Dr. DeForge Develops Breakthrough Surgery for Treatment of Cat Stomatitis

Feline Stomatitis Radiowave Radiosurgery with GBR: PART I
Part II of this article, featuring Radiowave Radiosurgery applications in Feline Stomatitis Radiowave Radiosurgery, will be published in the next issue.
Feline Stomatitis has been investigated by veterinary dentists for over twenty years. The etiology of this very painful pathology has yet to be determined. It has been, universally, recognized as one of the most painful oral conditions in the feline. The classic treatment for it in general practice has revolved around the usage of corticosteroids and antibiotics to suppress the immune response and treat soft tissue infection. The treatment by surgeons and dentists, for the last 15 years, after the completion of histopathology diagnostics, has been whole mouth extraction or extraction of all teeth distal to the canine teeth. Only 50-60% of the felines with this type of extraction surgery reach full recovery. Depending on the author, 4-5 patients out of each 10 felines treated with whole mouth extraction revert to some degree of the oral inflammatory state within 6-18 months post-surgery. As a treatment alternative, Feline Stomatitis Radiowave Radiosurgery has been developed at The Silver Sands Primary and Urgent Care Center's Department of Oral Surgery. It completely and permanently reverses the oral inflammation and pain evidenced in feline stomatitis patients.

Feline Stomatitis [FS], the most painful oral disease in the feline, has many faces and names. It is the most misunderstood, frustrating, and refractive of all feline oral conditions seen by the general practitioner as well as the oral specialist. It has been studied in detail by many researchers over the last twenty years and its etiology is still unknown.

FS has many pseudonyms depending on the author who is referencing the pathology. It has been coined Lymphocytic Plasmacytic Stomatitis, Gingivostomatitis, Immune Mediated Feline Refractory Stomatitis, and Feline Generalized Oral Inflammatory Disease. The histopathology of oral biopsies in these cats evidences a predominance of plasma cells, lymphocytes, and neutrophils. A polyclonal gammopathy is commonly noted.

Pathology Noted:
The name is not as significant as the pain that is caused by this disease. Feline Stomatitis [FS] produces a chronic non-responsive generalized oral pain affecting the gingiva, mucosa, palate, lingual and sublingual area, the glosso-pharyngeal arches, the commissures, and entire pharynx. Depending on the feline, all mentioned or site-specific pathology centers can be identified.

Historically Non-Productive Treatments:
The inflammation is progressive. There is no successful medical treatment for this disease. The inflammation can be hidden with glucocorticoids, immunosuppressants, herbs, gold salts, antibiotics, analgesics, vitamins, probiotics, local topical anesthetics, salicylate therapy, and multiple anti-inflammatory protocols. None are effective in the long term. Most often the pain relief is short lived while on these medicines and discomfort quickly returns.

Laser therapy is controversial in feline stomatitis and is not recommended by this author. Airway blockage caused by laser usage in the distal pharynx can lead to respiratory embarrassment or patient loss. In the J Vet Dent 24(4);240-249, 2007-J. Lewis, A Tsugawa, & A Reiter-[Use of C02 Laser as an Adjunctive Treatment for Caudal Stomatitis in a Cat] include a case report in which the laser was utilized and state: "It is difficult to determine what role the laser treatment played in resolution of the inflammation, especially after extraction of the remaining canine teeth performed at the fourth and last ablative laser treatment."

Sub-Groups of FS:
Three sub-groups of FS have been identified by this author. Juvenile [4 months to 18 months]; Adult onset 1.5 years to 10 years; and Geriatric or Late Onset [10+ to 20 + years].

A monomicrobial form of oral inflammatory disease, in very young felines, affecting the gingiva and moving into the alveolar mucosa at the mucogingival junction has been identified. It is seen in Bartonella positive felines.

Many young Bartonella positive felines, less than a year old, with a specific sub-type of feline oral inflammatory disease, most often, will respond to Azithromycin therapy as described by William D. Hardy, Jr, VMD at the National Veterinary Labs [info@natvetlab.com]. Dr. Hardy states, "veterinarians should consider Bartonella in their differential diagnosis as the etiologic agent for a subset of cats with oral inflammatory disease." Dr. Bill Hardy is to be recognized for his important clinical investigations into the study of Bartonella in cats and the multiple pathologies that they can cause. He is to be applauded for the information he has brought to feline medicine in this new Millennium through the Feline Bartonella test he has innovated. If a young patient, less than one year, that is Bartonella positive does not respond to Azithromycin therapy, it is most likely Juvenile FS and should be referred to an oral specialist/dentist/surgeon for diagnosis and treatment.

Power Point:
It must be emphasized that this author does not feel that Bartonella is the etiologic agent for FS. Azithromycin does definitely reverse some, oral inflammatory disease patients under twelve months of age that are Bartonella positive. In older Bartonella positive felines that have FS, treatment with Azithromycin does not help reverse the pathology.

