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10:33 PM   April 17, 2014
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Identifying and Treating Oral Pain

By D.H. DeForge, VMD

First maxillary molar, #109, with a crater carie (i.e. cavity); the patient was in severe pain from an open pulp canal in this tooth. Diagnostics included intraoral examination and oral radiology. Oral  X-rays  showed advanced root resorption. Root canal therapy was not applicable.  Exodontics was completed with Radiowave Radiosurgery/TM of the soft tissue creating a full thickness mucoperiosteal flap, osseous surgery, tooth sectioning and bone augmentation. Pain control was accomplished with pre-, intra -  and post-operative opioids. The patient recovery was uneventful without discomfort.
In the last five years, veterinary medicine has moved strongly toward pain control identification and treatment.  Pain control specialists are available for consultation with a plethora of management systems to bring true comfort to our patients.

One area of analgesia that is still seriously lacking is managing oral pain in the canine and feline.  Two problems exist.  First, there is incomplete understanding of oral diagnostics with the resultant lack of identification of oral pathology.  Oral radiology is still not common in veterinary hospitals.  Periodontal care is not always understood and patients are being given oral care awake, with tranquilization or with short acting intravenous/intramuscular sedation.  Until these practices are changed oral pain will continue to be under-diagnosed, misdiagnosed or not diagnosed. 

Secondly, some veterinarians may not believe that oral pain exists in dogs and cats. 

Diagnostics
Oral radiology must find its way into veterinary hospitals.  Without oral radiology, exact diagnosis is impossible.  No veterinarian should be performing an extraction without pre- and post-oral X-rays.  Similarly, no veterinarian should be extracting teeth in 2008 without informed consent. In certain cases, the option of root canal therapy versus extraction is a viable treatment choice.  Oral radiology is the most important key to understanding all options.  Pain control is directly connected to expedient diagnostics and treatment.

Signs of Oral Pain 
The oral cavity must be an integral part of physical exams if oral pain is to be identified.  The oral pain history must be taken.  I suggest creating an oral SOAP to be filled out during an exam.

When the history and preliminary oral exam is completed, the patient must then be anesthetized to finalize the oral exam and reach a definitive diagnosis.  It is essential to have a quality oral X-ray atlas in your operatory to review and identify pathology in the oral films.  If using digital oral radiology and you are not certain of the diagnosis, telemedicine services are helpful. 

The time has passed where oral inflammation is treated with glucocorticoids,  NSAIDs and antibiotics.  When I lecture at forums, the question will always come up concerning whether animals experience oral pain or are we creating a treatment for a condition that does not exist.  The anatomy of the endodontic system of a dog/cat and human is quite similar. So I tell the questioner to ignore a pain condition in their own mouth for one year and then call me with monthly updates.  Bringing pain home eliminates the “doubting Thomas” phenomenon. Just because there is no subjective oral pain it does not mean that we can ignore it.  Oral pain does exist.  We are the advocates of ALL the companions that we treat.  ALL ORAL PAIN is significant.
   
My oral record systems include the following statement. “Your companion will be pain free while under the care of Dr. DeForge and his technical staff. This will occur with the usage of pre-treatment analgesics, intra-operatory pain control and post-treatment pain control medicines.” 

There are many other pain control systems. Keep up to date, keep it simple and most importantly do not ignore pain.  My oral record statement is not for effect.  It is an honest realization of oral pain presence allowing the client to realize that their pet will be comfortable through every step of the oral care journey.

Table One: Signs of Oral Pain in the Canine and Feline

• Changed patterns of contact: pet with owner
• Hypersalivation
• Aggression
• Withdrawal
• Disturbances in sleep pattern
• Reduced grooming
• Changes in eating behavior
• Change in food preference-hard to soft
• Food tossing into mouth: swallowing food whole
• Chewing on one side of mouth only
• Smacking  of lips
• Mouth chattering
• Tooth grinding: especially in feline
• Tongue hanging out of mouth
• Change in play behavior
• Blood in food or water bowl
• Bloody discharge from nose
• Rubbing face or pawing at face
• Hair loss noted around muzzle
• The feline withdrawing from cheek rubbing for affection
• Dropping food outside of the food bowel-reluctance to masticate



Table Two: Oral Pain Conditions in Companion Animals

• Tooth root abscesses
• Advanced Periodontal Pathology
• Oral Ulcers
• Open Pulp Canals
• Newly Fractured Teeth
• Periapical Endodontic Disease
• Closed Periodontal Abscesses
• TMJ Pathology
• Oral Tumors/Cysts
• Feline Odontoclastic-Osteoclastic Resorptive Lesions
• Feline Oral Inflammatory Disease (Stomatitis)
• Jaw fractures and mouth trauma
• Subluxated and luxated teeth
• Impacted Teeth
• Crown or Root Caries (cavities)
• Incomplete Extractions with retained roots
• Pulpitis

Table Three: Pain Control Systems in Oral Care

NOTE: When using opioids in pre-emptive pain control, please evaluate each patient with a detailed pre-anesthetic assessment, especially the geriatric patient or the cardio-pulmonary patient. Dosage adjustments may be indicated. Do not just calculate dosages based on a formulary which should only be considered a guideline.

