna think it's only the gum tissue affected, and second of all, they're gonna say, oh, they're growing, they'll grow out of it.
00:24:31.359 --> 00:24:33.359
And what we see is not necessarily that.
00:24:33.519 --> 00:24:38.079
We see that this is periodontitis like you and I will get, like everybody gets, but it goes faster.
00:24:38.240 --> 00:24:56.079
And so what we have found looking at those cases in this retrospective study and following them over time is that we looked at 27 cases, and of those, two of them develop FCGS like lesions, and about seven of them had progression of that aggressive periodontitis, despite the cure that was provided.
00:24:56.240 --> 00:25:08.240
And so when you have those cases, it's really important to have those conversations with the owners of if we were on Facebook, we would be going steady because this is not something that I can fix with just one procedure.
00:25:08.400 --> 00:25:09.920
We're gonna do our evaluation.
00:25:10.079 --> 00:25:14.000
Chances are that extractions might be needed, even at this early of an age.
00:25:14.160 --> 00:25:16.880
It's not wild, it has been described.
00:25:17.039 --> 00:25:32.319
It is a more rapidly progressing form of periodontitis, and we can only define it and call it by that when we've had two subsequent evaluations six months apart, and we see that there's more attachment loss over that time than what we would like to see.
00:25:32.400 --> 00:25:41.359
And you can extrapolate the definition in humans to cats, and it really doesn't take much from one measurement to the other to say, oh yeah, this is aggressive periodontitis.
00:25:41.440 --> 00:25:53.359
And so then you have to explain to the owners is we're gonna do everything that we can, but you're gonna have to come to see me more often than you would expect for a cat that doesn't have this, and the lifespan of those teeth is probably gonna be shorter.
00:25:53.519 --> 00:25:57.279
We'll do everything in our power to keep them for longer, but it's probably gonna be shorter.
00:25:57.440 --> 00:26:03.599
Or oh, by the way, the inflammation could extend to the rest of the mouth, so we're gonna keep a close eye on that, right?
00:26:04.319 --> 00:26:13.440
So there definitely is a risk that it could progress on to chronic feeling and divostomatitis, so we have to keep a close eye on them.
00:26:13.839 --> 00:26:21.119
But because it is aggressive, it is a earlier onset type periodontitis.
00:26:21.279 --> 00:26:30.160
We have to be aggressive in our interventions to try and control.
00:26:30.880 --> 00:26:33.920
We also have to be very proactive with home care, trying to brush.
00:26:34.000 --> 00:26:40.000
These are the cats that definitely you want to try and get them to be um compliant with brushing.
00:26:40.160 --> 00:26:59.680
And I think it also supports the fact of you know starting those evaluations in cats earlier early on, as soon as like six months of age to see that this pericoronitis that tends to happen with eruption resolves and it doesn't continue to be um something that is inflammation beyond the the eruption process.
00:27:00.799 --> 00:27:01.599
Gotcha.
00:27:01.759 --> 00:27:12.160
Is there any correlation from the research that you know of in regards to Khaleesi virus with these cats and the aggressive periodontitis?
00:27:12.400 --> 00:27:12.960
Good question.
00:27:13.119 --> 00:27:17.519
Not not currently, but there's somebody actually looking at that right now.
00:27:17.680 --> 00:27:21.839
So hopefully that will be something that will see the light of day here soon.
00:27:22.000 --> 00:27:25.359
Somebody in on the East Coast is actually looking at that right now.
00:27:25.440 --> 00:27:27.759
So I'm we're working together on that.
00:27:28.160 --> 00:27:28.880
That's great.
00:27:29.039 --> 00:27:29.839
Good to know.
00:27:30.000 --> 00:27:35.599
Yeah, because I think there's still so much unmisunderstood about that specific condition.
00:27:36.079 --> 00:27:41.839
Um, there is a product which we can talk a little bit more about treatment here in a bit.
00:27:42.160 --> 00:28:01.039
But before I guess I before I talk about any treatment and that kind of thing, what would you say to a client who presents a cat that has chronic feline gendivistomatitis in regards to what they should expect?
00:28:01.279 --> 00:28:16.640
And we're gonna be talking more about what they need to do at home, what we might be doing procedurally, um, what would be a normal kind of spiel or something that you would talk to them about if you diagnosed this?
00:28:16.880 --> 00:28:17.440
Yeah.
00:28:17.680 --> 00:28:24.319
Um, so most of them come to our practice already frustrated because they've tried so many different things.
00:28:24.480 --> 00:28:30.559
They've tried multiple anesthesias, some extractions, they may have already tried medical management.
00:28:31.119 --> 00:28:35.440
And so um they are desperate because their animal is still in pain.
00:28:35.599 --> 00:28:43.759
And at that point, sometimes even some of them don't even know or remember what their cat was like before they had the disease.
00:28:44.640 --> 00:29:01.839
Um, and so we have a conversation about how the knowledge about this disease of our time has progressed, and how unfortunately we're still at the point of the gold standard of treatment being near full mouth extractions to full mouth extractions.
00:29:02.160 --> 00:29:13.039
And I try to explain to them because this is a misconception that I think a lot of owners come in here with in it is that they think that we're extracting teeth just to extract them.
00:29:13.359 --> 00:29:36.240
And though it is true that we end up doing extractions of sometimes some healthy teeth, the reality is that there's so much dental disease in these patients that the extractions are needed just based on that for the tooth resorption that we see, for the root remnants that we find, for the moderate to severe parodontal disease that we find in these patients.
00:29:36.559 --> 00:29:42.000
Just that alone is justification for extractions in these patients.
00:29:42.240 --> 00:29:45.759
Now, having to go beyond that, that we still don't quite understand.
00:29:45.920 --> 00:29:49.759
Why do we need to go beyond that and end up extracting as many teeth?
00:29:49.920 --> 00:30:00.319
And I do have the conversation with the owner of I know if I had that disease and I went to the dentist and they said we got to extract everything, I'd be running away immediately.
00:30:00.640 --> 00:30:28.559
So I don't expect them to subscribe to that message immediately, but I do quote the information that we know from multiple studies on the surgical management of this disease that have repeatedly found that about 70% of patients will have a desirable outcome, whether it is complete resolution of the inflammation or at least improvement and improvement of their clinical signs.
00:30:28.799 --> 00:30:33.440
And we've seen that repeatedly from different institutions looking at this.
00:30:34.160 --> 00:30:37.680
That is to me convincing evidence.
00:30:37.839 --> 00:30:38.880
Could we be doing better?
00:30:39.119 --> 00:30:39.920
Oh, absolutely.
