2010 Cabot Blvd. West Suite D Langhorne, PA 19047 www.vetcares.com

Mark Your Calendars!

Case Study: Contact Mucositis in Dogs

Summer has arrived, and with it some hot topics that all of us at CARES are really excited to share with you! What’s new? We have added Dentistry and Oral Surgery, with Dr. Carlos Rice heading up this specialty service. Our Internal Medicine department will be expanding to 6 days per week with the addition of Dr. Jessica Midence. We’ve upgraded our CT from a single slice unit to a high speed 16 slice one - the difference is enlightening to say the least! And we have another full day CE on the horizon. This event was a huge hit last year and this year’s symposium will include a technician tract in addition to the veterinarian session.

Wishing you and yours a wonderful summer!

Jon M. Rappaport, VMDDirector, CARES

Introducing New Services, Equipment and CE Opportunities

Case Study: Contact Mucositis. . . Continues on page 2

Summer 2014

Follow CARES on at: www.Facebook.com/CARESvet

By: Carlos A. Rice, DVM, DAVDC

Contact mucositis is an inflammation of the paradental tissues which include the vestibular mucosa, palatal mucosa, lips, and tongue. The disease is often frustrating for the pet parent and veterinary practitioner alike. Animals affected develop a focal or multifocal type III hypersensitivity to plaque bacteria independent of the amount of plaque deposition or concurrent periodontal disease. Contact mucositis may occur in any breed of dog with the Maltese overrepresented. The condition is typically found on mucosa contacting the canine and carnassial teeth but can occur in any area of the mouth (figure 1). Patients often present with a combination of clinical signs including severe halitosis, ptyalism, spontaneous hemorrhage and ulceration of the paradental tissues, pain, anorexia, fever, and lethargy.

A proper workup includes a thorough physical examination in which a pronounced mandibular lymphadenopathy is often appreciated. Preanesthetic diagnostics include a CBC and chemistry panel. In approximately 50% of cases a polyclonal gammopathy will be evident. This finding may reinforce one’s suspicions of antigenic stimulation and support a diagnosis of the disease. A complete oral examination under general anesthesia, a professional cleaning with intraoral radiographs and charting is necessary. Biopsy of the affected tissues can be performed to rule out neoplasia.

Meticulous control of plaque is essential to properly manage this truly debilitating condition. Patients often require regular professional dental cleanings (i.e., every 3 months) along with once to twice daily tooth brushing if the patient’s comfort level permits. Use of a mucositis solution composed of equal parts viscous lidocaine 2%, an antacid such as Maalox, and diphenhydramine elixir can be compounded and prescribed if a patient is too painful to eat. The solution can act as a numbing and soothing agent when given prior to feeding. Use of chemical agents such as chlorhexidine rinses are discouraged as most of these solutions are alcohol based which can further irritate the oral mucosa. Use of a hydrophobic barrier sealant (OraVet) can also help to inhibit plaque accumulation. However, this product should only be applied once the teeth have been scaled

Figure 1. Typical clinical appearance of contact mucositis paradental to a maxillary canine tooth in a Maltese dog. These lesions are very painful and caused by a type III hypersensitivity to the presence of plaque bacteria on the surface of the tooth.

ANESTHESIOLOGY AND PAIN MANAGEMENTAndrea Caniglia, VMD, DACVA

THE CANCER CENTER AT CARESJennifer L. Baez, VMD, DACVIM(Oncology and Internal Medicine)Beth Overley, VMD, DACVIM (Oncology)

CARDIOLOGYMegan K. King, VMD, DACVIM (Cardiology)

CLINICAL PATHOLOGYRaquel Walton, VMD, PhD, DACVP

DENTISTRY AND ORAL SURGERYCarlos A. Rice, DVM, DAVDC

DIAGNOSTIC IMAGING Jessica Basseches, DVM, DACVR Christopher Ryan, VMD, DACVR

INTERNAL MEDICINEJennifer A. Adler, MSc, VMD, DACVIM(Small Animal Internal Medicine)Jennifer Midence, DVM, DACVIM(Small Animal Internal Medicine)

NEUROLOGYEd Darrin, VMD, DACVIM (Neurology)

OPHTHALMOLOGYRobert L. Peiffer, DVM, PhD, DACVOMartha Low, DVM, DACVO

SURGERYDavid A. Puerto, DVM, DACVSBrian Bretz, DVM, DACVS

EMERGENCY AND CRITICAL CARESuzanne M. Dempsey, DVM, DACVECC Kimberly DiTata, DVM Morgan Callahan, VMDKarlin Erk, VMDJessica L. Frankel, DVMJanine Haney, VMDBakul Patel, DVMJennifer Wintergrass, DVM

DIRECTORJon M. Rappaport, VMD

CARES2010 Cabot Blvd. West Suite DLanghorne, PA 19047Tel (215) 750-2774Fax (215) 750-3623

www.vetcares.com

The CARES Teamprofessionally with the patient under general anesthesia. Once the teeth have been cleaned, we attempt to reduce the inflammation with anti-inflammatories and antimicrobials. Doxycycline offers the benefits of targeting oral bacteria, has anti-inflammatory properties and concentrates in crevicular fluid which allows for titrating the dose to low levels and reducing the dosing frequency. Doxycycline’s anti-inflammatory effects are exerted through inhibition of matrix metalloproteinases (MMP’s) 8 and 12, which are collagen and elastin cleaving enzymes; with collagen and elastin being the two main structural components of the gingival connective tissue and oral mucosa, respectively.

