Full mouth extractions in cats

RE: Full mouth extractions in cats

Alexander Geddes — Tue, 26 Feb 2019 14:25:06 GMT

Thanks Pete! I have missed that one! No info on affecting outcome/prognosis though? Thanks!

RE: Full mouth extractions in cats

Peter Southerden — Tue, 26 Feb 2019 14:16:19 GMT

Hi Alex

Hope you are well.

Association between oral health status and retrovirus test results in cats Kornya, Matthew R ; Kornya, Mathew R ; Little, Susan E ; Scherk, Margie A ; Sears, William C ; Bienzle, Dorothee. Journal of the American Veterinary Medical Association, 15 October 2014, Vol.245(8), pp.916-22 - Shows correlation between stomatitis and FIV. I think there is at least one older paper as well. To my knowledge there is no correlation with FeLV infection.

Re post op analgesia. I agree that the ideal is overnight hospitalisation post op so that analgesics can be tailored for individual cats. I dont think there is a one size fits all protocol. We prefer to have them in so that we can deal with any immediate post op issues. Less stressful for the cat and owner.

Cheers

Pete

RE: Full mouth extractions in cats

Alexander Geddes — Tue, 26 Feb 2019 13:45:35 GMT

Hi Kate,

I think my pontifications got me a little lost - we also send all our cats home same day. Our only exceptions are the full mouth extractions and other big cases with co-morbidities. We're a teaching hospital so things move slower obviously! And I would say sometimes that overnight stay is as much GA recovery after a long one as anything else! Agree overall with your recovery/analgesia comments but wanted to stir up a bit of thought about what we're all doing!

Not aware we have knowledge coronavirus plays a role.

Do you mean calici? The debate still goes on. Hennet's recent paper from France suggested an association with lingual ulcers but not stomatitis. He reported calici load was not correlated with stomatitis severity or post operative healing. Can't say we really swab - might not get a representative sample and even if we do - what does it change? Might move you towards using an antiviral also if you do get a result. I will admit its not recognised as a component in the USA in the same way.

I'm confident we don't have literature looking at FIV/FeLV and this condition.

Hope that helps!

RE: Full mouth extractions in cats

Kate Richardson — Tue, 26 Feb 2019 13:24:04 GMT

Thank you everyone, haven't had time to reply fully until now.

Good to know there is no right or wrong, and that if staging, to do one side, then the other, is what you are all doing, which is what I have been doing, but was just the way I have ended up doing it! Also good to hear that I'm not the only one with a concentration window, of about 2-3 hours, it does start to get a bit wearing by then, so I feel better about saying, ok, lets stop here, and reschedule for the other side.

Some interesting discussion points as well.

Going back to virus testing, do you know the relevance of the coronavirus, if any?

I'm another who doesn't test for FCV, as I understood it was debatable whether it affected prognosis, and even if they come back negative, I'm still going to assume they could still be carriers? Would that still be a correct assumption?

And does FIV status affect prognosis?

Haven't seen an FeLV+ve cat for years now, but am sure there are still pockets of it.

The pain relief/home versus hosp discussion is interesting. My experience favours getting them home asap. Even in the most cat friendly hospitals, a lot of cats will not display normal behaviour and will not eat, even if completely pain free. So I think this really affects our assessment of pain. The tendency is to assume painful so load it up with more drugs, but it mustn't be forgotten that they are not benign and can cause inappetance in themselves. I have seen many zombied cats on ketamine drips, almost because it is, dare I say it, 'trendy' to do so. If they absolutely need it then fair enough, but I believe good surgical technique, pre emptive analgesia and nerve blocks means most cats having multiple extractions can be home on meloxicam. I also use medetomidine in my premed and on occasion will top up with this intra-op and is a valuable addition to the analgesic range. Pain assessment in cats relies a lot on expression or not of normal behaviour, and I would venture to say this is almost impossible to assess accurately in the veterinary environment compared to the home environment.

RE: Full mouth extractions in cats

Evelyn Barbour-Hill — Tue, 19 Feb 2019 13:33:27 GMT

[quote user="Alexander Geddes"]With opioids its definitely important to remember euphoria does not equal analgesed![/quote]

An excellent point. Although, if you are euphoric do you care whether you have nociception or not?

RE: Full mouth extractions in cats

Anthony Todd — Mon, 18 Feb 2019 19:20:49 GMT

[Dare I ask] Wot's the first thing that happens when a cat is frightened/unhappy/ in pain/disturbed..... etc.

