Chronic plasmacytic- rich gingivostomatitis

RE: Chronic plasmacytic- rich gingivostomatitis

Eamon McAllister — Fri, 07 Oct 2016 16:52:39 GMT

[quote user="Anna Battek-Kosiorowska"]

Before I managed to get back here and read the suggestions owners demanded to be given something. I will burn in hell for sure but I gave them 10 days worth od prednisolone tablets and I shall see them back next week. I emphasised that problem is most likely to be ongoing and they seem to understand that. It is difficult to tell for sure but they don't seem to be very keen on extractions.

[/quote] Anna - what dosage of Pred did you use? Can you please let us know how the patient responded when the tablets are finished?

RE: Chronic plasmacytic- rich gingivostomatitis

Anna Battek-Kosiorowska — Thu, 06 Oct 2016 17:45:21 GMT

Well, I abandoned Vetsurgeon for a while and now I'm slightly surprised to what I caused oops

On the serious note thank you all for all suggestions.

1. Yes, multiple antibiotics were tried and no it didn't make much of difference

2. Metacam and Onsior were tried and no it didn't make much of difference

3. When first time seen in May there was a lot of tartar and inflamed mucosa and colleague booked the dog for a dental

4. Removal of carnassials were considered but not performed - he is a healthy labradoodle with massive, healthy carnassials, fussed as described in records

5. The patient is quite protective of his oral cavity and although I sent the owner with a pack of chlorehexidine wipes I doubt it they were capable of doing that

6. Interestingly no, the lesions do not look as those in links. No microscopically visible ulcerations. Red mucosa to a naked eye but histopathology report states it is. No, I never thought about taking pictures...If I have any brain left it is certainly not at its sharpest.

7. Before I managed to get back here and read the suggestions owners demanded to be given something. I will burn in hell for sure but I gave them 10 days worth od prednisolone tablets and I shall see them back next week. I emphasised that problem is most likely to be ongoing and they seem to understand that. It is difficult to tell for sure but they don't seem to be very keen on extractions.

Thank you all for your input. As always invaluable and thought provoking

RE: Chronic plasmacytic- rich gingivostomatitis

Anthony Todd — Thu, 06 Oct 2016 16:07:14 GMT

[quote user="Anthony Dennison"]Anyway, I won't post again on this matter as it won't get anyone anywhere. [/quote]

Me too, until someone comes up with just one of the reports supporting this:

"There are plenty of case reports reporting complications with steroids"

when they are are given sensibly as I've described.

And I'll wager nobody does.

RE: Chronic plasmacytic- rich gingivostomatitis

Anthony Dennison — Thu, 06 Oct 2016 13:22:39 GMT

[quote user="Anthony Todd"]Jeepers, you can't have a title better than "Acute toxicity of corticosteroids in the rat" to add weight to the idea that corticosteroids are toxic![/quote]

[quote user="Anthony Dennison"]designed to determine the sort of LD50 for their use in rats by giving them increasing doses until they died of infection.....!![/quote]

The study design was to give a toxic dose of corticosteroids to rats. You even said so!

[quote user="Anthony Todd"]

People think that the title of a paper, and the more of them the better, can support any view and prove any theory they support, and we've seen this on here before.

Mostly, because they don't read the paper, just add it to their references; it is therefore assumed it supports the paper they have just published; often it's irrelevant or just the opposite.

[/quote]

To publish an article in a peer-reviewed publication, you cannot just cite something because the title fits. It has to be relevant, useful and supportive of someone's reasoning behind why the study was done, or used to support a point in the discussion.

If anything, you are reading the title of something, then reading the abstract, and getting all your assumptions from that. Without reading the full paper to look at the sample size to determine the weight of the study, whether there was a null hypothesis to be proved or disproved, and whether findings were significant at all.

PLUS - you've cited a paper from 1966. Why? There are so many more papers you could use, but wanted to find one with the words ' toxicity' and 'corticosteroids' in so google brought that up for you.

May I suggest you have a look at the journal club thread about critiquing papers - have a read through of the open access article that has been discussed (in it's entirety), then make some point from what you've read.

Anyway, I won't post again on this matter as it won't get anyone anywhere.