00:30:40.079 --> 00:30:46.400
And that's what I'm working towards, trying to get to the point where we don't have to extract the healthy teeth, but we're not there yet.
00:30:46.480 --> 00:30:59.599
So at the moment, that's the one solution that I can, or the one treatment that I can propose that will give us a good, a good chance of improving the quality of life of the patient.
00:30:59.920 --> 00:31:04.079
And so that's usually what I try to explain to the owners.
00:31:04.160 --> 00:31:11.839
And I to be fair, most of them by the time they come here, they've been they've heard about full mouth extractionists or partial mouth extractionists right.
00:31:12.240 --> 00:31:20.160
So there is a risk that it could progress on to chronic feline gendivostomatitis, so we have to keep a close eye on them.
00:31:20.480 --> 00:31:32.880
But because it is aggressive, it is earlier onset type periodontitis, we have to be aggressive in our interventions to try to control.
00:31:33.599 --> 00:31:36.640
We also have to be very proactive with home care, trying to brush.
00:31:36.720 --> 00:31:41.839
These are the cats that definitely you want to try and get them to be compliant with brushing.
00:31:42.000 --> 00:31:58.480
And I think it also supports the fact of starting those evaluations in cats earlier early on, as soon as like six months of age to see that this pericoronitis that tends to happen with eruption resolves and it doesn't continue to be something that is inflammation beyond the eruption process.
00:31:58.640 --> 00:31:59.119
Gotcha.
00:31:59.279 --> 00:32:09.039
Is there any correlation from the research that you know of in regards to Khaleesi virus with these cats and the aggressive periodontitis?
00:32:09.279 --> 00:32:09.680
Good question.
00:32:09.839 --> 00:32:13.839
Not not currently, but there's somebody actually looking at that right now.
00:32:14.000 --> 00:32:17.759
So hopefully that will be something that will see the light of day here soon.
00:32:17.920 --> 00:32:21.119
Somebody in on the East Coast is actually looking at that right now.
00:32:21.200 --> 00:32:22.799
So um, we're working together on that.
00:32:23.039 --> 00:32:23.519
That's great.
00:32:23.680 --> 00:32:24.240
Good to know.
00:32:24.400 --> 00:32:28.799
Because I think there's still so much misunderstood about that specific condition.
00:32:28.960 --> 00:32:43.440
Before I talk about any treatment, what would you say to a client who presents a cat that has chronic feline gendivistomatitis in regards to what they should expect?
00:32:43.599 --> 00:32:56.720
And we're going to be talking more about what they need to do at home, what we might be doing procedurally, what would be a normal kind of spiel or something that you would talk to them about if you diagnosed it?
00:32:57.039 --> 00:33:02.559
So most of them come to our practice already frustrated because they've tried so many different things.
00:33:02.720 --> 00:33:08.319
They've tried multiple anesthesias, some extractions, they may have already tried medical management.
00:33:08.480 --> 00:33:12.000
And so they are desperate because their animal is still in pain.
00:33:12.079 --> 00:33:19.920
And at that point, sometimes even some of them don't even know or remember what their cat was like before they had the disease.
00:33:20.160 --> 00:33:34.160
And so we have a conversation about how the knowledge about this disease of our time has progressed and how unfortunately we're still at the point of the gold standard of treatment being partial mouth to full mouth extractions.
00:33:34.319 --> 00:33:39.680
And I try to explain to them because this is a misconception that I think a lot of owners come in here with.
00:33:40.079 --> 00:33:43.839
It is that they think that we're extracting teeth just to extract them.
00:33:44.000 --> 00:34:03.920
And though it is true that we end up doing extractions of sometimes some healthy teeth, the reality is that there's so much dental disease in these patients that the extractions are needed just based on that for the tooth resorption that we see, for the root remnants that we find, for the moderate to severe periodontal disease that we find in these patients.
00:34:04.160 --> 00:34:08.880
Just that alone is justification for extractions in these patients.
00:34:09.119 --> 00:34:16.719
Now, having to go beyond that, that we still don't quite understand why do we need to go beyond that and end up extracting as many teeth?
00:34:16.800 --> 00:34:26.960
And and I do have the conversation with the owner of I know if I if I had that disease and I went to the dentist and they said we got to extract everything, I'd be running away immediately.
00:34:27.199 --> 00:34:50.719
So I don't expect them to subscribe to that message immediately, but I do, you know, quote the information that we know from multiple studies on the surgical management of this disease that have repeatedly found that about 70% of patients will have a desirable outcome, whether it is complete resolution of the inflammation or at least improvement and improvement of their clinical signs.
00:34:50.880 --> 00:34:54.880
And we've seen that repeatedly from different institutions looking at this.
00:34:55.119 --> 00:34:57.519
That is, to me, convincing evidence.
00:34:57.679 --> 00:34:58.719
Could we be doing better?
00:34:58.960 --> 00:34:59.760
Oh, absolutely.
00:34:59.840 --> 00:35:05.679
And that's what I'm working towards trying to get to the point where we don't have to extract the healthy teeth, but we're not there yet.
00:35:05.760 --> 00:35:15.840
So at the moment, that's the one solution that I can, or the one treatment that I can propose that will give us a good chance of improving the quality of life of the patient.
00:35:16.000 --> 00:35:19.679
And so that's usually what I try to explain to the owners.
00:35:19.760 --> 00:35:27.519
And I took most of them by the time they come here, they've been, they've heard about full mouth extractions or partial mouth extractions at least once before.
00:35:27.599 --> 00:35:29.679
So they're not completely adverse to it.
00:35:29.840 --> 00:35:31.840
I still give them the schve, as you say.
00:35:32.000 --> 00:35:34.159
So I just assume that they know everything.
00:35:34.239 --> 00:35:35.679
I kind of uh do the opposite.
00:35:35.760 --> 00:35:39.679
I say, let's pretend like you don't know anything about this disease and let's talk.
00:35:39.760 --> 00:35:42.559
Uh right, just start from the beginning and explain.
00:35:42.719 --> 00:35:43.039
Yeah.
00:35:43.280 --> 00:35:45.119
And then we talk about expectations too.
00:35:45.199 --> 00:35:50.800
If there's FELV, FIV in the history, we know that those tend to have more of a guarded prognosis.
00:35:50.960 --> 00:35:53.599
Probably the disease is modifying the prognosis.
00:35:53.679 --> 00:35:55.679
And so we talk about that too.
00:35:55.840 --> 00:36:04.480
And we talk about if we fall in that 30% of cases that don't respond to whatever we do, there are other options and and we can cross that bridge.
00:36:04.639 --> 00:36:07.280
Usually by then, their cognitive load has been reached.
