anti-fungal mouth treatments

Re: anti-fungal mouth treatments

Evelyn Barbour-Hill — Tue, 17 May 2011 19:49:47 GMT

[quote user="Richard Fox"]I'll stop there Best had [/quote]

Well, what did he have?

Re: anti-fungal mouth treatments

Richard Fox — Tue, 17 May 2011 12:35:33 GMT

I'll stop there Best had

Re: anti-fungal mouth treatments

Gina Dungworth — Tue, 17 May 2011 12:15:12 GMT

[quote user="Bob Russell"]

OK here goes - we are opposite the third pony on the right, very few sheep here!

[/quote]

But watch out for the pigs.

Re: anti-fungal mouth treatments

Bob Russell — Tue, 17 May 2011 11:13:37 GMT

[quote user="Mark Hedberg"]

[quote user="Martin Jones"]

Cornwall. A55, M6, M5, A30. Turn right at the second sheep and stop just before the beach.

[/quote]

Cue the sheep jokes! ;)

[/quote]

OK here goes - we are opposite the third pony on the right, very few sheep here!

Re: anti-fungal mouth treatments

Mark Hedberg — Mon, 16 May 2011 22:26:40 GMT

[quote user="Martin Jones"]

Cornwall. A55, M6, M5, A30. Turn right at the second sheep and stop just before the beach.

[/quote]

Cue the sheep jokes! ;)

Re: anti-fungal mouth treatments

Evelyn Barbour-Hill — Mon, 16 May 2011 22:09:26 GMT

[quote user="Richard Fox"]

Do you not use the terminology of the free gingival margin (F)?

[/quote]

Er, yes.... (cautiously) (Thinks: where is this leading..........?)

Re: anti-fungal mouth treatments

Richard Fox — Mon, 16 May 2011 09:00:24 GMT

Do you not use the terminology of the free gingival margin (F)?

Re: anti-fungal mouth treatments

Evelyn Barbour-Hill — Fri, 13 May 2011 18:39:58 GMT

Bother. That's a bit far.

Re: anti-fungal mouth treatments

Martin Jones — Fri, 13 May 2011 15:13:22 GMT

Cornwall. A55, M6, M5, A30. Turn right at the second sheep and stop just before the beach.

Re: anti-fungal mouth treatments

Evelyn Barbour-Hill — Fri, 13 May 2011 00:03:24 GMT

[quote user="Martin Jones"]To be fair, Evelyn, you're welcome to pop round whenever and have a butchers. I'll put the kettle on.[/quote]

Where are you?

Re: anti-fungal mouth treatments

Evelyn Barbour-Hill — Thu, 12 May 2011 23:56:43 GMT

[quote user="Richard Fox"]

[quote user="Evelyn Barbour-Hill"]

[quote user="Richard Fox"]gingival lesions healing after tooth extraction[/quote]

I'm sorry if I've missed the point somehow, but that is somewhat stating the bloomin' obvious, isn't it?

[/quote]

Not really but there you go - didn't mean just periodontal gingiva - however some cases where the teeth are clean, no calculus with good oral hygiene and regular dentals still give severe gingivits yes? and after dental extraction they go yes? So what causes the gingivitis? That was the point I was making Evelyn

[/quote]

OK so I did miss the point.

Yes. Extract the tooth, there's no gingival sulcus so there's nowhere for plaque to accumulate, mature and induce gingivitis. That would be my interpretation. If there's a claim that the teeth are "clean" yet there's a gingivitis yet tooth extraction is curative, I'd like to have examined the mouth myself, pre-extraction, before I'd be convinced that the teeth had no subgingival plaque. Of course if the patient had something wrong with its immune system, that would be a different matter.

Calculus is a bit of a red herring. And if there's good oral hygiene the patient will not need regular "dentals".

I'm baffled by the concept of gingiva that isn't periodontal, though.