Signs of FS:
The main characteristics of all age groups are advanced oral inflammation and severe pain. No veterinarian should rely on corticosteroids and antibiotics as the treatment protocol for these felines. It is non-productive, does not help the patient in the long-term, and most importantly can predispose the patient to systemic pathology. This author sees many cases of FS that have been treated for years with corticosteroid therapy with adrenal disease, liver disease, kidney disease, and transient diabetes. Others present with septic oral pathology that has been influenced by the immune system being suppressed by glucocorticoids.

Some patients with long-term FS are very aggressive, when presented, because of the long-term pain that they have experienced. The owners comment that not only mouth pain aggression is present but relate that they can be attacked by their cat at home at any moment. Many of these cats have been gentle and well socialized before developing FS. It is not uncommon to also see in advanced FS patients dehydration, cachexia, and anorexia.

Diagnosis of FS:
Diagnosis of FS is accomplished with biopsy and histopathology. The practitioner must never confuse FS with Squamous Cell Carcinoma [SCC] or any other oral neoplasia in the feline. Biopsy must be deep and representative of the pathology. Superficial biopsies are useless to the histopathologist. This author recommends both soft tissue and bone biopsy specimens be sent to an oral histopathologist for examination.

These areas are not easy to biopsy and significant bleeding can occur. It is recommended to perform all soft tissue biopsies with Radiowave Radiosurgery [RWRS]. An understanding of Indirect Radiowave Radiosurgery Coagulation [IRRC] is recommended. See on-line The Journal of Veterinary Radiowave Radiosurgery [www.vetoralradiosurgery.com]

Pre-Anesthetic Testing:
Whether for biopsy or for surgical treatment, all FS felines should be scrutinized for other existing non-related medical problems. The young feline should have a Comprehensive Chemistry Profile, CBC, and U/A along with a current Leukemia and Immunodeficiency virus test. If respiratory or GI problems are present, chest and abdominal radiology along with an U/S of the abdomen is recommended to rule out other problems that can be co-existent with oral inflammatory disease. All middle aged cats with murmurs should have chest x-rays and ECG's before any anesthesia is contemplated. The geriatric feline should have a full cardio-pulmonary work-up including an Echocardiogram. Feline Leukemia testing should be repeated if not performed within the last year in all age groups. Feline Immunodeficiency Virus testing [FIV] should be ordered but is not considered a contraindication for anesthesia, by this author, if positive.

Feline Leukemia positive cats should be evaluated by an Internal Medicine Specialist. Surgery is not recommended in these felines. If there is a question of ANY complicating health issue, contact an Internal Medicine Specialist before proceeding.

A Feline Bartonella test is ordered for all felines. As stated earlier, it is this author's opinion, Bartonella disease is not the cause of FS and FS patients cannot be successfully treated with Azithromycin. It is recommended to test FS cats and treat the Bartonella positives, with Azithromycin, because of the public health significance of a Feline Bartonella positive feline in the home with oral oozing sores and ulcers in the mouth.

Mixed Pathology and FS:
Mixed pathology is found in the FS patient. Feline Eosinophilic Granuloma Complex, external and internal root resorption, root ankylosis, and bone changes can all be present. The soft tissue changes are the most extreme with ulcerated sites that bleed readily when being examined. In many FS patients the attached gingiva, under general inhalation anesthesia, can be peeled back from the tooth and bone as easily as peeling a banana.

Power Point: Feline Stomatitis: A Disease of Bone-Not a Dental Disease
Study at The CT and NY Specialty Centers for Oral care have confirmed that FS is not a disease of the dentition but is a disease of bone. A polymicrobial bone pathology is the hypothesis presented by this author.

Characteristic changes are noted in the bone, utilizing digital oral radiology, in all age groups of FS patients. The pathologist in FS soft tissue biopsies will describe an inflammatory infiltrate composed primarily of plasma cells, neutrophils, and lymphocytes. At the CT and NY Specialty Centers for Oral Care, bone is also sent for histopathology examination. The histopathologist when examining the bone in FS patients consistently reports osteomyelitis is present. Although noted, this has been ignored in the past as consequential to dental pathology. Tissue culture and bone culture are the systems needed to confirm a polymicrobial hypothesis. [If there is a university clinical research team that wishes to participate in such a study contact by E-Mail DonDeForge@aol.com] The fact that all patients respond to aggressive osseous surgery sheds new light on a bone origin of FS. If FS pathology was of a dental origin, ALL patients would fully respond to whole mouth exodontia. This is not the case. Only 50-60% of the patients respond fully to exodontia with a complete permanent resolution of the inflammation.

Power Point: Feline Stomatitis Radiowave Radiosurgery [FSRWRS] is THE ANSWER to Feline Stomatitis
Feline Stomatitis Radiowave Radiosurgery can successfully treat any feline with FS and reverse the pathology so that the patient has a pain free quality of life. FSRWRS is a surgery of bone. It utilizes oral digital radiology to identify areas of sclerosing osteomyelitis, condensing osteitis, sclerotic alveolar crestal bone loss, and hypertrophic bone reaction with resorption. [See An Atlas of Veterinary Dental Radiology-Second Edition -Amazon.com- for a visualization of all pathology described]

Once the pathology is identified, Radiowave Radiosurgery [Ellman International-www.ellman.com] is utilized, to cut all soft tissue and expose all of the pathology, identified earlier with digital radiology. Using the fully filtered rectified waveform, Radiowave Radiosurgery produces a blood-free atraumatic surgical field that allows visualization of the bone pathology to be treated.