00:36:07.360 --> 00:36:16.079
So I try not to overwhelm them with what happens if they're refractory, but I do mention it because 30% of refractory cases, that's a real number.
00:36:16.159 --> 00:36:16.800
That's not 5%.
00:36:17.199 --> 00:36:20.480
So I mention it to make sure that they keep it in mind.
00:36:20.800 --> 00:36:21.760
That's a possibility.
00:36:22.480 --> 00:36:41.440
They're coming to you to be the miracle worker at UC Davis, thinking that you have more tools in your tool belt, or definitely you have more knowledge than most on this subject, but still it's hard to work miracles when we're still beyond the ability to have a simple cure.
00:36:41.679 --> 00:36:44.559
What would you want a general practitioner to know?
00:36:44.719 --> 00:36:56.239
Since you're at the referral end of things and you're getting cases that have been through potentially years of management, medical management, maybe some surgical management.
00:36:56.480 --> 00:37:08.800
What would you want general practitioners to know to help avoid potential years of things that aren't necessarily going to make that pet more comfortable?
00:37:09.119 --> 00:37:09.679
Good question.
00:37:09.920 --> 00:37:12.639
Gosh, I take my hat off with general practitioners.
00:37:12.719 --> 00:37:15.840
Their primary care practitioner has such a tough job to do.
00:37:16.079 --> 00:37:18.400
First of all, kudos to them for all their work.
00:37:18.639 --> 00:37:25.360
I think they do a fantastic job in trying to manage such a complicated disease and such hard conversations with the owners, right?
00:37:25.440 --> 00:37:39.679
Because, you know, they come in for the first time with their animals not eating, and all of a sudden you basically wax them with this information of they have somatitis and the gold standard three minutes full mouth extraction, and that would surprise anybody.
00:37:39.840 --> 00:37:43.039
And yet that's the role, and they do it so well.
00:37:43.280 --> 00:37:51.360
So well that by the time owners come here, they're almost like, please take all teeth out, and you're like, wait, yes, we we will probably end up doing that, but let's have the conversation first.
00:37:51.519 --> 00:37:55.679
So, so I think that overall general practitioners doing a fantastic job at this.
00:37:55.840 --> 00:38:06.480
But I think that it's a conversation that I have very commonly with primary care practitioners is the fact that you have to treat the patient acutely, and then there's also the chronic treatment.
00:38:06.639 --> 00:38:09.280
Acutely, you have to get the patient to feel better.
00:38:09.599 --> 00:38:12.480
And so then pain medications are necessary.
00:38:12.639 --> 00:38:15.920
Sometimes antibiotics are necessary if there's secondary infection.
00:38:16.079 --> 00:38:27.280
We try to be very judicious with our use of antimicrobials, but the tissues are abnormal, they can get secondarily infected, and we know that a certain percentage of patients, roughly around 30%, will show some response to antimicrobials.
00:38:27.440 --> 00:38:34.079
It is a transient response, nonetheless, but it could help the patient wait until they can get to the extraction period.
00:38:34.239 --> 00:38:42.639
And then there could be a role of using anti-inflammatories even before extractions, again, to improve the quality of life of the patient before they get to the extractions.
00:38:42.800 --> 00:38:48.159
So consider that acute timeline of the disease and manage that, right?
00:38:48.320 --> 00:38:53.920
Um, other things to think about now with the current literature is the fact that a lot of them can have esophagitis.
00:38:54.000 --> 00:38:58.159
So maybe treating for that would be a good idea acutely to help them feel better.
00:38:58.320 --> 00:39:05.199
And then newer data suggests that maybe they also have tracheal bronchitis, but that study didn't look at viral infections in those cases.
00:39:05.280 --> 00:39:17.440
So I wonder if it's secondary to that, because we do see that those upper airway viruses uh in association with stomatitis, or I do typically see a lot of my stomatitis cases also having upper airway disease and things like that.
00:39:17.599 --> 00:39:18.800
So those are things to consider.
00:39:18.960 --> 00:39:24.239
Then um, you know, the workup to figure out that they can undergo anesthesia is very important.
00:39:24.400 --> 00:39:27.920
And, you know, most of my kids that come here are already, they've already done that.
00:39:28.079 --> 00:39:34.559
Checking FELV FIB status just to see if prognosis is going to be any different is important.
00:39:34.719 --> 00:39:46.719
And then planting the seed with the owners with the need of anesthesia and dental radiographs and charting to see how many teeth are already affected with paradontitis, tooth resorption, if there's any root remnants.
00:39:46.880 --> 00:40:08.400
Perhaps if the owner's very hesitant to take the chronic management approach of full mouth extractions, then biopsying might not be a bad idea, especially if it's proliferative and staging extractions by taking care of the teeth that are obviously beyond the point of return, doing a cleaning and the rest of the teeth, seeing how the patient does before you make any other recommendations.
00:40:08.639 --> 00:40:20.639
It's not a bad idea so long as you continue having that pain management dialed down across the entire timeline of the disease, from the acute to the chronic to post-extractions until the animal's doing better.
00:40:20.800 --> 00:40:21.920
I think that's very important.
00:40:22.159 --> 00:40:26.480
And just making sure they're keeping up their weight and managing their nutrition accordingly.
00:40:26.639 --> 00:40:33.280
And then also we have conversations about the reality of performing full mouth extractions and primary care practice.
00:40:33.440 --> 00:40:42.639
And my take on this is the following: I think that in an ideal world, full mouth extractions would be done in gosh, less than three hours, ideally, right?
00:40:42.719 --> 00:40:44.320
And that's a hard ask.
00:40:44.480 --> 00:40:50.800
That's a hard ask for somebody that's not doing this every day to get to the point that you're so proficient that you can do it so quickly.
00:40:51.039 --> 00:40:57.039
So I sometimes just say to priority care practitioners that you need to be realistic with what you can do.
00:40:57.199 --> 00:40:59.519
You self-evaluate and you say, Can I get to that point?
00:40:59.679 --> 00:41:01.119
If I get to that point, go for it.
00:41:01.280 --> 00:41:17.280
If you're not getting to that point, then refer them because in that period of time that you do that full mouth extraction, you can help so many more patients by seeing your regular appointments and doing your the work that you know you are proficient and efficient at, that you're better off doing that, to be quite honest.
00:41:17.440 --> 00:41:23.360
The other option is that, you know, if you know you're not going to be able to do it within a reasonable amount of time, stage them.
00:41:23.519 --> 00:41:28.079
If the patient's not systemically healthy, I wouldn't necessarily have that as my first option.
