Non-healing mouth after extraction

Re: Non-healing mouth after extraction

Stephen Cahalan — Fri, 03 Oct 2014 11:24:37 GMT

As far as I'm aware, the average length of survival time after diagnosis with feline oral SCCs is 2 months. Unfortunately bad news indeed.

I made a similar mistake with a non-healing feline oral ulcer when I was in practice. I felt awful after it.

Hayes AM, Adams VJ, Scase TJ, Murphy S: Survival of 54 cats with oral squamous cell carcinoma in United Kingdom general practice. J Small Anim Pract 48:394–399, 2007.

Re: Non-healing mouth after extraction

Evelyn Barbour-Hill — Fri, 03 Oct 2014 00:49:16 GMT

Poor old cat. I suppose it's going to be euthanasia?

[quote user="Stephen Courtney"]I think maybe we should factor biopsies into the clinical plan for older cat dentistry - or at least keep some tissue in formalin for future reference if things don't go well?[/quote]

Exactly what I do if there's anything "a bit suspicious". If something looks not quite right, then it probably isn't. However the trouble is, sometimes, seeing any tissue you can biopsy with confidence; not deep enough and the pathology report will invariably be "inflammation". Just the other day I extracted with suspicious ease a set of cheek teeth, but neither inspection nor radiography suggested what might be a representative bit to biopsy.

The other danger, especially on a busy day maybe, is that you are all set to do one thing, you are sure of what's wrong, and when you see something not quite right you kid yourself and rationalise it away. That tissue looks a bit odd.... nah, it's just fibrin.... I made a horrible mistake of that nature a good number of years ago (which led to my needing to do a maxillectomy on New Year's Eve) and it was an Awful Warning.

Re: Non-healing mouth after extraction

Stephen Courtney — Thu, 02 Oct 2014 23:05:29 GMT

Thanks for the update. I'm sorry to hear this, but not surprised.

I think maybe we should factor biopsies into the clinical plan for older cat dentistry - or at least keep some tissue in formalin for future reference if things don't go well?

Re: Non-healing mouth after extraction

Linda Filshie — Thu, 02 Oct 2014 22:05:09 GMT

Ronnie's mouth wasn't looking too bad yesterday, but not fantastic (I'd left my phone at home, so no pics I'm afraid). Histo is back and those of you that reckoned SCC were sadly correct. I'll post the XR tomorrow if I get a chance.

DIAGNOSIS

Squamous cell carcinoma

PROGNOSIS

Guarded

MARGINS

Biopsies submitted

HISTOLOGY

History: non-healing tooth extraction site from Ronnie.

Description: the submitted biopsies have been processed without sectioning. The biopsies contain portions of a neoplastic cellular proliferation dissecting between fragments of bone. The neoplastic cells are polygonal with granular eosinophilic cytoplasm and oval nuclei with finely stippled chromatin and small nucleoli. Mitoses average one per high power field.

This is a squamous cell carcinoma. These neoplasms can invade bone, as has occurred here. There is also a risk of metastatic disease to the local lymph nodes.

Re: Non-healing mouth after extraction

Linda Filshie — Wed, 01 Oct 2014 08:50:51 GMT

Still waiting for the histo. He was doing ok a couple of days after the last surgery, and I'm seeing him back this morning.

Re: Non-healing mouth after extraction

Evelyn Barbour-Hill — Wed, 01 Oct 2014 00:48:38 GMT

Did we get a histopathology report? How's the patient?

Re: Non-healing mouth after extraction

Peter Southerden — Mon, 22 Sep 2014 16:40:53 GMT

Hi Linda - I can't be certain without seeing the radiographs. From what you have described this doesn't sound like osteomyelitis. In cats osteomyelitis/osteitis tends to be localised, the affected bone may appear to be thickened, there may be an overlying periosteal reaction, there can be an accentuated trabecular pattern or there may be no change at all radiographically. In dogs I commonly see osteomyelitis associated with devitalised necrotic exposed bone - radiographically the bone looks relatively normal. I haven't seen osteomyelitis present like this as far as I can remember in a cat and therefore assume it's rare.