RE: Chronic plasmacytic- rich gingivostomatitis

Anthony Todd — Thu, 06 Oct 2016 13:05:09 GMT

[quote user="Anthony Dennison"]Sorry to prove you right Anthony, but you have cherry picked. You've selected a paper that doesn't really have any relevance to the discussion (except the fact they use corticosteroids) and was designed to find toxicity. [/quote]

You make my point very well, but then you obviously had a look at it as I did!

Jeepers, you can't have a title better than "Acute toxicity of corticosteroids in the rat" to add weight to the idea that corticosteroids are toxic!

Some think that the title of a paper, and the more of them the better, can support any view and prove any theory they support, and we've seen this on here before.

Mostly, because most don't read the references, just add it to their list; it is therefore assumed it supports the paper they have just published; often it's irrelevant or just the opposite.

RE: Chronic plasmacytic- rich gingivostomatitis

Anthony Dennison — Thu, 06 Oct 2016 09:30:40 GMT

[quote user="Anthony Todd"]

Here's one to start:

Acute toxicity of corticosteroids in the rat

Got to be a goody, you know lab. animals and all that...

But when you go to the link

http://www.sciencedirect.com/science/article/pii/S0041008X6680011X

you find it was in 1966 and designed to determine the sort of LD50 for their use in rats by giving them increasing doses until they died of infection.....!!

[/quote]

Sorry to prove you right Anthony, but you have cherry picked. You've selected a paper that doesn't really have any relevance to the discussion (except the fact they use corticosteroids) and was designed to find toxicity.

RE: Chronic plasmacytic- rich gingivostomatitis

Anthony Todd — Wed, 05 Oct 2016 14:44:16 GMT

Here's one to start:

Acute toxicity of corticosteroids in the rat

Got to be a goody, you know lab. animals and all that...

But when you go to the link

http://www.sciencedirect.com/science/article/pii/S0041008X6680011X

you find it was in 1966 and designed to determine the sort of LD50 for their use in rats by giving them increasing doses until they died of infection.....!!

RE: Chronic plasmacytic- rich gingivostomatitis

Anthony Todd — Wed, 05 Oct 2016 13:23:43 GMT

[quote user="Peter Southerden"]You havent described how you use steroids. What dose? How long?[/quote]

Yes I have and every time it comes up

[quote user="Peter Southerden"]There are plenty of case reports reporting complications with steroids [/quote]

There sure are!

Every time the dosage is excessive, continuous, or the report is just laughable [remember the one where everyone in the family was dosing the dog 'cos they thought nobody else was.....]

And that was cited, rather embarrassingly, as something like "Toxicity of corticosteroids"!!

Please, just for the record find me just one; if I do it I'll be accused of "cherry picking"

[quote user="Peter Southerden"]It is very likely that your patients will have intermittent or chronic pain unnecessarily. [/quote]

Well they certainly will if you don't relieve them, that's for sure.

There's nothing to stop you giving steroids and concurrently, when the pain and friability subsides, starting you dental hygiene [which I should have made clear at the beginning!]

RE: Chronic plasmacytic- rich gingivostomatitis

Peter Southerden — Wed, 05 Oct 2016 09:42:16 GMT

Dear Anthony

You havent described how you use steroids. What dose? How long?

There are plenty of case reports reporting complications with steroids and you are as capable as I am of searching and reading them (if you want to). The side effects of steroids are so widely accepted (see NOAH data sheets, Plumbs etc) that you wouldnt get a study to provide additional evidence past any sort of ethical review. As a veterinary surgeon who has the welfare of domestic animals at heart I am sure you wouldnt advocate carrying out a study to prove what we know already.

Chatting to one of our medicine specialists this morning - he has seen cases of cushings in dogs on as little as 0.5mg/kg eod. Dismiss that if you want.

Using steroids in cases like the one described is largely unnnecessary. You are masking the symptoms and not dealing with the underlying cause. It is very likely that your patients will have intermittent or chronic pain unnecessarily. You may (depending on the dose you are giving) be immunosupressing your patients and therefore risk making things worse. You are risking unnecessary side effects.

As a specialist in veterinary dentistry I am happy to say that your approach is not an approach that I could support.