I.  Intra Operatory-Local Anesthesia: Used with Patient Under General Inhalation Anesthesia-(Reduce inhalant intraoperative requirements)

  • Infiltrative-Regional-and Periodontal Ligament Blocks
    .
  • Regional Blocks-Infraorbital-Mandibular-Mental

(SPECIAL NOTE: With mandibular blocks, self-trauma can occur when the patient awakes. Lips, tongue and cheek may be bitten from a lack of sensation)

  • Bupivicaine (Marcaine) 0.5%
    .
  • Mepivacaine 1% (Carbocaine)
    .
  • Lidocaine 2% (Xylocaine)
    .
  • Dosage varies with procedure being performed, depth of anesthesia, vascularity of tissue and duration of anesthesia.

II. Pre-Anesthesia Pain Medicines: titrate to patient’s health, length under anesthesia, and cardio-pulmonary heath

III. Intra operatory and Post-Anesthesia Pain Medicines: titrate to need, procedure performed, and post-anesthesia recovery status

  • Buprenorphine HCl: Partial Opiate agonist at the mu receptor; decrease in blood pressure and heart rate can occur;
    use with caution in patients with head trauma or CNS dysfunction; vomiting not commonly seen; excellent transmucosal oral absorption in cats; respiratory depression is an adverse warning sign; 0.005-0.01 mg/kg IM, IV, or S/Q q 4h-8h-titrate to patient need
    .
  • Morphine Sulfate: 0.05-0.5 mg/kg q4-6 hours, titrate to patient need; vomiting, diarrhea and bradycardia can occur; dysphoria noted in cats, not common but reported at high dosages
    .
  • Hydromorphone: Pure agonist opioid; CNS depression reported; respiratory depression noted under general inhalation anesthesia; can cause bradycardia, panting, vomiting diarrhea; 0.05 to 0.2mg/kg IM or SC q 4-6 hours, titrate to patient need; can cause hyperthermia in cats

NOTE: Ventilatory depression and sedation caused by opioids may be reversed with opioid antagonists.  Remember that as the opioid is reversed the pain can return as the analgesia is also reversed.  Naloxone should be available if narcotics are routinely utilized (dilute with saline with slow IV titration to reduce side effects). Also, consider nalbuphine and butorphanol.

IV. Post Operative Evaluation: Pain Control at Home 
Follow-up with the client after discharge will affect excellent pain control. Ask if the patient is restless, eating OK, is there appropriate litter box usage in cats, and whether there is normal defecation and urination in dogs.  Opioids can cause constipation (decreased intestinal peristalsis) in some patients.  Overdosage can cause respiratory depression and severe sedation.   Use opioids with extreme caution with other CNS depressants such as antihistamines, phenothiazines, barbiturates and tranquilizers. These drugs can have additive effects with an exacerbation of respiratory depression.

  • Tramadol (canine and feline) 50 mg tablets
    Synthetic mu-receptor opiate
    1-2mg/kg PO every 6-8 hours
    Cats 12.5mg every 8 hours
    High dosages may cause prolonged sedation
    .
  • Gabapentin (feline) 100 mg capsules
    Oral pain control in feline
    Give ½ of a 100 mg capsule (PO) once or twice daily (50 mg)
    Can be compounded or mixed in food
    Can cause sedation in high dosages
    .
  • Morphine sulfate immediate-release tablets (canine) 15 mg tablets   0.4mg/kg every 12 hours (PO)

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Identifying and Treating Oral Pain

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Reader Comments
I'm so grateful to see an article about treating oral pain in cats. My cat recently had a dental - only tartar was removed. She came home in excruciating pain, grinding her teeth, shaking her head and pawing at her cheeks - hungry but unable to eat because of pain. After 2 more anaesthesias and xrays, 2 under the gum FORLS were removed. Although the pain is a little improved (2 weeks later) she is still suffering pain which no-one can identify the cause of. She is a 17 year old Himalayan, and to say this has been distressing would be an understatement. She is on Buprenorphine 8 hourly. I will definitely be speaking to my Veterinarian about the other treatments. The best diagnosis we have is FOPS. I suspect this is far more common than most people realise - numerous people say their cat does badly after an anaesthesia, and goes downhill - I wonder how many of these cases are due to pain. As I understand it, a cat has very delicate nerves running near the roots of their teeth, and these can easily be disturbed.
Marie, Johannesburg, AL
Posted: 12/14/2011 12:31:38 PM
For Dr. DeForge: I have 10 cats who suffer oral ulcers. My vets say they are related to various autoimmune diseases. Treatment for pain is 1 cc. Depo-Medrol once a month, administered subcutaneously by me. Some don't need it that often, others do. Is there an alternative treatment for pain, one that would be more effective, less risky? I love my cats dearly, but am on a limited budget. I work part-time for a vet though, and get excellent discounts. If there is an alternative treatment I would love to hear it. I don't feel right giving them so many steroid shots, I feel that there are terrible side effects looming in the future. Please write me: poetry_man61@earthlink.net
Michael, Hutchinson, KS
Posted: 6/12/2009 10:34:47 AM
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