It stops eating.....

RE: Full mouth extractions in cats

Alexander Geddes — Mon, 18 Feb 2019 18:48:22 GMT

Yes absolutely - who knows! I guess I try and provide what I think appropriate based on the suspected level of pain. With opioids its definitely important to remember euphoria does not equal analgesed!

RE: Full mouth extractions in cats

Evelyn Barbour-Hill — Mon, 18 Feb 2019 16:41:40 GMT

[quote user="Alexander Geddes"]100% agree its worth discussing - "I give this because I've done this procedure and I've done it this way + the patient has responded this way so far" - hence the human vs veterinary dentistry approach which is so often bought up by practitioners.[/quote]

Agreed.

But, you know, and this is a bit of a ..... if you can't tell whether the patient is in pain how do you know your analgesic drugs are achieving anything... or required?

RE: Full mouth extractions in cats

Alexander Geddes — Mon, 18 Feb 2019 03:44:09 GMT

Definitely agree they know their cat better than me and subtle signs can often be detected. But clients vary hugely in their ability to do this as does each cat. I guess my concern comes from that 2 day period onwards where the cat has recovered but is still uncomfortable - maybe not enough to hide away etc.

I understand the differentiation you're making, I still respectfully disagree - stress is never going to modulate the cats pain perception better than the pharmacological manipulation I can provide in hospital. And that point continues with handling of their cat - if I'm providing that analgesia its because I expect the cat to still be painful, so I can accept 10 seconds of discomfort on administration of the drug for 6-8 hours of superior analgesia.

100% agree its worth discussing - "I give this because I've done this procedure and I've done it this way + the patient has responded this way so far" - hence the human vs veterinary dentistry approach which is so often bought up by practitioners.

RE: Full mouth extractions in cats

Evelyn Barbour-Hill — Mon, 18 Feb 2019 03:25:54 GMT

[quote user="Alexander Geddes"] I'll Glasgow pain score them [/quote]

Don't get me wrong, I think formalised assessments such as the Glasgow one are great, especially for training, as long as they don't lead people to not bother to learn the more subtle signs. In my day (here we go! ) nobody taught this stuff – one had to learn it through observation and experience. Which some of us did and no doubt some didn't.......

[quote user="Alexander Geddes"] I think you could send some of these cats home with no pain relief and some owners would not report "pain".[/quote]

Ah, there I disagree a bit. They might not report "pain" but they will report changes – they will report what they observe, very perceptively sometimes. Remember they know their own cat.

[quote user="Alexander Geddes"] I don't think though that stress is a factor I am more concerned about than post operative pain in a major oral surgery.[/quote]

You may have misunderstood me. My argument is, bluntly, that being at home will cause less pain to be felt compared to that felt when they are confined in the hospital.

[quote user="Alexander Geddes"]Sublingual bup is indeed sub-optimal - but its what we have to work with. I advise the owners how to provide this with minimal disruption to the surgery sites as possible - which we also advise not to mess with otherwise. Anecdotally we don't have issues with dehiscence any more than anyone else.[/quote]

Ah, I wasn't thinking of disruption of the sites, I was thinking of pain caused by handling and poking the sites. And, however much I demonstrate, I'm not confident that the majority of owners can manage even to dose Metacam without hurting the cat. Of course if the cat won't eat then they have to, but most of my cases do eat. Dehiscence? I don't think that ever happens.

I wonder, when discussing pain control regimes, whether we need to simultaneously discuss the operative technique?

RE: Full mouth extractions in cats

Alexander Geddes — Mon, 18 Feb 2019 02:59:37 GMT

I agree a crude assessment can be mode post-operatively. I'll Glasgow pain score them q4 post op regardless of how they've performed peri-op with blocks +/- CRIs. If in doubt I'll continue the CRI's or provide an opioid.

I'm not convinced I can rely on that assessment so well in the following days as the cat moves towards comfort. Especially the owners perspective assessing the subtleties of feline pain. I think you could send some of these cats home with no pain relief and some owners would not report "pain".

I agree getting them home, especially cats, is an important factor in the recovery process. Undoubtably stress plays into the cats wellbeing and pain. I don't think though that stress is a factor I am more concerned about than post operative pain in a major oral surgery.