In many cases fastidious plaque control cannot be maintained and full-mouth surgical extractions may be necessary. This traditionally time consuming and very invasive surgery can be made less so with the use of a piezosurgical unit and handpiece (figure 2) now used at CARES. Piezosurgery is a state-of-the-art technology which allows the operator to rapidly and safely cut through bone and tooth structure while sparing soft tissue. The extraction tip oscillates rather than spins at a frequency of 28-36 kHz, thus the tips are active on hard tissue, limiting the risk of soft tissue injury which results at a much higher frequency.

After surgery the patient should be hospitalized and pain managed with opioids in a constant rate infusion. Once the patient is eating, oral medications can be instituted. Occasionally the hypersensitivity persists despite removal of the dentition and long-term comfort may require the use of protracted doses of glucocorticoids and antimicrobials. This condition is typically life long but responsive to a balance of medical and surgical management.

Case Study: Contact Mucositis . . . Continued from page 1 Mark Your Calendars!Join us for these upcoming veterinary technician CE events at CARES. Each session is approved for 2 hours of RACE credit.

Tips, Tricks & Ways to Make Care BetterTuesday, September 23rd from 7:00 – 9:00 p.m.

Trauma - Cars and fights and falls, oh my!Wednesday, November 19th from 7:00 – 9:00 p.m.

CARES will be hosting a day long Continuing Education Symposium for both veterinary technicians and veterinarians on October 26, 2014. Space is limited so reserve your spot today at www.vetcares.com/RSVP. The program for veterinarians will include:

Useful Updates on Internal Medicine Presented by Jennifer A. Adler, MSc, VMD, DACVIM

and Jessica Midence, DVM, DACVIM

Forelimb Lameness in the Dog – Diagnosis to TreatmentPresented by David Puerto, DVM, DACVS and Brian Bretz, DVM, DACVS

Management of Acute GlaucomaPresented by Martha Low, DVM, DACVO

Oral Oncologic Surgery

Presented by Carlos A. Rice, DVM, DAVDC

Managing Common Anesthetic ComplicationsPresented by Andrea Caniglia, VMD, DACVA

Multidisciplinary Approach to Management of Head TraumaPresented by Ed Darrin, VMD, DACVIM (Neurology)

Suzanne M. Dempsey, DVM, DACVECC and Chris Ryan, VMD, DABVP, DACVR

The program for veterinary technicians will include:

History and Physical Exam - Making a Lasting ImpressionPresented by Jessica Kerr, BA, CVT, VTS (ECC)

Lymphoma - It’s Not Always a Death SentencePresented by Samantha Fritz, CVT

Feline Emergencies - Save Our KittiesPresented by Alison Gottlieb, BS, CVT, VTS (ECC)

Anesthesia - Don’t PanicPresented by Stacey Reiling, CVT, VTS, (Anes)

CPR - Old and New ConceptsPresented by Alison Gottlieb, BS, CVT, VTS (ECC)

Figure 2. Piezosurgery unit. This is a state-of-the-art surgical tool intended solely for use in dental bone surgery. This unit allows for bone and tooth structure to be cut while sparing soft tissue. This technology allows surgical extractions to be performed with minimal invasiveness.

CARES Welcome Jessica Midence, DVM, DACVIMPlease help us welcome Jessica Midence, DVM, DACVIM to the Internal Medicine Department! Jessica attended Cornell University School of Veterinary Medicine and will soon complete her Medicine Residency at Penn. She will be joining CARES as of August 13th and will be available for appointments and transfers Wednesdays through Saturdays. CARES will now offer Internal Medicine Services six days a week, with Dr. Jennifer Adler available Monday through Wednesday. We are excited to have Jessica join the practice!

Case Study: Open-Mouth Jaw Locking in CatsBy: Carlos A. Rice, DVM, DAVDC

A 12 yo MC DMH was transferred to the dentistry and oral surgery service at CARES for evidence of open-mouth jaw locking. On physical examination a left-sided mandibular drift was present. In addition, decreased retropulsion of the right eye could be appreciated.

Differential diagnoses for trismus or open-mouth jaw locking in cats can include uni or bilateral temporomandibular joint luxation, previous condylar fracture with secondary joint ankylosis, entrapment of the coronoid process of the mandible ventral or lateral to the zygomatic process of the temporal bone, and neoplasia.

With the patient under general anesthesia, a complete oral examination was performed. It was apparent the bones of the mandible were intact and a dorsoventral luxation of the right mandibular condyle was suspected.

Using the new GE LightSpeed Pro 16-slice helical CT

scanner now available at CARES the patient’s skull was imaged and a 3D reconstruction of the scan allowed us to confirm a diagnosis of temporomandibular joint luxation as well as diagnose a large boney callous associated with the mandibular condyle. The boney callous could be seen stemming from the mandibular condyle, bridging across and fusing to the zygomatic arch (Figure 1).

Using a minimally invasive bone cutting instrument known as a surgical Piezotome, a zygomectomy and condylectomy with resection of the boney callous was performed. Within 12 hours of surgery the patient no longer had a malocclusion and had

normal range of motion when opening and closing the mouth.

The patient was seen at CARES two weeks later for the first follow up visit since surgery. The patient was found to have normal occlusal interlock and full range of motion. The owner states the cat is very comfortable and continues to eat and drink normally, no longer showing signs of oral pain.

Figure 1. A boney callous seen stemming from the right mandibular condyle bridging across and fusing to the medial aspect of the zygomatic process of the temporal bone. This boney callous made the patient unable to close it’s mouth. Surgical resection of the zygoma, condyle, and bone callous proved curative.