Re: anti-fungal mouth treatments

Richard Fox — Thu, 12 May 2011 20:59:56 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Richard Fox"]gingival lesions healing after tooth extraction[/quote]

I'm sorry if I've missed the point somehow, but that is somewhat stating the bloomin' obvious, isn't it?

[/quote]

Re: anti-fungal mouth treatments

Aurelijus vet — Thu, 12 May 2011 20:56:24 GMT

Daktarin oral gel 20mg/g 40g (Miconazol 20 mg) Janssen-Cilag

Re: anti-fungal mouth treatments

Martin Jones — Thu, 12 May 2011 20:28:05 GMT

[quote user="Evelyn Barbour-Hill"]

However, Martin has seen the lesions and none of us has seen them, and he feels that they are not periodontal disease.

[/quote]

To be fair, Evelyn, you're welcome to pop round whenever and have a butchers. I'll put the kettle on. But what we're going to do is essentially add in some oral hygiene to begin with - dentisept sounds just the job - so it could just be a moot point in any case.

See, even the blind man can stumble in the right direction, albeit by accident.

Re: anti-fungal mouth treatments

Evelyn Barbour-Hill — Thu, 12 May 2011 19:17:56 GMT

[quote user="Richard Fox"]gingival lesions healing after tooth extraction[/quote]

I'm sorry if I've missed the point somehow, but that is somewhat stating the bloomin' obvious, isn't it?

Re: anti-fungal mouth treatments

Evelyn Barbour-Hill — Thu, 12 May 2011 19:14:50 GMT

[quote user="Kate Richardson"]This reminded me of a case I was treating last year. A 10yo ish Cocker spaniel- ulcers in exactly the same areas above the upper canines bilaterally, but also some ulcers on the gingiva and in contact mucosa over the upper premolars and molars. Always improved following a scale and polish, teeth were very healthy, but dog built up plaque very quickly on all teeth and was very resistant to mouth washes etc to the extent of biting the owner. Antibiotics made very little difference to the lesions. cytology and bacterail cultures of the lesions were unremarkable. I sought advice (can't remember where from now, sorry) and one possibility was that the dog was reacting/hypersensitive to its own plaque. Given the difficulty in maintaining oral hygiene in this dog, and the owners getting fed up with him needing a scale and polish every 4-5 months, we elected to extract the teeth in the location of the worst lesions and see if this improved the situation which it did. So much so that 6 months later we removed the remainder of his teeth and he has never looked back. My question is 'is a plaque hypersensitivity a recognised condition or is it just b******t?'[/quote]

Thick plaque is going to inflame anything it is constantly apposed to. One does not have to postulate a mysteriousl "plaque hypersensitivity" (although it might exist - in feline chronic gingivostomatitis maybe???).

It's quite possible, nay likely, that the lesions are indeed just periodontal disease caused by plaque - which is why I suggested to Martin that it would be interesting to see what happened to the lesion in the vicinity of the tooth he extracted, and also why I asked him what the state of the other upper canine was.

However, Martin has seen the lesions and none of us has seen them, and he feels that they are not periodontal disease.

Note that in both Martin's case and Kate's case the dog resented any oral hygiene measures. That's the key, isn't it? It's pointless doing repeated scale and polish if there's no oral hygiene in between. (And if there were oral hygiene, then you wouldn't need to do frequent scale and polish.)

Re: anti-fungal mouth treatments

Richard Fox — Thu, 12 May 2011 09:58:18 GMT

I hope I am not stepping on toes here but there is definitely a suspicion in literature of oral bacterial overgrowth syndrome causing gingival lesions so I don't see why not even if it is not a true hypersensitivity reaction? And there are many a story of gingival lesions healing after tooth extraction?

Re: anti-fungal mouth treatments

Kate Richardson — Thu, 12 May 2011 08:34:04 GMT

[quote user="Martin Jones"]

The ulcers are really confined to the gingiva and in-contact mucosa above the upper canines on both sides: no gum margin involvement, and not apparently associated with periodontal disease.