Sublingual bup is indeed sub-optimal - but its what we have to work with. I advise the owners how to provide this with minimal disruption to the surgery sites as possible - which we also advise not to mess with otherwise. Anecdotally we don't have issues with dehiscence any more than anyone else.

RE: Full mouth extractions in cats

Evelyn Barbour-Hill — Mon, 18 Feb 2019 02:41:49 GMT

I feel fairly sure I can make at least a crude assessment of a cat's pain after a full-mouth extraction. Facial expression, behaviour, all sorts. And immediately after waking (which I delay as long as possible by means of not giving any reversal agents) they are clearly in significant pain regardless of any local blocks and other intra-operative drugs. So immediately after waking they get morphine and that's repeated every two hours or as often as necessary. But in general I don't keep them overnight. I would rather see them go home – invariably woozy on their latest dose of morphine - because I am sure they will feel better at home. Pain and stress are interlinked. Pain is more than nociception – pain is an emotion. I think that what owners report to me the next day justifies this.

(I emphasise that that is my general approach and any case is judged on its merits.)

I also advise owners not to mess with the mouth at all, so I find the idea of their giving sublingual buprenorphine just a little bit odd.

RE: Full mouth extractions in cats

Alexander Geddes — Mon, 18 Feb 2019 01:04:52 GMT

I think its important to remember what we may be doing in these cats that differs from human dentists - if you had closed extractions of perio/endo compromised teeth I can very much appreciate the relief in before vs after.

If you're taking alveolar bone and cutting periosteum (all of us are to various degrees) - those things are for sure painful!

I couldn't accurately assess the cats oral pain prior to the procedure, why should I be able to any better after? I'll dispense a week of buprenorphine sublingual in cats and gabapentin as an adjunct for those full mouth extractions. As with Rachel our full mouth stay overnight and they'll get ketamine/fentanyl CRI's peri/post op dependent on how the local blocks did.

RE: Full mouth extractions in cats

Evelyn Barbour-Hill — Mon, 18 Feb 2019 00:56:24 GMT

[quote user="David Mills"]I think sometimes we forget the relief that removal of pain focus brings. Amputations, enucleations etc.[/quote]

Agreed.

[quote user="David Mills"]NAVC stuff abiut dentistry[/quote]

Don't believe everything that comes out of the USA. Have I mentioned that before?

RE: Full mouth extractions in cats

David Mills — Mon, 18 Feb 2019 00:28:57 GMT

[quote user="Anthony Todd"]PS I've had a fair bit of pain when my local wears off though![/quote]

I've had 5 molars removed as an adult. All were causing pain before for a significant period of time. All under local.

What a relief after. No pain relief required.

I think sometimes we forget the relief that removal of pain focus brings. Amputations, enucleations etc.

I remember BSAVA about 7/8 years ago, NAVC stuff abiut dentistry. Animals going home on tramadol, bupe, melox, all sorts. At the time general consensus over treatment. Be a shame if we went the same way.

RE: Full mouth extractions in cats

Evelyn Barbour-Hill — Sun, 17 Feb 2019 18:41:33 GMT

[quote user="Rachel Perry"] my own timescale for concentration is about 2 hours.[/quote]

Wimp....

Seriously though, that's a good point For myself, my fingers certainly get tired and lose sensitivity.

RE: Full mouth extractions in cats

Rachel Perry — Sun, 17 Feb 2019 17:28:09 GMT

I will often do full mouth in one sitting, but my own timescale for concentration is about 2 hours. I can usually do all premolars and molars in this time. My decision on extraction is all premolars and molars, and then assess canines and incisors individually. As Norman pointed out, the Jennings 2015 paper did not find a difference in outcome between full-mouth extractions and partial (PM and M). But, if there is significant inflammation, periodontitis or resorption affecting canines and incisors then they go too.

Root fragment retrieval if they exist.

I've start using fentanyl CRIs peri-operatively to good effect, then they stay overnight while being weaned off and onto buprenorphine.

Bupivacaine nerve blocks.

I will discuss staging it with clients.

I am not bothered about calici testing as we can assume 98% are going to be positive and doesn't affect treatment or apparently outcome. But I do test Felv/FIV as they are more likely to have a negative outcome. This is an open access paper and worth a read:

https://www.frontiersin.org/articles/10.3389/fvets.2017.00209/full

Also interested to read the Kouki paper in JVIM 2 years ago which showed high incidence of oesophagitis in these cats- I've definitely seen these, so wonder if we should also be considering specific treatment for that.