Best wishes

Pete

RE: Chronic plasmacytic- rich gingivostomatitis

Peter Southerden — Wed, 05 Oct 2016 09:12:42 GMT

Agree with Evelyn except that it is possible to get owner brushing well enough to control this sort of problem in dogs. I see about 10 of these a year and most of them are, in the long term, controlled by brushing.

RE: Chronic plasmacytic- rich gingivostomatitis

Peter Southerden — Wed, 05 Oct 2016 08:58:53 GMT

I agree that CHX should not be overused and this is one of the few oral conditions that I do and only in the early stages. Yes - brushing without CHX can work very well. Plaque removal is the goal.

RE: Chronic plasmacytic- rich gingivostomatitis

Evelyn Barbour-Hill — Tue, 04 Oct 2016 22:52:53 GMT

[quote user="Beats"]

[quote user="Peter Southerden"]Mechanical removal of biofilms is the only effective treatment - that's why we brush our teeth. That's why tooth brushing is the cornerstone of the successful treatment of plaque related disorders.[/quote]

What about tooth-brushing without the chlorhexidine then?

[/quote]

Toothbrushing with some other suitable antibacterial could also be effective. In the particular case, I doubt if one could achieve the desired result just with brushing for the simple reason that I doubt whether literal brushing of the necessary thoroughness will be possible.

[quote user="Beats"]I remain concerned that the decrease in use of relatively unimportant systemic antibacterials is being matched by an increase in the use of chlorhexidine likely to lead to resistance headaches to such a critical antibacterial in the future.[/quote]

Interesting point, but chlorhexidine is not being suggested as a sort of alternative or substitute for systemic antibacterial drugs; as already pointed out, the systemic antibacterials are just irrelevant here. And although I believe resistance to chlorhexidine has been found in odd bacteria here and there, resistance is not a big problem and shows no signs of becoming one. Chlorhexidine is near as dammit the ideal disinfectant for intra-oral use and when it's needed it should be used.

I'll be interested to see what Peter says, he may disagree.

RE: Chronic plasmacytic- rich gingivostomatitis

Beats — Tue, 04 Oct 2016 22:31:33 GMT

What about tooth-brushing without the chlorhexidine then?

I remain concerned that the decrease in use of relatively unimportant systemic antibacterials is being matched by an increase in the use of chlorhexidine likely to lead to resistance headaches to such a critical antibacterial in the future.

RE: Chronic plasmacytic- rich gingivostomatitis

Evelyn Barbour-Hill — Tue, 04 Oct 2016 22:23:24 GMT

[quote user="Anthony Todd"]

[quote user="Anna Battek-Kosiorowska"] Result is chronic plasmacytic- rich gingivostomatitis, cause unknown, believed to be multifactorial.[/quote]

Does this sound like an infection to anyone; more like some sort of immune response to me??

[/quote]

Sigh.

It doesn't "sound like" anything in particular. Basically it's just saying "the gingiva and oral mucosa are inflamed, and we don't know why". In fairness to pathologists, it is just their job to say what they see. And they have ruled out pemphigus, pemphigoid, lupus and neoplasia.

I don't see anyone on this thread suggesting that it is "an infection".

And just to confuse you further, remember that the pathogenic effects of any infection often come from the immune response to that infection.

[quote user="Anthony Todd"]That presentation [with the fauces often involved] is common in cats and responds well in cats to steroids even when all the teeth have previously been removed!![/quote]

Yes yes, Feline Chronic Gingivostomatitis is moderately common in cats, a well-recognised syndrome that with some justification we generally consider to be a disease in its own right. Er, the original post and the ensuing discussion is about a dog. And, er, the presence or absence of "gross calculus or tartar" is pretty irrelevant in most cases of either FCGS or of periodontal disease. And the use of a glucocorticoid (which I presume is what you mean by "steroids") whether at high, low or middling dose, or given pulse-wise, intermittently, to effect, as required or when the moon is full on a Thursday, only rarely results in good longterm control of FCGS and certainly not in a cure.

And this discussion is about a dog not a cat.

RE: Chronic plasmacytic- rich gingivostomatitis

Anthony Todd — Tue, 04 Oct 2016 20:51:35 GMT

[quote user="Peter Southerden"]all the potential side effects of long term use [/quote]

Please, anyone, someone, give me some evidence of this when used correctly ie as I describe.