00:41:28.239 --> 00:41:33.199
I would try to get everything done at once with the appropriate monitoring and expertise.
00:41:33.360 --> 00:41:35.840
Maybe hopefully anesthesiologist could be involved.
00:41:36.000 --> 00:41:38.719
But staging should not be frowned upon.
00:41:38.800 --> 00:41:51.119
I think that if it's done with the appropriate communication handling with the owner and with the patient's best interest in mind, I think that's also that should be a valid option.
00:41:51.360 --> 00:41:51.840
Wonderful.
00:41:52.079 --> 00:42:01.599
I know that in the past there have been some thoughts in regards to caudal mouth extractions versus extracting the canine teeth.
00:42:01.840 --> 00:42:21.119
If the gindival tissues are quiet around the canine teeth, or if they are not quiet and they are inflamed, do you think that that's a potentially appropriate treatment when we're talking about extractions for a general practitioner to start with caudal mouth extractions?
00:42:21.440 --> 00:42:23.039
Yeah, that's a good question.
00:42:23.199 --> 00:42:25.519
And that's the that's our treatment approach here.
00:42:25.599 --> 00:42:40.480
If we see that the inflammation is limited to the premolars and molars, um, and the incisors and canines are otherwise healthy on radiographs and charting and not significantly impacted by inflammation, we can start with the caudal mouth extractions.
00:42:40.719 --> 00:42:45.519
We just haven't run the data to see how many of them return to complete the full mouth extractions.
00:42:45.599 --> 00:42:46.400
We should definitely do that.
00:42:46.480 --> 00:42:49.440
But anecdotally speaking, I feel like a lot of them do.
00:42:49.599 --> 00:42:56.559
So I do tell the owner if we can manage this financially and you can come back for the monitoring, I'm all for this attempt.
00:42:56.719 --> 00:43:00.400
But know that a lot of people do come back to finish the full mouth extractions.
00:43:00.480 --> 00:43:07.280
And some people are even happy with getting six more months out of the maxary canines and mandaveric canines as functionally important teeth.
00:43:07.360 --> 00:43:08.400
And I'm all for that too.
00:43:08.480 --> 00:43:10.159
I'm in the business of trying to save teeth.
00:43:10.400 --> 00:43:17.679
So with appropriate communication and management of expectations of the owners, if it's the right patient, I think it's um it's a good idea.
00:43:17.920 --> 00:43:18.320
Right.
00:43:18.639 --> 00:43:22.880
And potentially would then set them up for that staging idea.
00:43:23.119 --> 00:43:33.119
When do you think it's inappropriate to not be aggressive and just go for full mouth extractions as soon as the disease is diagnosed?
00:43:34.079 --> 00:43:39.599
Gosh, I'm I'm more of a gray stone kind of person with adequate communication with the owner.
00:43:39.760 --> 00:43:45.519
So um when would I think it's inappropriate to not go straight to full mouth extractions?
00:43:45.679 --> 00:43:47.840
I think in my case, I can I can tell you an example.
00:43:48.000 --> 00:43:51.840
In my case, it would be the cat that has been managed with steroids for two years.
00:43:52.000 --> 00:43:59.760
And I see open the mouth and I see obvious tooth resorption, feline resorptive lesions, or I see obvious gingival recession and root exposure.
00:44:00.000 --> 00:44:06.400
And I see obvious disease there that's present and the animal is hasn't had that handled yet.
00:44:06.559 --> 00:44:08.880
I think that that to me is a no-brainer.
00:44:09.199 --> 00:44:09.519
Sure.
00:44:09.760 --> 00:44:13.039
And potentially if the animal's not eating well, right?
00:44:13.199 --> 00:44:19.280
If they are losing body weight and there's no other reason that we can contribute to body weight loss.
00:44:19.360 --> 00:44:24.960
And with cats specifically, I know how incredibly difficult it is to get them to lose weight on the case.
00:44:25.119 --> 00:44:30.400
Absolutely trying to control their calories and increase their exercise.
00:44:30.559 --> 00:44:36.480
If you have a win with losing weight in a cat because you're trying to, that's amazing.
00:44:36.639 --> 00:44:46.480
But usually if a cat presents that we see they've lost a pound in the last six months, we start to get really concerned about something else systemic in the body.
00:44:46.719 --> 00:45:02.079
But in cases where it's specifically obvious that the mouth is a problem and they want to eat, but they're just so painful they can't that it may become more urgent that they do more aggressive treatment, which could be full mouth extractions.
00:45:02.239 --> 00:45:03.119
Does that sound right?
00:45:03.360 --> 00:45:05.039
That sounds absolutely right.
00:45:05.599 --> 00:45:05.920
Okay.
00:45:06.320 --> 00:45:20.719
When we think about these kitties, what symptoms or signs do you think the owner might notice so that we could better educate the cat parents on how to look for signs?
00:45:20.960 --> 00:45:21.599
Oh, absolutely.
00:45:21.760 --> 00:45:25.760
I think we already talked about the fact that it's typically a multi-cat household.
00:45:25.920 --> 00:45:27.280
Could be an indoor-outdoor cat.
00:45:27.440 --> 00:45:29.360
Maybe they don't want to go outdoors as much.
00:45:29.519 --> 00:45:34.079
At home, you may notice them running away from the food bowl, pawing at their mouth.
00:45:34.239 --> 00:45:36.159
I've had some that vocalize when they eat.
00:45:36.320 --> 00:45:40.880
Non-grooming, they could be hiding from the owner or other cats in the household.
00:45:41.119 --> 00:45:45.119
Salivation can be another sign, and it could be blood tinged, yellow, or green.
00:45:45.280 --> 00:45:48.800
And then you can see them shying away from you, trying to pet their face.
00:45:48.960 --> 00:45:57.199
And salivation may show as literally saliva coming up, but it could be also crusting around the face or on the front paws and the neck region.
00:45:57.440 --> 00:45:59.599
So it's also a good idea to look at that.
00:45:59.760 --> 00:46:02.719
Quality of their coat if they're not grooming is going to look poor.
00:46:02.800 --> 00:46:07.440
And weight loss could be also detected as a result of not eating if it's chronic enough.
00:46:07.599 --> 00:46:07.840
Right.
00:46:08.079 --> 00:46:14.320
And potentially they may be sleeping more and hiding or just hiding, not interacting with the family.
00:46:14.480 --> 00:46:16.079
Like you said, that's a sad thing.
00:46:16.159 --> 00:46:20.559
They don't remember what their cat was like before they had this disease.
00:46:20.960 --> 00:46:29.360
That's something that I brought up because I think that um part of monitoring how they do over time has to do with looking inside the mouth.