RE: Full mouth extractions in cats

Anthony Todd — Sun, 17 Feb 2019 16:46:05 GMT

[quote user="Evelyn Barbour-Hill"]Most cats are eating avidly the next day. Many eat as soon as they get home.[/quote]

That's what the owners told me, and in the days before any pain relief let alone local blocks......

Actually most cats with terrible mouths seemed to eat regardless, and the grotty mouth was only noticed by a vet, cat [!] dribbling, or the smell. It was their demeanor which seemed to improve noticeably.

PS I've had a fair bit of pain when my local wears off though!

RE: Full mouth extractions in cats

Liz Barton — Sun, 17 Feb 2019 16:11:41 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Steve Leonard"]

Hi,

any preferences for peri-operative pain relief as some really struggle to eat due to pain pre- and post-op

regards

Steve

[/quote]

Judicious tactical local blocks.

Morphine (or methadone) immediately post-op, repeated once or twice.

Meloxicam immediately post-op and at home for several days.

Most cats are eating avidly the next day. Many eat as soon as they get home.

Just now and then I've used an oesophagostomy tube, in cases of FCGS.

[/quote]

Similar - methadone in premed, local blocks with lido-bupiv combination, metacam

Methadone or buprenorphine post-op after pain score assessment.

Home with metacam.

Never placed an OG tube at the same time as dental, but definitely something I'll consider for the severe cases.

RE: Full mouth extractions in cats

Evelyn Barbour-Hill — Sun, 17 Feb 2019 15:47:37 GMT

[quote user="Steve Leonard"]

Hi,

any preferences for peri-operative pain relief as some really struggle to eat due to pain pre- and post-op

regards

Steve

[/quote]

Judicious tactical local blocks.

Morphine (or methadone) immediately post-op, repeated once or twice.

Meloxicam immediately post-op and at home for several days.

Most cats are eating avidly the next day. Many eat as soon as they get home.

Just now and then I've used an oesophagostomy tube, in cases of FCGS.

RE: Full mouth extractions in cats

Steve Leonard — Sun, 17 Feb 2019 12:38:16 GMT

Hi,

any preferences for peri-operative pain relief as some really struggle to eat due to pain pre- and post-op

regards

Steve

RE: Full mouth extractions in cats

Evelyn Barbour-Hill — Sat, 16 Feb 2019 18:54:46 GMT

Just to drift this thread even further from its original question.......

There are reasons other than FCGS sometimes to do a total extraction, or a total distal to canine extraction.

My observation is that the maxillary canines often look in reasonable periodontal order at the first quick look but turn out to have horribly deep probing depth on the palatal side to the extent of requiring extraction. This is not at all often the case with mandibular canines. On the other hand what one does see with the latter is a huge degree of root resorption while the crown and gingiva are apparently fairly normal (I don't generally extract such, but I make sure the owner understands)

RE: Full mouth extractions in cats

Bob Partridge — Sat, 16 Feb 2019 18:14:36 GMT

Interested in results of Norman's study - My impression is that + FVC has a more guarded Px.

For true Chronic FGS - initial stage is a full work up. We also see FCoV on occasion, together with FeLV etc. Helps to give the owner an informed choice re proceeding with Tx. Extract all diseased teeth (& retained roots). Plaque control measures, then Caudal Clearance. If fails to resolve then Canines (however if diseased would have been extracted at 1st stage)

If still failure then Interferon, Atopica, Lactoferrin etc

Bob

RE: Full mouth extractions in cats

Anthony Todd — Sat, 16 Feb 2019 17:18:08 GMT

Nobody has mentioned the frequent pharyngeal involvement, with or without "vesicles" which often accompanies the bright red gingivitis along all arcades but not, or hardly ever, the canines.

The canines were usually left; all the incisors often having already fallen out.....

IMHO it was rare for the canines to be involved.

PS Glen, my son's pedigree short hair is a different and much happier cat and was so in days!! A thin red healing line is all that remains.

RE: Full mouth extractions in cats

Norman Johnston — Sat, 16 Feb 2019 17:09:59 GMT

We use the quantitative PCR service from Scanelis. We have a research project running to see if the FCV score correlates with prognosis. Useful to find out if other viruses also present. Apart from FHV and the retros we had a positive coronavirus recently