Power Point:
The fully rectified filtered waveform is a pure continuous flow of high-frequency energy. The fully rectified filtered waveform produces the least amount of lateral heat and tissue shrinkage. The fully filtered waveform resembles the scalpel incision most and is the only waveform that allows cutting in close proximity to the bone, due to the minimal amount of lateral heat produced. [Sherman J, Waveform Types and Properties, Oral Radiosurgery-3 rd Edition, Chap. 2, p.9;Taylor and Francis-2005.]

Power Point: Osseous Surgery and Guided Tissue Regeneration are the important keys to the completion of Feline Stomatitis Radiowave Radiosurgery [FSRWRS]

There is an antibiotic protocol after surgery to eliminate the osteomyelitis that cannot be surgically treated because of proximity to vital anatomy. Feline Stomatitis Radiowave Radiosurgery surgical time, under Sevoflurane and/or Isoflurane inhalation anesthesia, is three to four hours with patient monitoring by an anesthesia technician.

Pain control is paramount intra-operatory and post-operatory at The CT and NY Specialty Centers for Oral Care. The pain present is not, primarily, from the surgery itself but is from the oral inflammation and ulcerations present pre-surgery. Contrary to past belief, Feline Stomatitis Radiowave Radiosurgery has proven that the abnormal soft tissue does not need to be removed at the time of surgery. The inflammation, in soft tissue, quickly resolves once the osseous surgery is completed.

Any Feline Stomatitis edentulous feline who has experienced complete exodontia by a qualified surgeon or veterinary dentist with return of the oral inflammatory disease can be successfully treated with Feline Stomatitis Radiowave Radiosurgery. This proves that FS is not a dental disease but a bone disease. What remains to be show is the identity of the proposed polymicrobial system in the bone initiating the immune-related oral inflammation.

Whenever a new surgical protocol is discovered or initiated, there is doubt and disbelief in the surgical community. This is common in human as well as veterinary surgical communities. That cannot be changed. This author's contributions to bone augmentation were challenged for years and now bone alloplast [i.e. Consil™-www.Nutramaxlabs.com] is being used by veterinary dentists, veterinary oral surgeons, and veterinary orthopedic surgeons throughout the United States.

Feline Stomatitis Radiowave Radiosurgery will, eventually, become the only treatment for FS because it can permanently remove this pathology from any FS patient. Whole mouth extraction or extraction distal to the canine teeth, as previously stated, can only resolve 50-60% of the patients treated. The rest will return to some form of oral inflammatory pathology within the first eighteen months post-exodontia. This statistic has been shown to be valid by data collected from veterinary dentists by the CT and NY Specialty Centers for Oral Care. Excluded from Feline Stomatitis Radiowave Radiosurgery are patients with feline oral cancer and/or feline leukemia.

It has been a privilege to develop this surgery and to see a quality of life and pain free existence return to these pre-surgery pain patients. The aggression noted in FS patients pre-Feline Stomatitis Radiowave Radiosurgery patients is invariably reduced or completely removed post-FSRWRS as the pain disappears. The letters, e-mails, cards, and phone calls from the pet owners of FSRWRS patients are heart rendering. The nursing teams in CT and NY at three FSRWRS Centers are to be congratulated for their hard work in the anesthesia and post-surgical care of these FS patients. A special "tip of the hat" to these dedicated technicians who have seen first hand the results of FSRWRS.

The photos below depict the different forms of oral inflammatory disease found in Feline Stomatitis. The inflammation can affect the gingiva, oral mucosa, lingual area, sub-lingual area, pharynx, palate, and vestibules of the oral cavity. The areas are extremely ulcerated and painful to the patient. The pathology can be successfully treated with Feline Stomatitis Radiowave Radiosurgery with no reoccurrence of the inflammation. In the Spring Issue of the JORWRS-Volume 1 No. 2, there will be additional photography of the surgery using Radiowave Radiosurgery with some post-recovery visuals.

Editor's Note:
Dr. DeForge is the Director of The Silver Sands Primary & Urgent Care Center in Milford, CT. He is an Adjunct at Northwestern CT College in CT and Mercy College in NY in Oral Radiology, Oral Surgery, and Periodontology. Dr. DeForge has an Oral Radiology Telemedicine Interpretation Service for analog and digital oral x-rays [VetDent Oral Imaging]. He can be reached at DonDeForge@aol.com or Ph: 1-800-838-3368

He is Director of The CT and NY Centers for Oral Care located at The New York Veterinary Specialty Center in Farmingdale, NY; The East End ER and Specialty Center in Riverhead, NY; and The Silver Sands Primary and Urgent Care Center in Milford, CT., see [www.VETDENTDOC.com]; also, visit The Journal of Veterinary Radiowave Radiosurgery at: [www.vetoralradiosurgery.com] . Dr. DeForge also Directs: The Cat Center of Connecticut at: www.CatCenterofCT.com

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