Help please! Oral lesions in a staff pet.

RE: Help please! Oral lesions in a staff pet.

Miriam Lodewyks — Wed, 23 May 2018 16:58:34 GMT

Fascinating case. Thanks for sharing!

RE: Help please! Oral lesions in a staff pet.

KathW — Mon, 21 May 2018 23:20:11 GMT

It may have been jus because I was photographing a radiograp on a computer screen and didn’t focus it very well.

I can see what you mean- I’ll go back and look at the original radiographs tomorrow.

RE: Help please! Oral lesions in a staff pet.

Liz Barton — Mon, 21 May 2018 22:53:58 GMT

Thanks for posting this case. I was worried with the initial radiograph there seemed to be soft tissue opacity extending caudally through the nasal chamber - which I thought would be cancerous. It is much less obvious on this follow up X-ray and the bony detail appears better so probably just infected tissue / fluid.

RE: Help please! Oral lesions in a staff pet.

KathW — Mon, 21 May 2018 22:14:06 GMT

Update on this one. Doing really well. Had 3 weeks of clindamycin at osteomyelitis dose.

Apologies, I didn't get a good photograph of the mouth - gum has healed well - sutures still present on the photograph. I think I should have removed 101 as well though, I'll re asses and probably remove at next set of follow up radiographs. The follow up radiograph - doesn't look to have any more active bone destruction.

Happy for comments and other opinions though.

I plan to re radiograph in another 3-4 weeks as well but its looking hopeful I think.

RE: Help please! Oral lesions in a staff pet.

Evelyn Barbour-Hill — Thu, 12 Apr 2018 00:54:53 GMT

That's quite unusual. Please keep us posted.

RE: Help please! Oral lesions in a staff pet.

KathW — Wed, 11 Apr 2018 23:12:53 GMT

Results are now back from the lab:

Culture Pasteurella multocida - , multiple sensitivites. Anaerobes - mixed growth

HISTOLOGY COMMENT This is a region of severe chronic active ulcerative gingivitis with granulation tissue proliferation. This inflammatory process impinges on regional bone tissue and I suspect there has been concurrent osteomyelitis that may account for bone loss radiographically. No convincingly neoplastic cells are visible in these sections. Since the samples are fragmented and variably oriented, I have requested additional deeper sectioning to further ensure no neoplastic tissue can be identified and an addendum will follow in due course.

HISTOLOGY Additional deeper sections are now available. These identify further similar features to those seen initially. In addition, there is one small area underlying a region of hyperplastic epithelium with a proliferation of small spindloid to stellate cells amongst scant to moderate stroma. These cells lack atypia or mitoses. There are small amounts of acellular eosinophilic matrix amongst the tissue and small rests of well differentiated odontogenic epithelium. No overtly malignant tissue is seen.

COMMENT Histological features are mostly similar to those reported initially and I suspect the significant inflammatory change has extended from periodontal disease and caused a degree of osteomyelitis. However, there is one small area in these deeper sections that could be compatible with sampling from a peripheral odontogenic fibroma (formerly fibromatous epulis). This is only a small area and could conceivably be a reactive change in the periodontal region rather than a true neoplasm, particularly if no discrete mass was seen clinically. Continued monitoring of this site is advised following dental surgery, debridement of this region and medical management of residual inflammation and infection. If there is ongoing clinical concern, additional biopsy may be warranted.

So fingers crossed this may be osteomyelitis. I realise that I should have re radiographed after removing the loose teeth and biopsying the area. I now plan to sedate the patient and do that tomorrow so I have a comparison for follow up radiographs (in a few weeks initially) to continue monitor the area.

The patient is already on clindamycin and i will continue that (does three weeks seem a decent course initially?) and although I think the pasteurella is probably just an opportunist here (any thoights anyone?) I will treat for that as well.

My flap is apparently holding and the patient seems comfortable and is eating well.

RE: Help please! Oral lesions in a staff pet.

Evelyn Barbour-Hill — Tue, 10 Apr 2018 16:02:43 GMT

[quote user="Bill Nolan"]

[quote user="Evelyn Barbour-Hill"]

Urgh, looks like nasty neoplasia all right

[/quote]

Any chance you could describe what you see? I've recent started performing dental rads and still trying to build a guide for normal vs abnormal

[/quote]

Extensive bony destruction from midline to 104. 102 "floating" without visible attachment.

Root of 104 looks sound (periodontal ligament traceable all round, no resorption I can see, pulp canal normal) though it has suffered some bone loss, as has 204, presumably from plain perodontal disease.

RE: Help please! Oral lesions in a staff pet.

Bill Nolan — Tue, 10 Apr 2018 06:27:27 GMT

[quote user="Evelyn Barbour-Hill"]

Urgh, looks like nasty neoplasia all right

[/quote]

Any chance you could describe what you see? I've recent started performing dental rads and still trying to build a guide for normal vs abnormal

RE: Help please! Oral lesions in a staff pet.