I want EBM, not just a quote from a text-book or authority, actual evidence!

PS A single yellow star is not evidence!

RE: Chronic plasmacytic- rich gingivostomatitis

Anthony Todd — Tue, 04 Oct 2016 20:09:45 GMT

[quote user="Anna Battek-Kosiorowska"] Result is chronic plasmacytic- rich gingivostomatitis, cause unknown, believed to be multifactorial.[/quote]

Does this sound like an infection to anyone; more like some sort of immune response to me??

RE: Chronic plasmacytic- rich gingivostomatitis

Anthony Todd — Tue, 04 Oct 2016 20:01:48 GMT

[quote user="Thomas Johnson"]I would completely disagree and say that this is a very rare presentation in dogs, [/quote]

Depends on what you are talking about, and I admit my phrasing was confusing. Gingivitis with a grotty mouth is, of course common in older dogs, and resolves nicely, and always, with the appropriate dental treatment.

My understanding is what we are talking about here is gum inflammation without gross calculus or tartar and pretty normal teeth.

That presentation [with the fauces often involved] is common in cats and responds well in cats to steroids even when all the teeth have previously been removed!!

In my experience the similar presentation, as described is less common, even uncommon in dogs, and I am not surprised at the anonymous red-star, which is the norm whenever anyone suggests steroids for anything...

Of course there is never any evidence for the side-effects or "toxicity", just the perpetuated dogma.

As this condition is said to have an allergic component in humans [just google the pictures] I still contend it is worth exploring coincidentally with the pulse 'roids f necessary.

RE: Chronic plasmacytic- rich gingivostomatitis

Anthony Todd — Tue, 04 Oct 2016 19:46:15 GMT

[quote user="Evelyn Barbour-Hill"]Lots of things we need to do are not easy.[/quote]

Er, not a very helpful reply really, and surely easier to accomplish if the gums are not so inflamed which I tried to suggest.

RE: Chronic plasmacytic- rich gingivostomatitis

Peter Southerden — Tue, 04 Oct 2016 17:17:48 GMT

Dear Anthony

Plaque is a biofilm and antibiotics at normal therapeutic doses wont kill bacteria in biofilms. If the inflammation is a plaque contact mucositis antibiotics will not work. Mechanical removal of biofilms is the only effective treatment - that's why we brush our teeth. That's why tooth brushing is the cornerstone of the successful treatment of plaque related disorders.

In cases where brushing is impossible and tooth extraction is not an option then use of steroids should be considered but I wouldnt look at this as successful treatment - not just because of the risk of side effects - but because the dog would have recurrent episodes of severe oral pain.

Yours

Pete

RE: Chronic plasmacytic- rich gingivostomatitis

Evelyn Barbour-Hill — Tue, 04 Oct 2016 16:51:22 GMT

[quote user="Anthony Todd"]

[[quote user="Peter Southerden"]So my question is, if the cause is both identifiable and treatable why would you want to use steroids as your first line of treatment?[/quote]

Well this for start!

One of my patients 7yr MN labradoodle after months of treatment with antibiotics and nsaids by my colleagues and me not really responding to any of that [!!!!]

(my bold)

which is from the first post so, although it has been identified and had lots of treatment with absolutely no improvement, a better question would be "Why not use steroids?"

[/quote]

Because, perhaps, it had not yet had any useful treatment. To wit, professional correct dental treatment followed by scrupulous oral hygiene.

On a more practical note, I'd start that dog off not with literal brushing but with "brushing" by finger (bare finger or with thin glove, not one of those beastly finger-brushes): slathering one of the more gel-like chlorhexidine dentifrices around. Copious gel lubricates everything so that pain is minimised.You can progress to a spongy thing and then to a soft brush and eventually to a slightly more bristly one. And you have to take the time to demonstrate all this to the client and to experiment to find what works best in the individual patient.