[/quote]

This reminded me of a case I was treating last year. A 10yo ish Cocker spaniel- ulcers in exactly the same areas above the upper canines bilaterally, but also some ulcers on the gingiva and in contact mucosa over the upper premolars and molars. Always improved following a scale and polish, teeth were very healthy, but dog built up plaque very quickly on all teeth and was very resistant to mouth washes etc to the extent of biting the owner. Antibiotics made very little difference to the lesions. cytology and bacterail cultures of the lesions were unremarkable. I sought advice (can't remember where from now, sorry) and one possibility was that the dog was reacting/hypersensitive to its own plaque. Given the difficulty in maintaining oral hygiene in this dog, and the owners getting fed up with him needing a scale and polish every 4-5 months, we elected to extract the teeth in the location of the worst lesions and see if this improved the situation which it did. So much so that 6 months later we removed the remainder of his teeth and he has never looked back. My question is 'is a plaque hypersensitivity a recognised condition or is it just b******t?'

Re: anti-fungal mouth treatments

Richard Fox — Thu, 12 May 2011 07:32:34 GMT

I apologize for going down a different track, I was just sticking up for my felow kin diagnosing epulis - I did say if symptomatic treatment doesn't work then I would go for bx :) Obviously It all depends on cash and owner compliance as always

I am afraid I still stand on my comment about fungal ulcers - fine keep them in your ddx list but like AI disease don't stick them at the top because the lesion are at present idiopathic? Is this big book of dog disease American by chance, they get awful fungal diseases over there unlike the UK!

Good luck

Re: anti-fungal mouth treatments

Evelyn Barbour-Hill — Thu, 12 May 2011 01:23:55 GMT

[quote user="Martin Jones"]Evelyn, not sure why my description of the state of the canine was inadequate, but more than happy to accept that it is so, and certainly have enough wish to cling to the tattered remnants of my dignity not to try describing it again. Suffice to say it was an exposed tooth that needed to come out, but I didn't feel it was related to the ulceration.[/quote]

Oh come on, Martin, don't get miffed.

I just said I couldn't follow your description.

No-one is criticising you: we're trying to help. And, of course, getting carried away into side discussions. But that happens on this forum.

It looks to me as if you are the first veterinary surgeon to actually take any trouble with this patient.

[quote user="Martin Jones"]So, current plan is to be on nothing but topical treatment for a week or two, assess response and go for biopsy if insurance company is at least not giving a flat 'no'. [/quote]

That sounds like a good plan.

Re: anti-fungal mouth treatments

Martin Jones — Wed, 11 May 2011 21:55:27 GMT

Gosh, I'm in way over my head here......

Just for the record, patient is NOT on steroids, but has been in the past: I certainly wasn't going to go back onto them at this point. Current meds are post-extraction clindamycin, and some tramadol as pain relief, as that is reported to have worked well in the past.

Reason for not biopsying the lesions was that the dog was booked in for a scale / polish, and as a brand-new locum I was unaware of any previous history; owner wasn't contactable during the procedure, so I took some bloods but had to wait for permission to run them. Biopsy was discussed when I was discharging the dog, as the next step in diagnosis, although it will largely depend on the owner's insurance company: 'routine' dental work like scale / polish isn't covered, but we will argue that ulceration of an aetiology other than periodontal disease should be covered.

Evelyn, not sure why my description of the state of the canine was inadequate, but more than happy to accept that it is so, and certainly have enough wish to cling to the tattered remnants of my dignity not to try describing it again. Suffice to say it was an exposed tooth that needed to come out, but I didn't feel it was related to the ulceration.

Many thanks for the suggestions about gels: because of the dog's current responses to having its mouth played with, a gel-based treatment would make more sense than an aqueous solution, and it was exactly this practical help I was after - ask and ye shall receive, as always on vetsurgeon.