Evelyn Barbour-Hill — Mon, 09 Apr 2018 20:56:22 GMT

[quote user="Noweia"]

[quote]Sorry, why which? [/quote]

Sorry, why do not extract 404?

[/quote]

Ah. Well, why extract it (trauma, hassle, expense, pain, and at the end she's missing a tooth) when you can just shorten it?

RE: Help please! Oral lesions in a staff pet.

Noweia — Mon, 09 Apr 2018 12:17:13 GMT

[quote]Sorry, why which? [/quote]

Sorry, why do not extract 404?

RE: Help please! Oral lesions in a staff pet.

Evelyn Barbour-Hill — Sun, 08 Apr 2018 23:08:18 GMT

Urgh, looks like nasty neoplasia all right.

RE: Help please! Oral lesions in a staff pet.

KathW — Sun, 08 Apr 2018 22:57:51 GMT

Thank- you Evelyn.
Radiographed, biopsied - tissue and hopefully some bone. I now wonder if I should have tried to be more aggressive with trying to get bone - there was a largish cavity with tissue at the edges very friable.

i didn’t want to cause too much trauma and totally disrupt the area.
102 and 103 removed in a "mush" of tissue. Samples sent for histology and for culture. Home on clindamycin (osteomyelitis dose + NSAID and a few days of sublingual buprenorphine)
Managed to raise a flap to cover the deficit in the gum between 101 and 104.Hopefully it will hold.

RE: Help please! Oral lesions in a staff pet.

Evelyn Barbour-Hill — Sun, 08 Apr 2018 21:30:47 GMT

[quote user="Noweia"]

[quote user="Evelyn Barbour-Hill"]

Radiograph!

Highly likely to be arising from disease of 104. Biopsy if 104 is truly healthy on radiograph. Neoplasia is always possible.

As for 404, whatever you do don't extract it. Shorten it if you have to.

[/quote]

Why? Asking out of interest.

[/quote]

Sorry, why which?

RE: Help please! Oral lesions in a staff pet.

Noweia — Sun, 08 Apr 2018 21:01:34 GMT

[quote user="Evelyn Barbour-Hill"]

Radiograph!

Highly likely to be arising from disease of 104. Biopsy if 104 is truly healthy on radiograph. Neoplasia is always possible.

As for 404, whatever you do don't extract it. Shorten it if you have to.

[/quote]

Why? Asking out of interest.

RE: Help please! Oral lesions in a staff pet.

Evelyn Barbour-Hill — Sat, 07 Apr 2018 22:30:54 GMT

Radiograph!

Highly likely to be arising from disease of 104. Biopsy if 104 is truly healthy on radiograph. Neoplasia is always possible.

As for 404, whatever you do don't extract it. Shorten it if you have to.

RE: Help please! Oral lesions in a staff pet.

KathW — Tue, 03 Apr 2018 21:25:20 GMT

Thanks for the replies. Sorry long day, I did transpose 104 and 404!

RE: Help please! Oral lesions in a staff pet.

Kate Richardson — Tue, 03 Apr 2018 21:09:22 GMT

[quote user="KathW"]Thoughts are to GA and perform dental radiographs + remove affected tissue and send for histology.[/quote]

Good plan.

I don't think 404 would suddenly cause problems unless there is recent unknown trauma? Suspect 404 exacerbating problem, not cause. Could be related to 104 though, ie root abcess as overlying bone looks sl swollen. But await xrays and biopsy results. Agree neoplasia high on list, so deep biopsy as Rob suggests very worthwhile. Antibiotics and metacam in mean time. Leave 404 alone otherwise unless you plan to extract for palliative reasons?

RE: Help please! Oral lesions in a staff pet.

Rob Davis — Tue, 03 Apr 2018 19:36:19 GMT

It's rather difficult to see well from the photos, and I'm no expert, but I'll kick things off....

[quote user="KathW"]When the mouth is closed the tip of the crown of 104 just sits in the middle lesion but I think that this is incidental and not due to any change in position of 104.[/quote]

I assume this is a typo and you mean 404?

[quote user="KathW"]Thoughts are to GA and perform dental radiographs + remove affected tissue and send for histology.[/quote]

Sounds like a sensible starting point. Neoplasia is unfortunately high on the list. If more radical surgery would be considered (if appropriate) in due course, then try to keep the margins of your biopsy site small as these will need to be included in any future resection. Ensure you biopsy deep enough (ideally including some bone) or you may just find misleading inflammatory tissue.

[quote user="KathW"]Should I reduce the crown on 104 as well (I really don't feel that this tooth is the issue or cause of this).[/quote]

Not unless you are prepared to perform endodontic treatment as the pulp will come close to the tip even in an older cat. Occasionally this type of impingement is seen in younger cats with a mild malocclusion, and these can often be treated by reshaping the maxillary mucosa with a diamond bur to avoid entrapment of the lower canine tip. I wouldn't want to embark on anything like that until neoplasia had been ruled out.

Interested to see others' thoughts, and please keep us posted with progress.