RE: Chronic plasmacytic- rich gingivostomatitis

Thomas Johnson — Tue, 04 Oct 2016 16:39:54 GMT

[quote user="Anthony Todd"]This is not that rare a presentation, and certainly in cats and usually in dogs responds very well to the 'roids alone with no mouth cleaning and tartar removal and "a dental" only when obvious tartar or disease.[/quote]

I would completely disagree and say that this is a very rare presentation in dogs, it is a bit more common in cats. In first opinion practice I see a reasonable number of dogs with inflammation in their mouths, the vast majority of them have identifiable problems with their teeth, and appropriate treatment of this resolves the inflammation. I don't see how in a case like this glucocorticoids are going to do anything other than give temporary relief, surely it is much better, though probably harder, to try and deal with the underlying problem.

RE: Chronic plasmacytic- rich gingivostomatitis

Anthony Todd — Tue, 04 Oct 2016 16:10:35 GMT

[[quote user="Peter Southerden"]So my question is, if the cause is both identifiable and treatable why would you want to use steroids as your first line of treatment?[/quote]

Well this for start!

One of my patients 7yr MN labradoodle after months of treatment with antibiotics and nsaids by my colleagues and me not really responding to any of that [!!!!]

(my bold)

which is from the first post so, although it has been identified and had lots of treatment with absolutely no improvement, a better question would be "Why not use steroids?"

This is not that rare a presentation, and certainly in cats and usually in dogs responds very well to the 'roids alone with no mouth cleaning and tartar removal and "a dental" only when obvious tartar or disease.

There seems to be some evidence that, in humans, this is a reaction to contact with something, so concurrent trial and elimination might be advisable, with the 'roids alleviating the discomfit as, and only when, necessary.

As usual there is the tendency on these forums to dismiss completely successful 'roid treatments, usually on some hypothetical scientific ground, such as the "immunosuppressive action of the 'roids" without citing or showing any actual evidence that this has ever caused any actual documented harm when used in a sensible pulse, as necessary, regime.

RE: Chronic plasmacytic- rich gingivostomatitis

Peter Southerden — Tue, 04 Oct 2016 15:12:30 GMT

Dear Anthony

I'm not sure that this an ancient/modern issue.

There are undoubtedly oral conditions where steroids are indicated. However, if my assumptions are correct, this case has an identifiable, bacterial cause. Remove the cause (plaque) and the inflammation will resolve.

Tooth brushing may be challenging but is achievable in most cases with committed owners and good analgesia. These cases are often very painful and therefore they usually need multimodal analgesia to get them into a position where tooth brushing is possible. However once effective tooth brushing starts improvement is usually quite quick.

It seems likely that dogs that develop this sort of mucositis demonstrate an exaggerated immune response to a common antigenic stimulus (plaque). Intermittent steroids will provide intermittent control and this is suboptimal as there will inevitably be periods of avoidable pain though I agree the likelihood of serious steroid related side effects using then intermittently is reduced though not completely eliminated.

Would you use steroids at an immunosuppressive or anti-inflammatory dose? Prednisolone at less than 1mg/kg in the face of infection is unlikely to control the inflammation adequately, immunosuppressive doses in the face of infection are contradicted.

So my question is, if the cause is both identifiable and treatable why would you want to use steroids as your first line of treatment?

Yours

Pete

RE: Chronic plasmacytic- rich gingivostomatitis

Evelyn Barbour-Hill — Tue, 04 Oct 2016 13:57:24 GMT

[quote user="Anthony Todd"]Good luck with the "hygiene" approach, it won't be easy.[/quote]

Lots of things we need to do are not easy.

RE: Chronic plasmacytic- rich gingivostomatitis

Anthony Todd — Tue, 04 Oct 2016 00:13:26 GMT

[quote user="Peter Southerden"]Steroids are a temporary/partial fix with all the potential side effects of long term use and therefore (as there are effective alternative options) I would not use them.[/quote]

Not sure that, with sensible pulse use only if necessary, there are any potential side effects of long term corticosteroid [if that's the right word] treatment

Love to see some sort of actual evidence 'cos all the previous cast iron examples turn out to be abuse or misuse of the drug, or just wrong citations, but it's embedded in modvets DNA so hey-ho.

You could always relieve the animals suffering with the 'roids and, concurrently, try and improve oral hygiene as the experts advise, which seems more humane and sensible.

Good luck with the "hygiene" approach, it won't be easy.