As I mentioned before SCC is a common cause of non healing extraction wounds in elderly cats. SCC causes rapidly progressive osteolysis. So if the radiographic picture is one of rapidly progressive osteolysis associated with a non healing extraction site you almost have your diagnosis. Depending on the clinical context (cat, owner expectations etc) I may not do any surgery at all as the prognosis at this stage is very poor. However if confirming the diagnosis is important I would just take a biopsy. The reasons for this are: 1. If the patient was a possible surgical candidate any other surgery would make a resection more difficult. When resecting an oral SCC it's not just a matter of removing the mandible as the soft tissue component of the tumour also needs to be resected with an appropriate margin. So if you have curetted the surgical site and raised a flap the margin of say 1cm (and some would argue more than this ) would need to be taken around your previous soft tissue surgery. This would make the surgery more extensive, more difficult and with a poorer prognosis. 2. If surgery is not an option then raising a flap and curetting the area is an unnecessary surgical procedure which will have no benefit for the patient and may hasten the progression of the disease. 3. If this was extensive rapidly progressive osteomyelitis local curettage wouldn't cure it.

I completely understand that these decisions need to be made in context and am trying to be constructively critical which is hopefully what this sort of forum is about. If you get the chance to post the radiographs and the biopsy results that would be great.

Re: Non-healing mouth after extraction

Evelyn Barbour-Hill — Fri, 19 Sep 2014 00:56:30 GMT

I'd like to reassure everyone that two dentist arguments in one week represents nothing more than coincidence. Well, I hope it does.

I'm sure Linda appreciates the usual principles of biopsy and oncological surgery as do you and I.

But.

In this case there's already been surgical interference (the original 308 extraction, with sutures so a flap must have been mobilise, and then the first curettage) so the area that-must-be-removed-plus-margin (is there a term for that?) had already been unquantifiably extended.

There was never a visible lump or mass that could be stated to be a suspect cancer of defined area so it is unlikely that any excision would be able to be confined to something less than a partial mandibulectomy.

If the bonein this case is of abnormal appearance due to cancer, then for excision nothing short of mandibulectomy will suffice. In my opinion.

So how far the "necessary margin" might have been extended is not terribly relevant in this case.

For sure, the strictly correct thing would be to biopsy only and await the pathology report before doing anything else. Then, if in fact there's only (only!) osteomyelitis, the treatment has been delayed and another GA session will be necessary.

I'm always banging on to clients, both owner and veterinary surgeons, about not interfering with oral suspect tumours till you know what they are,and planning your biopsy approach, but in this case the plan of action has been very reasonable.

In my opinion.

Re: Non-healing mouth after extraction

Linda Filshie — Fri, 19 Sep 2014 00:52:34 GMT

[quote user="Peter Southerden"]

If this is neoplastic and resection was an option, curetting the surgical site and closing it with a flap are going to increase the size of the resection and make achieving clean margins more difficult. If for arguments sake you decide to take a 1cm margin around your tumour, you need to apply this to the biopsy tract as well, as it is likely to be contaminated with tumour cells. In your case you now have to achieve this margin around the area that you have curetted and the surgery performed to raise the flap.

[/quote] I appreciate what you are saying Peter, but the owner is unlikely to go for resection. Furthermore if it comes back as an osteomyelitis then I know she wouldn't thank me for wanting to put the cat under a further GA to extract the 309 and curette out any crap. Radiographically there are bony changes evident extending up to the angle of the jaw and beyond (i.e. well beyond the limits of my interference) - would this change your thinking/decision making?

Re: Non-healing mouth after extraction

Peter Southerden — Fri, 19 Sep 2014 00:15:14 GMT

Re: Non-healing mouth after extraction

Stephen Courtney — Thu, 18 Sep 2014 17:44:54 GMT

I'd be very suspicious of a squamous cell carcinoma but you can get other flavours too, sadly. Oral neoplasia in the cat often mimics dental disease, indeed they often coincide as usually the animals are older.

Re: Non-healing mouth after extraction

Linda Filshie — Thu, 18 Sep 2014 16:11:31 GMT

I will post pic of the new radiograph later but the bone does indeed look horrible. I extracted 309 vaaaairy gently, took biopsies, curetted like mad, lavaged like billy-o and closed the whole with a nice big flap. Now to see what the biopsies tell us...

The opposing teeth weren't traumatising the site, and while they looked a bit yuck it was actually pretty superficial (not helped by all the bacteria rich biofilm that has been in their vicinity for the last several weeks).

Re: Non-healing mouth after extraction

Evelyn Barbour-Hill — Wed, 17 Sep 2014 22:33:24 GMT

Looking at it pragmatically:

If those radiographic changes are real, as it were, then there's either osteomyelitis or a horrible cancer.

