Page 254 - WSAVA2018
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 25-28 September, 2018 | Singapore
a complaint of having difficulty eating and the owner was concerned about a TMJ problem because of the way he moved his jaw after eating. Oral exam revealed significant trauma to the lips secondary to the mandibular canines.
The treatment was to perform coronal amputation and vital pulp therapy on the mandibular canines. This is much less painful for the patient and will maintain the strength in the rostral mandible.
Eosinophillic Granuloma Complex
The true etiology of these conditions is unknown; however a local accumulation of eosinophils is thought to initiate the inflammation and necrosis. The accumulation may result from a local (food) or systemic allergies; although these lesions have been seen in cases where allergic disease has been ruled out. Additional causes include a response to irritation, such as chronic grooming or traumatic malocclusion. There may also be a genetic predisposition.
Indolent Ulcers are the most common oral manifestation, and they will present as brownish-red lesions on the upper lip or around the maxillary canine teeth.
Linear granulomas can be single or multiple; the most common sites are the lips, gingiva, palate and tongue. They are generally non-painful, but can become secondarily infected. The typical presentation is a raised, lobulated yellow-pink mass; however, they can also appear ulcerative causing severe damage to the oral mucosa and underlying bone. This may lead to severe periodontal loss, pathologic fractures, or oronasal fistulas.
Histopathology should be performed to confirm the diagnosis. Following confirmation of the diagnosis, a thorough allergy evaluation should be conducted including food trial, flea treatment, +/- allergy testing.
The acute disease process is best treated with systemic corticosteroids; however corticosteroids should NOT be used for long term disease control due to the significant systemic side effects. The typical initial protocol is prednisone 2 mg/kg q 12 hours for 3-4 weeks. Additional options include intralesional triamcinalone (3 mg weekly) or methyl prednisone injections. Antibiotic therapy is required occasionally to induce remission and/or treat secondary infection. There are also cases that appear
to respond to antibiotic therapy alone. Therefore, we initially treat mild cases with antibiotics alone and more severe cases with a combination of antibiotics and corticosteroids.
Many cases remain idiopathic, requiring lifelong therapy; options for this include antibiotics and cyclosporine. Fewer side effects may be expected with cyclosporine in comparison to steroids, but there are reports of opportunistic fungal and fatal protozoal infections associated with its chronic use. Use the lowest effective dose,and perform regular therapeutic levels and routine
blood testing.
Caudal Stomatitis
This is another frustrating oral inflammatory disease. The best description is a severe immune mediated reaction to dental tissues. Some feel that this may actually be a group of disease processes that look the same clinically which is why they can be very frustrating to treat.
The history will generally include anorexia, drooling, gagging, and pain during mastication. Physical exam will typically include a thin pet with unkempt fur. The oral exam will reveal severe stomatitis usually over all teeth. The inflammation will most commonly be worse on cheek teeth than canines and incisors. However, faucitis is the key clinical finding. Severe hyperplastic inflammation to the gingiva can result from periodontal disease, however faucitis will not be present.
A pre-operative blood panel will generally show a marked elevation in globulins (Polyclonal gammopathy) and total protein.
Medical Therapy: Most medical therapies will work for a while, however in general resistance will start within a year or less. In addition, most therapies have side effects worse than the disease process in and of itself. In general, medical therapy is very frustrating to the practitioner and client.
Corticosteroids are the mainstay of most medical therapy today. It is generally very effective at first and is relatively inexpensive for the client. In my experience, injectable (depomedrol 10 mg IM) is much more effective than
oral preparations in my experience. However, they will typically loose effectiveness after a year or so requiring higher and higher doses at shorter increments. This generally results in significant deleterious effects. About 10% of stomatitis cases we treat are already diabetic!!!
Antibiotics are safer than steroids but much less effective, especially in long term therapy. They are generally disappointing in their success. Metronidazole and clindamycin are the mainstays of therapy; however Clavamox and amoxicillin can be used as well. Metronidazole may be the antibiotic of choice due to its anti-inflammatory effect.
Other immune suppressive such as Imuran, Cytoxan, Gold Salts, Cyclosporine have been used. However, they are all very expensive with numerous adverse side effects (mylosuppression). Cyclosporine is currently the most commonly prescribed immune modulatory drug (other than steroids) for this disease process. However,
its chronic use is somewhat expensive and has been implicated in severe fungal and protozoal infections. Starting dose is 5-10 mg/kg. Look for a trough level of about 500 ng/ml on regular basis. In most dentists opinion it is only really effective AFTER teeth are removed. However, it has shown promise in resistant cases.
Laser therapy is not proven at all, most clients and

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