My big bumper book of dog bothering tells me that fungal ulcers exist, but doesn't give much indication as to rarity. Bearing in mind that million-to-one chances pop up about nine times out of ten, relative rarity doesn't put me off pursuing a diagnosis. One day I SHALL diagnose a phaeochromocytoma. Before it dies.

So, current plan is to be on nothing but topical treatment for a week or two, assess response and go for biopsy if insurance company is at least not giving a flat 'no'. Even for an idiot like me, I think I've got the patient's best interests covered

Thanks to all.

Re: anti-fungal mouth treatments

Richard Fox — Wed, 11 May 2011 14:33:38 GMT

An excerpt from the latest JAMVA paper:

[quote]The term epulis is often applied to expansile gingival lesions. The term is purely descriptive, derived from the Greek term epi-oulon, meaning on the gum; it does not provide additional information with regard to the histologic or pathological nature of a lesion.7 Dubielzig et al3 were among the first to attempt classification of canine epulides, which they believed to be of periodontal origin. They described 3 types: fibromatous epulis, ossifying epulis, and acanthomatous epulis. Another group then reclassified fibromatous and ossifying epulides as variations of the same lesion, the fibromatous epulis.8 Further clarification was attempted through comparison of canine fibromatous epulis with the well-established but uncommon human POF (WHO type).9,10 The comparison revealed that the 2 lesions were equivalent, and it was suggested that the canine lesion be referred to by the same name as the human lesion. To add further confusion, Dubielzig’s group did not differentiate among fibromatous epulides, neoplastic lesions, and FFH, which are reactive inflammatory lesions with similar histological features. Several other authors have since attempted to clarify the difference between these histologically similar lesions, and the current acceptable term for the inflammatory lesion is FFH.5,6,10,11 Because FFH constitutes a large proportion of gingival lesions in dogs and given the confusion surrounding its histologic identification and nomenclature, clarification of its nonneoplastic nature is important.6
The so-called acanthomatous epulis has some microscopic features in common with human ameloblastoma. Clinically, however, the canine lesions have similar invasive and destructive behavior to the human intraosseous ameloblastoma. The tumor is now named CAA because it is its own entity with no precise human equivalent.7,12,13 Several other less common odontogenic tumors have been identified in dogs, including APOT and
odontoma; however, few case reports and studies exist to help elucidate their nature in dogs.5,6,14[/quote]

My understanding was that POF has not been accepted over the fibromatous epulid of periodontal origin - perhaps I am out of date but it is interesting paper that suggests that the fibrous epuli and gingival hyperplasia should be designated FFH?

The paper goes on to explain:

[quote]Because we believe that this description is in fact a combination of the histologic features of POF (neoplastic) and FFH (reactive),5,6,9,11 we subdivided the lesions that fit the WHO histologic criteria of fibromatous epulides of periodontal origin into POF and FFH on the basis of whether odontogenic epithelium was present.5,6,9 [/quote]

So WHO = Fibromatous epulis of odontogenic origin

This paper and some older papers suggest = Peripheral odontogenic fibroma

Sorry to everyone else

Re: anti-fungal mouth treatments

Richard Fox — Wed, 11 May 2011 14:10:22 GMT

[quote]On the other hand: wouldn't you agree that oral pathologists sometimes miss the diagnosis (possibly because the biopsy was inadequate) and report as "inflammation" when the disease is actually squamous cell carcinoma or even worse[/quote]

Most definitely - I think the oral cavity is very much like the skin just harder to reach, biopsy and assess

With regard to epulis you are correct but I am afraid we have to pigeon hole these lesions somehow - classification of oral lesions is terrible and needs sorting out - we have no other terms to use at present - There is some convention in calling some of these lesions (acanthomatous ameloblastomas) basal cell tumours and I think that some very well are and are not of odontogentic origin but this need further investigation and classification? Pathologists rely on the WHO fascicle classification or recent journal articles and if its not there we can't just make it up unfortunately If you want to start a working group for oral pathology I would be eternally indebted

http://cldavis.org/index.asp?PageAction=VIEWCATS&Category=16

In pathology we have soooo many badly terminology which is historical but we have to live with it at present - how about the skin neoplasm "basal cell tumour" - tumour also just means mass not a neoplasm!