00:46:29.440 --> 00:46:34.559
But the other very vital part that sometimes we undermine is how they're doing at home.
00:46:34.719 --> 00:46:48.719
And so what I like to do with owners, and this is based on research that we've done with a collaborator that is working on stem cell treatment for these patients, is getting a good understanding of the behaviors that went away when the disease started.
00:46:48.880 --> 00:46:53.199
So we can look at those specifically over time and see if they will come back.
00:46:53.360 --> 00:47:05.360
And that will tell us that will make something that can be very subjective, become more objective, and really help us track their quality of life at home because sometimes that will improve before the oral cavity improves.
00:47:05.599 --> 00:47:06.400
Interesting.
00:47:06.719 --> 00:47:17.679
And just seeing the improvement in the behaviors that they did have before the disease could really be an indicator that their quality of life is improving as well, right?
00:47:18.639 --> 00:47:18.960
Okay.
00:47:19.360 --> 00:47:35.679
So if full mouth extractions are done, and let's say a cat comes to you and that's where we're at with things, hoping for a cure, do you guys have any specific things that you do that are you feel new medicine, cutting edge, or something that you feel is important?
00:47:35.840 --> 00:47:58.559
I remember hearing that if any tooth root fragments are left behind, or if we don't curette out the alveolus to get all periodal ligament fibers out, that we could be dealing with refractory cases because there's some portion of the tooth that's still there and maybe misinformation regarding any of that.
00:47:58.800 --> 00:48:05.679
What do you have to tell us about specifically when the surgery is done technique-wise, that's important for these kids?
00:48:06.000 --> 00:48:07.280
I think that you're spot on.
00:48:07.360 --> 00:48:14.079
I think that post-operative radiographs or imaging in general is absolutely necessary to make sure you don't leave any tooth material behind.
00:48:14.159 --> 00:48:27.840
And we don't have a good explanation for why that happens, but sometimes refractory cases come in, and the first thing we want to do is some form of imaging to assure that there's no tooth material left under the gum line because some of them will respond by just managing that.
00:48:28.000 --> 00:48:29.360
And so that's important.
00:48:29.599 --> 00:48:33.440
And again, I can't emphasize enough the need for pain management.
00:48:33.599 --> 00:48:46.960
Post ops are done and until the inflammation goes away, because this is a chronic enough disease where behaviors change at home and they're normalized and they're not picked up as pain, even though these are painful, painful animals.
00:48:47.199 --> 00:48:48.960
So, yeah, post-op rates are important.
00:48:49.039 --> 00:49:06.480
And then for those cases that look atypical where there could be proliferation or the inflammation is asymmetric biopsy, too, to make sure that you are dealing with lympoplasmacytic inflammation and not eosinophilic inflammation or not something like a squamous cell carcinoma, that would be important too.
00:49:06.639 --> 00:49:09.760
So tell me more about the eosinophilic inflammation.
00:49:10.000 --> 00:49:15.199
Cats potentially with asthma, is there anything specific to those?
00:49:15.679 --> 00:49:36.800
Yeah, you know, we talk about eosilic granuloma complex, and we when we hear about that, we think about the indolent ulcer and we think about the proliferative lesions that can happen in the oral cavity on the tongue or in other areas that look pretty typical with their pinpoint yellow to tan deposits on the top that are almost like pathonomonic for eusinophilic granulomas.
00:49:36.960 --> 00:49:51.440
But we've had some cases come in with more of a stomatitis presentation, and we're doing work on that now, but they don't all respond the same way that you would expect with a case that only has lipoplasmacytic inflammation and not ecinophils in there.
00:49:52.079 --> 00:49:52.400
Okay.
00:49:52.960 --> 00:49:53.119
Okay.
00:49:53.599 --> 00:50:05.679
Now you mentioned cases where cats have maybe the trifecta, they have periodontitis leading to bone loss and tooth attachment loss of periodontal ligament.
00:50:05.840 --> 00:50:11.760
They may have stomatitis, which is the topic of the day, but also tooth resorption.
00:50:11.920 --> 00:50:16.239
We are just talking about not leaving any tooth remnants behind.
00:50:16.400 --> 00:50:25.920
But what if someone discerns that there's type two resorption on a tooth in a cat's mouth that also has chronic feline gendival stomatitis?
00:50:26.159 --> 00:50:29.119
Do you still recommend doing core amputations?
00:50:29.519 --> 00:50:37.280
In these cases, typically what you see is type one resorption in general, because that's the resorption that we see in association with inflammation.
00:50:37.360 --> 00:50:47.199
But we have we see enough stomatitis here that we have seen cases with type two resorption, which is typically around the maxurate canines and non-inflammatory in nature.
00:50:47.440 --> 00:50:53.039
In those cases, I would say that sometimes you can do more harm trying to extract a tooth that is no longer a tooth.
00:50:53.199 --> 00:51:18.159
And so I think that it's not completely unjustified to continue taking the approach that we would for a tooth with type two feline resorption, where we follow the guideline of if the root no longer have a predontal ligament space and you can't see a root canal system, and the density of the root is more similar to bone in the area than teeth in the area, then you can consider crown amputation.
00:51:18.239 --> 00:51:27.360
But thinking about it, really it's very unusual to find that type of scenario in a cat with somatitis, but then healthy cat altogether.
00:51:27.440 --> 00:51:32.559
When we get to perform crown amputations for the right indications, it's like a reason to celebrate in dentistry.
00:51:32.639 --> 00:51:35.679
It's less, even less commonly seen in FCGS.
00:51:35.760 --> 00:51:37.440
Typically in FCGS, it's type one.
00:51:37.519 --> 00:51:39.599
And in those cases, you have to extract the entire tooth.
00:51:39.679 --> 00:51:39.840
Okay.
00:51:40.000 --> 00:51:53.840
But then those would be ones that I would follow up very closely and perhaps even do radiographs in three to six months to make sure that the tooth continues to go away and then explain to the owner hey, our data shows that typically if we're going to see an improvement, we're going to see it within two months.
00:51:53.920 --> 00:52:05.360
But maybe in this case, because we have this atypical type of resorption for these cases of type two, and we have to handle it this way, maybe we're going to give it a little bit more time and we want to see actually that tooth going away.
00:52:05.599 --> 00:52:06.320
That makes sense.
00:52:06.559 --> 00:52:18.159
With these cats, when we think about their in surgery, maybe they have full mouth extractions, and we know that they have been malnutritioned, losing body weight.
00:52:18.320 --> 00:52:23.599
What percentage of cats do you place a feeding tube on if they're getting full mouth extractions?
00:52:24.880 --> 00:52:26.960
Rarely ever do we have to do that.
