Caudal Stomatitis and Other Autoimmune Oral Disease
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Caudal Stomatitis and Other Autoimmune Oral Disease Yuck, no practitioner wants to deal with these cases… But treating these will benefit your patients Autoimmune Oral Disease Multiple expressions of over response of the immune system Most common are; Caudal Stomatitis Chronic Ulcerative Paradental Stomatitis Juvenile Periodontitis Caudal Stomatitis Primarily in feline patients Hallmarks in history: Oral pain Dysphagia Ptyalism Vocalizing Distinct halitosis Diagnosis of Caudal Stomatitis Primarily a diagnosis of history and oral evaluation Oral evaluation hallmarks Palatitis Glossitis Mucositis PALATOGLOSSAL FOLD PROLIFERATION, ULCERATION Other useful diagnostic tools Hypergammaglobulinemia Bartonella titer (this is of questionable clinical relevance) Histopathology almost always shows lymphoplasmacytic infiltrate with mild to moderate fibrosis Some neutrophilic infiltrate is common WHEN IN DOUBT, SUBMIT INCISIONAL BIOPSY Pathogenesis Well…This is really up for grabs. Thought to be auto-antibodies directed at the periodontal ligament There are certainly multiple etiologies and much needs to be elucidated Probable Caudal Stomatitis Unlikely Caudal Stomatitis OK, this is the big one THERAPY OF CAUDAL STOMATITIS Divide therapy into acute therapy directed at return to eating and definitive therapy directed at long term analgesia and return to function THERE IS NO CURE, WE ARE TREATING SYMPTOMS Acute Therapy 1. In anorexic, painful cats a. Analgesics 1. Opioids 2. Non-steroidal anti-inflammatories 3. Oral antibiotics for surface infection only, this does not treat long term 4. Oral rinses; primarily zinc containing rinses a. Immunomodulatory b. Difficult to apply in painful cats 1. One time, short duration use of corticosteroids a. Recurrent use of these will markedly lower long term success, cause diabetes mellitus and basically screw us all up Long Term Therapies Surgery Most successful 80-90% off medications in 6 weeks Distal extractions; all teeth distal to canine teeth results in 80% success Full mouth extractions; all teeth; results in 90% success It is CRITICAL to completely extract and perform alveoloplasty prior to closure Most surgical failures are the result of retained tooth root fragments Crown Amputation is used to treat tooth resorption, NOT Caudal Stomatitis Most Common Outcome of Extraction Therapy Treatment summary 1. Intense efforts at plaque control and medical therapy rarely results in acceptable response. 2. Surgical intervention is the preferred therapy and should be performed as soon as possible (at the time of this presentation). 3. Medical therapy should be reserved for cases in which the client will not allow or cannot afford to perform surgery. Other Therapies In order of descending success 1. CO2 laser ablation. Do not use as primary therapy. 2. Class 4 laser; there are NO STUDIES, but I believe it helps. Do not use as primary therapy. 3. Cyclosporine orally long term 4. Recombinant omega interferon Virbagen Omega; not available in the US (Well…) 5. Long term analgesics occasional antibiotics Only use these if owner has been completely informed of risk - Important; document discussions with owners - Long term corticosteroids - Important to monitor patient with hematology, serology, urine cultures ONCE WE ARE DOWN TO USING THERAPIES ON THIS PAGE, WE ARE GRASPING AT STRAWS Chronic Ulcerative Paradental Stomatitis Primarily in canine patients Results in raised, ulcerative, erythemic lesions at labia, palate, tongue Nearly always associated with periodontitis and horizontal bone loss Therapies Again, treated in stages, there is no cure 1. Aggressive plaque control Important to perform complete subgingival curettage Often will require coronally reappositioned flaps Often will require professional cleanings every 3-4 months HOME CARE IS CRITICAL, BUT DIFFICULT 2. Localized extraction or extraction of teeth at the sites of contact ulcerations 3. Full mouth extractions REMEMBER Caudal Stomatitis? Etiology Again, as in Caudal Stomatitis, etiology is unknown This is much more likely to be a localized response to plaque and calculus, however. Aggressive professional care and determined home care is more likely to result in control than in Caudal Stomatitis IMPORTANT POINT These teeth are severely inflamed and often have marked ankylosis or degradation of periodontal ligament These are NASTY, FRUSTRATING extractions You will note marked hemorrhage and difficulty in complete extraction As in Caudal Stomatitis, crown amputation will guarantee treatment failure So…. 1. Prepare the owner These are time consuming, difficult extractions Estimates should reflect surgical time required, not the tooth to be extracted This is not cheap work 2. Schedule appropriate surgical time Having time constraints will often lead to rushing Rushing causes surgical mistakes Stress is killing veterinarians, we can control some of this Extraction tips continued 3. Have appropriate equipment Good lighting; you cannot extract what you cannot see Overhead and lighting on loupes will facilitate extraction Loupes 2.5 power are tremendously easy to use Sharpened elevators, luxators Suction How anyone can perform oral surgery without suction is beyond me Good help Retraction, exposure is critical Juvenile Periodontitis I prefer the term Juvenile Gingivoperiodontitis as there is marked gingival proliferation MUCH more common than previously thought Make oral evaluation AND RECORDING a point in each wellness examination and you will note this Juvenile Periodontitis is not as painful Caudal Stomatitis, but still nasty Juvenile Periodontitis Begins at eruption of deciduous and (especially) adult teeth Significant inflammation, edema, even ulceration of attached gingiva OCCASIONALLY will see thickened, fibrous gingiva over erupting teeth that may require resection Halitosis is common Does NOT extend onto palate, palatoglossal folds Etiology Unknown; Is there a trend in oral auto- immune disease? MARKED ASSOCIATION with early respiratory disease Calici virus is most common association FIV also associated Diagnosis Young cat Severe inflammation without marked gingival enlargement No progression onto hard, soft palate Oral radiology CONSISTENTLY shows horizontal bone loss Bone loss primarily noted at mandibular bodies and especially at fourth premolar, first molar teeth Note little paradental spread of inflammation Horizontal bone loss; especially at the distal mandible You will see this consistently with Juvenile Periodontitis Two distinct syndromes 1. Self-limiting One study showed that 50% will respond well to aggressive professional care and determined home care Home care is critical but difficult 2. Progressive 50% progress to an early form of Caudal Stomatitis Caudal Stomatitis is best treated using full mouth extraction So… It behooves us to aggressively treat these Juvenile Periodontitis patients Treatment 1. Complete, careful Oral Cleaning, Scaling and Polishing 2. Occasionally, gingivectomy will free entrapped premolar, molar teeth. 3. It is not uncommon to be forced to extract mandibular premolar, molar teeth at the time of initial cleaning, scaling and polishing. 4. Patients progressing to Caudal Stomatitis require full mouth extraction. Prognosis In some cases, inflammation recedes in first 2 years of life Horizontal bone loss is not curable Others can be a life long struggle Some of these will turn into Caudal Stomatitis later in life.