Strictly one ought to get the biopsy (through the existing opening) (and deep) and get the report before any other interference. But the site has already been "messed with" once. If it's osteomyelitis then the radical curettage will be the treatment anyway, if it's cancer then you'll be doing a mandibulectomy anyway, so you'd only be concerned with the smallish extra risk of inducing lymphatic or haematogenous spread in the few days while you await the pathologist's report.

Or, of course, in a 15 year old cat the owners may be thinking euthanasia.

Re: Non-healing mouth after extraction

Peter Southerden — Wed, 17 Sep 2014 21:23:31 GMT

I would check the occlusion to check that the cusp of the maxillary fourth premolar is not causing trauma to the extraction site. Unlikely but worth checking.

Before you do anything else you should biopsy the extraction site as neoplasia (SCC) would be high on the list of differentials for a non healing extraction site in an elderly cat. Keep in mind how the tumour would be resected (if this is an option for this case/owner) as the biopsy tract ideally shouldn't make this more difficult. This obviously begs the question as to whether surgical resection of oral SCC in cats is ever a sensible option.

Re: Non-healing mouth after extraction

Linda Filshie — Wed, 17 Sep 2014 19:11:44 GMT

[quote user="Glenn Hodgson"]

Have you checked for fiv? I had one worse than this that was fiv +ve, all others gone well before and since the case in question.

Too k 4 months to come good but did heal. My cat was asymptomatic with exposed bone. Mind you, the whole mouth was dire pre clearance.

[/quote]

Haven't yet - will do. Don't seem to see too much of it around these days but worth checking definitely.

Re: Non-healing mouth after extraction

Linda Filshie — Wed, 17 Sep 2014 19:10:48 GMT

[quote user="Evelyn Barbour-Hill"]

PS looking at the radiographs, in the post-op one the bone deep to the whole site looks kinda motheaten compared to that in the pre-op one. (But that might be the effect of different technique? ) Is the big black hole by the mesial of 309 the result of an instrument slip, or is it due to disease?

[/quote]

Absolutely it does - it's more obvious on the photo of the radiograph than in the radiograph itself. I was thinking osteomyelitis at the time it was taken but obviously could be something else. It will be interesting to see what tomorrow's looks like.

As far as the black hole next to 309 goes I think it's due to disease. I try and be pretty careful with extractions and this extraction went smoothly - however I don't have an immediate post-op radiograph to confirm this because it was abundantly clear that I had extracted both roots entirely so I didn't take one

Thanks for the advice guys - I'll let you know how it goes.

Re: Non-healing mouth after extraction

Glenn Hodgson — Wed, 17 Sep 2014 18:42:50 GMT

Have you checked for fiv? I had one worse than this that was fiv +ve, all others gone well before and since the case in question.

Too k 4 months to come good but did heal. My cat was asymptomatic with exposed bone. Mind you, the whole mouth was dire pre clearance.

Re: Non-healing mouth after extraction

Evelyn Barbour-Hill — Wed, 17 Sep 2014 16:30:54 GMT

Re: Non-healing mouth after extraction

Evelyn Barbour-Hill — Wed, 17 Sep 2014 16:21:46 GMT

Wow. Bad luck there, that's pretty unusual.

Seeing as there is bone loss on the mesial root of the 309, I'd say this tooth is just complicating matters and ought to be extracted. (Be very careful with the distal root!)

Im sure you're wise to do a repeat Xray before you proceed.

Then – as far as I can see, and subject to what you actually find – I think I'd remove inter-radicular bone and make a pretty radical (no pun intended) curettage of the whole affected line. Curette like mad, flush like billy-o, and suture the site closed with nicely mobilised mucoperiosteum, very relaxed and comfortable. This is one case where I think strategically timed pre-operative antibiotic may help.

Not much point biopsying unless you take some suitable tissue really deep down.

What about the opposing maxillary teeth? They don't look too healthy in the photograph, but maybe that's just superficial.

What's the general state of health? Maybe this is a case where a blood profile would be truly useful.

Re: Non-healing mouth after extraction

Martin Atkinson — Wed, 17 Sep 2014 16:10:44 GMT

I think I'd be done with the other tooth get it out the way but in the light of the mandibular swelling take a bone biopsy as well, some of these don't heal because they are early osteosarcomas or SCCs. Despite your microbiology saying otherwise I don't trust Convenia on its own in oral infections, you need to get some Antirobe in as well for several weeks. Don't want to teach granny to suck eggs but I assume you've got the owner to try sprinkling it i the food or if not possible try dispersing it with a little water and syringing it in save them from bringing him in daily.