00:52:27.199 --> 00:52:33.440
Um I think in my residency I did it once and I haven't knocked a wood had to do it again.
00:52:34.400 --> 00:52:34.719
Okay.
00:52:34.960 --> 00:52:35.760
Well, that's good.
00:52:35.840 --> 00:52:37.280
That's less complicated.
00:52:37.599 --> 00:52:42.559
What if they do go home and they're still not doing well or they're still not eating?
00:52:42.719 --> 00:52:50.400
Would that be something that your primary care practitioner should consider getting them back in and doing a feeding tube placement?
00:52:50.480 --> 00:52:50.639
Yeah.
00:52:51.280 --> 00:52:56.079
Oh my gosh, it it happens so infrequently that it's not the mainline conversation that I have.
00:52:56.239 --> 00:53:02.000
I think usually stronger pain management would be my first go-to before I recommend a feeding tube.
00:53:02.079 --> 00:53:10.480
But I do know that some practitioners are firm believers of bypassing the oral cavity with a feeding tube to help with the control of inflammation.
00:53:10.639 --> 00:53:18.159
I, to my knowledge, there are no studies to necessarily support that, but I remember a person saying this to me before in our college.
00:53:18.320 --> 00:53:22.239
They're firm believers of bypassing the oral cavity to promote the healing.
00:53:22.480 --> 00:53:22.800
Right.
00:53:22.960 --> 00:53:37.360
I remember a cat in my general practice setting that had just horrible chronic feline genovistomatitis, and we did full math extractions, and it became just a refractory case that we were struggling with.
00:53:37.519 --> 00:53:47.920
And I think if I remember correctly, we may have tried some cyclosporin, but this cat was so head shy, mouth shy.
00:53:48.079 --> 00:53:57.280
It was also super thin, hadn't been eating well for a very long period of time leading up to the full mouth extraction surgery.
00:53:57.519 --> 00:54:08.480
And we did place a tube and was able to then give the cat better consistent nutrition, as well as the oral antibiotics and other medications.
00:54:08.719 --> 00:54:16.320
And I remember that cat specifically getting rapidly better when he got more consistent nutrition.
00:54:16.559 --> 00:54:26.800
Do you have any other suggestions given your experience with these cats on how to get them more consistent nutrition as they're recovering from something like full mouth extractions?
00:54:27.039 --> 00:54:27.199
Yeah.
00:54:27.360 --> 00:54:43.199
So barring any other systemic diseases that would determine what they should be eating, I think I I've had better experience with well, softer foods for sure, high caloric diets, and small meals multiple times a day rather than trying to give them a whole lot of food.
00:54:43.519 --> 00:54:47.760
Then the other thing is I've had cats that cats are impressive.
00:54:47.920 --> 00:54:50.320
I've had cats that hate soft food.
00:54:50.800 --> 00:55:03.760
And even those abstractions, I've had to cross my fingers and hope that the hard food does not interfere with the healing, but they need to go back to hard food because that's the only thing they'll eat even without having tea.
00:55:03.840 --> 00:55:06.159
So I think the conversations with the owners are so important.
00:55:06.320 --> 00:55:10.079
There's always the you don't know those patients as well as the owners do.
00:55:10.159 --> 00:55:16.480
And so taking these cues that the owners give you is so important to bringing them back to their normal routine.
00:55:17.039 --> 00:55:17.440
Right.
00:55:18.079 --> 00:55:19.280
Even what type of medication?
00:55:19.360 --> 00:55:21.599
Is it a pill cat or is it a liquid cat?
00:55:21.679 --> 00:55:23.440
Or do we have to try transhermal?
00:55:23.679 --> 00:55:28.159
And yes, there's no real evidence that it works so well, but let's give it a try.
00:55:28.320 --> 00:55:31.679
If you're willing to try it, I'm willing to try it and we'll see how the cat does.
00:55:31.760 --> 00:55:35.440
And so just thinking outside the box with cats is so necessary.
00:55:35.679 --> 00:55:46.079
Yes, they are their own little creatures, and each one is such an individual, and we have to cater to what the cat will accept and what we can do as pet parents.
00:55:46.320 --> 00:56:03.280
When we think about giving medications, you commonly suggest you mentioned potentially that we might be needing to use some antibiotics given certain microbiome populations, and then we need to talk about pain management as well.
00:56:03.519 --> 00:56:17.119
What kind of medical management acutely would you say you often do with these cats given chronic feline gendively stomatitis and potentially full mouth or near full mouth extraction cases?
00:56:17.360 --> 00:56:21.280
Yeah, typically buprenorphine is the first one that we go to.
00:56:21.519 --> 00:56:31.280
Recent being there have been studies looking at the analgesic effects and absorption of buprenorphine after bucklined administration in these cats with stomatitis.
00:56:31.519 --> 00:56:43.360
And even though it had a lower bioavailability and shorter absorption half-life in that study, the animals did have an analgesic effect from it and was beneficial for them.
00:56:43.440 --> 00:56:44.800
So that's usually our go-to.
00:56:45.039 --> 00:56:55.199
But things like gabapentin could be another option in the chronic setting where you're trying to manage them for enough time, something like amantidine could be an option.
00:56:55.440 --> 00:57:03.920
So, and then you hear about the newer forms of pain medication available for cats that monoclonal antibodies that could be considered too.
00:57:04.079 --> 00:57:12.559
We don't personally use them, but we do see a lot of cases that come in on that medication, and they seem to have good, successful effects in pain management too.
00:57:12.719 --> 00:57:14.960
So then steroids will help to some degree.
00:57:15.119 --> 00:57:21.199
And ansets I try to stay away from just because eventually you may need to use steroids in these patients.
00:57:21.360 --> 00:57:25.039
And so you don't want to have to have a cat wait for a washout.
00:57:25.119 --> 00:57:29.199
Although even that washout period recently has become a little bit controversial.
00:57:29.360 --> 00:57:33.599
I still go by it, but some people now say that a washout is not even necessary.
00:57:33.760 --> 00:57:43.199
I find it uh I things to consider the things how how medicine changes over time from how you're trained to where we are now does never cease to surprise me.
00:57:43.599 --> 00:57:47.280
But to be safe, let's do the washout, right?
00:57:47.440 --> 00:57:47.599
Yeah.
00:57:48.159 --> 00:57:53.280
When we think about while they're under anesthesia, I'm sure you are doing nerve blocks.
00:57:54.079 --> 00:58:00.639
Do you often do controlled rate infusions with these cats that are getting full mouth extractions under anesthesia?
00:58:00.719 --> 00:58:04.559
Yeah, sometimes we have to because the local blocks will not work as well.