Sorry I digress :) Back to the original topic?

Re: anti-fungal mouth treatments

Evelyn Barbour-Hill — Wed, 11 May 2011 13:38:28 GMT

[quote user="Richard Fox"]

I do have one question - Why is the dog on long term steroid and AB's, presumably for the oral lesions, Bacterial overgrowth warrants consideration even given the log term clindamycin - could these lesions be related to another underling disease or due to the long term meds?

I am sorry but this is a topic I am very passionate about so sorry for my apparent abruptness and frankness?

[/quote]

No need to apologise. I think we are all wondering why the dog has been (or still is?) on all these drugs. I think we are all agreed that a diagnosis has not been reached and it's time for biopsy.

[quote user="Richard Fox"]I suspect too they are also over suspected? I see almost every biopsy differential including AI - but given the rarity I see them (as a general percentage of skin/oral biopsies I receive) these should not be high in the list of differentials in most cases? [/quote]

Ah, touché!

On the other hand: wouldn't you agree that oral pathologists sometimes miss the diagnosis (possibly because the biopsy was inadequate) and report as "inflammation" when the disease is actually squamous cell carcinoma or even worse?

[quote user="Richard Fox"]BTW what do you mean "xyz "epulis"" - a fibromatous epulis of periodontal origin is a WHO recognised lesion and an acathomatous epulis is still in use (syn now WHO acanthomatous ameloblastoma)? [/quote]

I couldn't resist putting that in. I see pathology reports from referred patients in which the diagnosis is given as "epulis" , sometimes with added qualification. Epulis is not a diagnosis. Epulis just means "a growth in the mouth". Imagine sending a skin lump to a pathologist and getting a report of "lump". I did not know that the specific term fibromatous-epulis-of-periodontal-origin is still an officially approved term; I don't think it should be, but at least it refers to something which (I hope) to an oral pathologist is a specific disease. The dear old "acanthomatous epulis" I seem to recall has been a terminological nightmare for many decades. We all know that to term it an epulis is wrong, but we cannot agree on a more accurate term. I believe that it is not absolutely certain that it is an ameloblastoma, but maybe I am out of date there. Up to now I have favoured calling it an "acanthomatous epulis", simply because that is a suitably vague term and obviously wrong so we all know that no therapeutic or prognostic conclusions should be drawn from the term.

Re: anti-fungal mouth treatments

Richard Fox — Wed, 11 May 2011 12:22:28 GMT

Fair enough if you want to use fairly rare - There are not many AI diseases (were talking TRUE autoimmune disease here not under the banner of "immune mediated") that are limited to the oral location. Pemphigus Vulgaris I have seen probably twice in my life, as well al PE, never seen PV, rarely seen vesicular lupus but only in the skin, EM & PF are the only ones apart from interface reactions that I have seen in any number. PF is not oral and EM can rarely be limited to the intra-oral location.

I suspect too they are also over suspected? I see almost every biopsy differential including AI - but given the rarity I see them (as a general percentage of skin/oral biopsies I receive) these should not be high in the list of differentials in most cases? Most oral ulcers will we reported as non-specific as they are most often chronic and the inciding cause is not ID or is over shadowed by other lesions such as inflammation and often biopsied too late?

I of course do not know what these lesions are hence if symptomatic tx does not work and the lesions worsen then bx's maybe applicable.Fair enough comment about the Clorhexidine - I was concerned that it might make the condition worse? Probably not

I am sorry but this is a topic I am very passionate about so sorry for my apparent abruptness and frankness?

BTW what do you mean "xyz "epulis"" - a fibromatous epulis of periodontal origin is a WHO recognised lesion and an acathomatous epulis is still in use (syn now WHO acanthomatous ameloblastoma)?