Case Study: Mittens
Complications Associated with Feline Malocclusion
Mittens, a 12-year-old female spayed domestic short-haired cat, was presented to Veterinary Dentistry SpecialistsR (VDS) for a left maxillary erythematous swelling that was not responding to medical management. Mittens had previously been treated for periodontal disease and feline tooth resorption lesions with extractions of teeth 208, 209, and 403 by her primary care veterinarian, our referral partner at Touchstone Veterinary Center. Once her course of post-operative pain management was complete, she began to paw excessively at her mouth. She was noted to display bruxism (grinding of the teeth). She wanted and would attempt to eat, but then would return to pawing at her mouth. A medical progress evaluation by her primary care veterinarian found mucosal swelling with ulceration and mucopurulent discharge at the left caudal maxillary buccal mucosa. Additional pain medication and antibiotics were prescribed at that time.

Mittens’ comfort level improved while on the medication, but she was reported to be eating with her head tilted. When the course of pain medication was complete, she resumed pawing at her mouth. She began to growl after eating and running away from her food. A surgical biopsy was performed of the erythemic tissue from the left caudal maxilla. The histology report noted that her symptoms were “consistent with an ulcerative, inflamed, and reactive lesion. The underlying cause of this inflammation and granulation tissue was not apparent in the sections.” Oral discomfort and halitosis persisted. A therapeutic trial of prednisolone was administered to Mittens, which did not result in any associated improvement. As a mucopurulent discharge was still present, a culture with sensitivity was performed. Three bacterial organisms were identified. Two of these were deemed to be non-pathogenic. The third was identified as Pasturella multocida. An organism-specific antibiotic was, thus, administered. The halitosis and discharge improved. However, Mittens continued to paw at her face and vocalize when eating. She was referred for further evaluation.

Upon presentation, Mittens was noted to have oral discomfort. The previous extraction sites were all well-healed. An oral examination revealed gingival clefts and gingival recession secondary to traumatic contact of the cusps of the maxillary premolars with the gingiva of the lower premolars when in occlusion. This traumatic contact resulted in gingival recession and periodontal disease (Image 1). In addition, a 13 x 10 x 4 mm3 ulcerated, erythemic mucosa was noted in the left caudal maxilla. There was a depression near the distal aspect of this inflamed lesion. This depression was in direct contact with the cusp of tooth 309 even before the mouth was fully closed (Images 2a and 2b). This was consistent with feline pyogenic granuloma. 
Image 1. Significant gingival cleft/recession is secondary to traumatic contact with the cusps of the maxillary premolars.
Images 2a and 2b. Photograph of the ulcerated mucosal lesion with mouth open (contact not appreciable in this position) and with the mouth partially closed to demonstrate traumatic contact of the distal cusp of tooth 309 with the left caudal maxillary mucosa creating a feline pyogenic granuloma.
Tooth 309 was extracted to allow the tissues of the left caudal oral mucosa to heal as they would no longer be chronically traumatized. Multiple additional extractions were performed due to the periodontal disease associated with the trauma from the maxillary dentition cusps with the mandibular gingiva. An odontoplasty (reshaping of the tooth) followed by a light-cured sealant was performed on a right maxillary premolar and right mandibular premolar that had the potential to contact the opposing mucosa once in occlusion (Image 3). This was done to avoid possible future traumatic contact with the opposing mucosa and to avoid a possible future pyogenic granuloma lesion. She was discharged with post-extraction pain medication and instructions to be weaned off prednisolone.
Image 3. Odontoplasty followed by a light-cured sealant was performed on tooth 107. Note the “blunting” of the cusp of tooth 107.
Typically, excision of the pyogenic granuloma is recommended at the time of extraction of the opposing dentition creating the trauma. In this case, the original biopsy had noted salivary glandular tissue within the ulcerated section, creating concerns about the potential for salivary duct involvement in this area. The owners were advised of potential complications associated with surgery involving the salivary duct. To avoid any possible complications, the owner elected to monitor the area to allow it to regress on its own as much as possible prior to pursuing excision surgery in this region. 

The ulcerated, left caudal maxillary swelling continued to regress at each medical progress examination. Mittens remained comfortable and continued to eat well after oral surgery.
Image 4. One-month postoperative medical progress examination. Note the significant reduction of the feline pyogenic granuloma.
Image 5. Three-month postoperative medical progress examination. Note the resolution of the feline pyogenic granuloma.
Feline patients with an oral pyogenic granuloma may range from being completely asymptomatic to displaying a variety of significant symptoms of oral discomfort including drooling, vocalization during eating or yawning, chewing with the head tilted, weight loss, pawing at the mouth, etc. Despite the name pyogenic granuloma, these patients are not typically febrile. These lesions should always be biopsied to confirm the diagnosis. A diagnosis requires observation of the mouth while in occlusion or near occlusion. As a pathologist cannot visualize the occlusion, is it important for the clinician to identify this when the biopsy is performed. 

Treatment for feline pyogenic granuloma includes a biopsy, excision of the lesion as well as extraction or odontoplasty with sealant application (reshaping of the tooth) to alleviate the traumatic contact. Excision of the lesion only (without addressing the opposing tooth creating the traumatic contact) is expected to result in a recurrence of the pyogenic granuloma lesion. 

Mittens remains completely comfortable and happy at home!
Reihl J, Bell CM, Constantaras ME, Snyder CJ, Charlier CJ, Soukup JW, Clinical characterization of oral pyogenic granuloma in 8 cats, Journal of Veterinary Dentistry, 2014 Summer, 31 (2): 80-86.  
Gracis M, Molinari E, Ferro S, Caudal mucogingival lesions secondary to traumatic dental occlusion in 27 cats: macroscopic and microscopic description, treatment, and follow-up, Journal of Feline Medicine and Surgery, 2015 April 17 (4): 318-328.
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In support of our promise to provide the safest and most advanced dentistry and oral surgery for dogs and cats, veterinary cardiologist Dr. Megan King provides comprehensive cardiology services in our Mt. Laurel, NJ, location. Outpatient cardiology appointments are available Tuesday-Thursday. Patients do not need to be seeing dentistry or oral surgery to be cared for by Dr. King.

Additionally, dentistry or oral surgery patients with cardiac concerns can receive a cardiology evaluation on the day of their procedure to assess heart health [if necessary] before general anesthesia. Along with our cardiologist’s assessment, one of our board-certified veterinary anesthesiologists will design and monitor an anesthetic protocol tailored to each patient’s needs, leading to safer procedures and better outcomes.
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