00:58:04.800 --> 00:58:11.280
There's an acidic environment because of all the inflammation, and local blocks are super dependent on the pH of the environment.
00:58:11.360 --> 00:58:17.679
And so sometimes the blocks won't work and you have to rely on CRIs and other forms of pain control for them.
00:58:18.320 --> 00:58:18.719
Great.
00:58:18.880 --> 00:58:36.000
And I talk about that a lot when I talk about nerve blocks because people think that they work no matter what, but often under these chronic inflammatory states, we are up against a brick wall when it comes to having these types of drugs be our primary pain control.
00:58:36.239 --> 00:58:47.119
So having other tools in the tool belt or other ways of providing the pain control that these cats need while they're under anesthesia and beyond, I feel is something we need to educate ourselves about more.
00:58:47.280 --> 00:58:48.880
So very good to know.
00:58:49.039 --> 00:59:00.159
So when we think about preventing these cats from ever getting here, what is the future of research looking like that you know about?
00:59:00.480 --> 00:59:05.360
Yeah, the goal in the future will be to be able to get something called biomarkers.
00:59:05.519 --> 00:59:24.320
Biomarkers are different types of substances, it could be genetic material, protein, or a metabolite, or it could be, and it could be from saliva, it could be from a buckle swab, it could be from the blood, but it would be a hint of something that is an intrinsic factor in the cat that could be associated with this disease.
00:59:24.400 --> 00:59:27.599
And so that's where I think we're going to go in the future.
00:59:27.679 --> 00:59:43.679
And that's linked to this concept of personalized medicine where you say we measure these things ahead of time, and they're not going to guarantee that you're going to get the disease in the future, but it may change the way we treat you, we monitor you for sure, so that we hopefully catch things at the very least earlier on.
00:59:44.000 --> 00:59:44.400
Right.
00:59:44.639 --> 00:59:57.119
Before we have no other choice but to do full mouth extractions on these cats, or that they've been suffering for months to years with the most painful oral condition that we can probably imagine.
00:59:57.519 --> 00:59:57.760
Yeah.
00:59:58.000 --> 00:59:58.400
Absolutely.
00:59:58.639 --> 01:00:03.599
Well, there's so many avenues to think about when it comes to this specific condition.
01:00:03.840 --> 01:00:14.320
When we think about some of the other products that are out there and available, what do you know about using a laser in the mouth of these cats?
01:00:14.480 --> 01:00:15.519
Yeah, good question.
01:00:15.760 --> 01:00:17.760
I think there's two types of lasers, right?
01:00:17.840 --> 01:00:20.400
There's a therapeutic laser and the ablative laser.
01:00:20.559 --> 01:00:25.280
In terms of the therapeutic laser, there's no real evidence out there to support since its use.
01:00:25.440 --> 01:00:34.480
The ablative laser has low quality evidence, and that there's only like a case report with a literature review on ablative laser used for a cat with stomatitis.
01:00:34.559 --> 01:00:42.559
And in my experience, I've used CO2 laser and a cat with stomatitis before, um, more than one, to be honest, because of proliferative lesions.
01:00:42.880 --> 01:00:48.960
And my experience with it is that they are more painful, they get worse before they get better.
01:00:49.039 --> 01:00:51.760
And so a feeding tube on those would be a good idea.
01:00:51.920 --> 01:00:57.679
And you need to do multiple treatments to promote that fibrosis that will resolve the inflammation.
01:00:58.239 --> 01:01:22.320
And so I use it as a means to debulk proliferative lesions or as a last resort because I feel that it is a tough sell to an owner to say, and now I'm gonna make your cat feel worse before they feel better, especially now in this environment where in Europe there's feline recombinant interferon, and then in the United States, there's gonna be hopefully stem cell therapy here available in the near future.
01:01:22.559 --> 01:01:29.840
It would be very hard to justify making a cat feel worse if you have something that doesn't do that and it's FDA approved here soon.
01:01:30.000 --> 01:01:41.039
So um I think that it's something to know that it's there and it may have a role intraoperatively if you have very exuberant tissue to make the exhumation process less risky.
01:01:41.280 --> 01:01:47.599
But as a means of treatment for refractory patients, perhaps I wouldn't, it wouldn't be my first choice.
01:01:47.840 --> 01:01:48.800
Okay, perfect.
01:01:49.039 --> 01:01:50.880
What about sealants?
01:01:51.039 --> 01:02:11.119
There is a sealant out there that we have used for years and years in cats called Sanus, and we put that on as the last step of our dental cleaning procedure in all cats because we thought this lasts for six months and it could potentially prevent periodontitis or inflammation of the genival tissues.
01:02:11.280 --> 01:02:20.159
In specifically cases of aggressive periodontitis, which we had referred to as juvenile onset genivitis or periodontitis.
01:02:20.320 --> 01:02:26.719
This is happening earlier on in their life and is aggressive to the point that they're losing bone in attachment.
01:02:26.960 --> 01:02:45.440
I personally had seen some pretty remarkable differences between getting them anesthetized, getting their teeth cleaned, obviously taking full mouth dental radiographs, addressing any specific teeth that require extraction because of mobility, they're too far gone regarding bone loss even at a young age.
01:02:45.599 --> 01:02:52.480
And then putting that Xanos on, it seemed that the cats that we did that on, they quieted down pretty quickly.
01:02:52.719 --> 01:02:58.719
Do you have any thoughts or input or anything on specifically that particular sealant?
01:02:59.039 --> 01:02:59.840
No, not really.
01:03:00.000 --> 01:03:09.119
It it is VOHC approved, but I have not necessarily used it in our clinics and not specifically for that population of patients for sure.
01:03:09.440 --> 01:03:13.599
I try to er more towards let's try to get the teeth brushed.
01:03:13.760 --> 01:03:16.079
I think that would that is my main priority.
01:03:16.639 --> 01:03:17.039
Right.
01:03:17.280 --> 01:03:25.440
Which is, we will admit, difficult in cats, especially if they've had something really painful going on in their mouth.
01:03:25.760 --> 01:03:31.519
It seems like it would be a very hard sell to a cat just because they don't forget.
01:03:31.599 --> 01:03:40.639
They're like elephants and they remember if that dish of food caused them some sort of pain, like they never want to let a dish.
01:03:41.280 --> 01:03:42.559
And that's food again.
01:03:42.639 --> 01:03:44.239
Yes, definitely difficult.
01:03:44.480 --> 01:03:49.119
One of the products that we're talking about is a hot topic lately is hyaluronic acid.
01:03:49.280 --> 01:03:56.480
Do you have any thoughts or opinions in regards to hyaluronic acid when it comes to these chronic xeline genitalitis cats?
01:03:56.800 --> 01:03:59.440
I think that I again haven't used it personally.
01:03:59.599 --> 01:04:03.679
I think the data on hyaluronic acid in general is pretty solid.
01:04:03.920 --> 01:04:08.239
I think that for this disease, still we're learning more and more about it.
01:04:08.480 --> 01:04:13.039
And I would see it as an adjunct rather than a single agent.
01:04:13.199 --> 01:04:19.039
I do think that there are things that we talked about the complexity of this disease.
01:04:19.840 --> 01:04:26.400
And I do think that we have other methods that literally act like a Swiss Army knife for this disease.
01:04:26.559 --> 01:04:35.039
With that, I'm talking about stem cells that tackle like basically every single aspect that we have seen and talked about briefly here in FCGS.
01:04:35.199 --> 01:04:39.599
So I think that if we want to take a multimodal approach, it's not a bad idea.
01:04:39.760 --> 01:04:47.519
But there seems to be, especially for these refractory cases, the one treatment that will give you the multimodal approach in one thing, which is pretty remarkable.
01:04:47.760 --> 01:04:53.039
And I am very excited about the future for these cats because of that possibility, that option.
01:04:53.280 --> 01:05:04.639
Yeah, stem cell research is amazing and has really taken us a long way in finding some solution to many, many problems that we're dealing with with these patients and other patients.
01:05:04.880 --> 01:05:07.840
So that could be another episode that we talk about.
01:05:08.639 --> 01:05:12.320
Regenerative medicine and cuting edge of regenerative medicine.
01:05:12.480 --> 01:05:13.760
Yeah, so exciting.
01:05:14.079 --> 01:05:16.000
So we'll have to save that for another time.
01:05:16.320 --> 01:05:16.960
Sounds great.
01:05:17.199 --> 01:05:26.639
If there was one key message that you would like veterinary professionals to take away from this discussion about feline chronic gendivostomatitis, what would that be?
01:05:27.199 --> 01:05:27.840
Yes.
01:05:28.159 --> 01:05:31.599
Gosh, I think the disease itself is complex.
01:05:31.760 --> 01:05:41.280
I think that we need to continue to work on it to hopefully find a solution where we don't have to attract teeth that are healthy anymore and we can do better by these cats.
01:05:41.519 --> 01:05:59.760
But this is when I talk to students here, this is the disease that lets me show them how important client communication is and managing client expectations is, and making sure that clients understand that pain can be missed in these patients and emphasizing the need for pain management across.
01:06:00.239 --> 01:06:05.519
The board through this disease from the very beginning until the information is resolved.
01:06:05.760 --> 01:06:14.079
Um, so those are I think key home take-home messages that are key for me with my students and my clients in general in relation to this disease.
01:06:15.119 --> 01:06:15.760
Yeah.
01:06:16.400 --> 01:06:30.239
Really good advice and something that I think we can all use because when we are a patient advocate, one thing we're advocating for is that the patient has a not just good but exceptional quality of life.
01:06:30.400 --> 01:06:34.800
We want really good things for them, and that can then help with the human-animal bond.
01:06:34.960 --> 01:06:46.880
A cat that comes out and wants to interact with its people and is comfortable and healthy and happy is a really fun cat to have in your house and something that I think really enriches our lives as humans.
01:06:47.039 --> 01:06:55.119
So we want to be really educating them on what to watch for and then getting these cats in on a more routine basis.
01:06:55.280 --> 01:07:05.440
We found in my practice that a lot of cats weren't coming in on an annual basis because the owner was hesitant to try to get them in the crate and have to take them out of the cut.
01:07:05.760 --> 01:07:30.079
And it's yeah, the cat is so good at hiding and not being caught the day the vet appointment is and helping them with all those things by emphasizing how incredibly important it is, even more so in cats I feel than dogs, that we get in there and look in their mouth at least annually from looking for something like just gendivitis or doing a baseline full mouth dental radiographs and assessing things.
01:07:30.239 --> 01:07:33.440
But cats have such a high incidence of tooth resorption.
01:07:33.679 --> 01:07:35.840
Yeah, they're just terrible at showing pain, right?
01:07:35.920 --> 01:07:38.400
So you can't trust them to let you know what's happening.
01:07:38.880 --> 01:07:42.079
They're not gonna let us know, and they're suffering in silence.
01:07:42.239 --> 01:08:03.039
And so us as veterinary professionals really need to be proactive in a strong way to make sure that we are emphasizing how important it is that these cats get anesthetized on a frequent basis to investigate thoroughly and look for any signs of any other dental condition or squamous cell carcinoma, which we're gonna talk about with Dr.
01:08:03.199 --> 01:08:15.920
Goldschmidt at length because they're so good at hiding it, but it can really completely sabotage their quality of life and shorten their lifespan potentially if they were to get something significant like squamous cell carcinoma.
01:08:16.079 --> 01:08:16.399
Well, Dr.
01:08:16.479 --> 01:08:22.720
Robert, thank you so much for joining us today and for sharing your insights on this super challenging disease.
01:08:22.960 --> 01:08:27.199
It's your turn now, before we go, to leave a question for my next guest.
01:08:27.439 --> 01:08:27.680
Absolutely.
01:08:28.000 --> 01:08:34.399
So, what would your question be if you would like to ask an interesting question to someone like yourself or someone like myself?
01:08:34.640 --> 01:08:34.960
All right.
01:08:35.119 --> 01:08:46.000
So, my question is looking back in time, what concepts in veterinary dentistry did we get most wrong early on?
01:08:46.079 --> 01:08:48.159
And what are we still getting wrong today?
01:08:48.399 --> 01:08:49.359
That's great.
01:08:49.600 --> 01:08:52.640
I think that will be a perfect question for our next guest.
01:08:52.880 --> 01:08:56.960
Thank you so much for the question, and we will look forward to the answer.
01:08:57.119 --> 01:09:01.039
Thank you for being on Positive Veterinary Dentistry Podcast today.
01:09:01.199 --> 01:09:04.720
And to our listeners, thank you for tuning in to the podcast.
01:09:04.880 --> 01:09:09.119
If you found this episode helpful, we really are trying to grow our listenership.
01:09:09.199 --> 01:09:22.239
So please share it with your colleagues, anyone who is passionate about helping animals improve their dental care and to help advocate specifically for cats, given this episode focused on chronic delineostomatitis.
01:09:22.479 --> 01:09:30.159
Until next time, keep learning, keep growing, and keep doing cognitive dentistry making a difference for the patients that you care for.