The Team | Fall 2012 | Vol. 9, No. 4

Fall 2012 | Vol. 9, No. 4

A WealthEnhancing Resource for Independent Veterinary Practices

A Breakthrough in Allergy Treatments 3 | Competing with Dr. Google 9

Managing Oral Tumors 15 | Diagnosing Canine Hypothyroidism 23

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From the Desk of Dennis A. Nelson, dvm Fall 2012 | Vol. 9 | No. 4

A Wealth-Enhancing Resource for Independent Veterinary Practices

New Breakthroughs in Allergy Treatment Diagnosing and treating allergies is a challenge for both the veterinary practice and for pet owners, especially those who may be skittish about giving their pets the subcutaneous injections required for immunotherapy treatment.

A new breakthrough in allergy treatment from Heska, sublingual immunotherapy, Visit www.psi-inc.net for additional promises several advantages. educational articles. New articles include: The drops are administered • Tap the Potential of Senior Care under the pet’s tongue, a much • Feline-Friendly Handling Guidelines easier option for pet owners.

Plus, the treatment set does • Debt Consolidation not require refrigeration, an added convenience.

These exciting advancements offer wealth-enhancing business opportunities for the dermatology side of your practice. Read more on pg. 3.

On the Web

The Team is published to complement Pet Quarterly®, an educational resource for your clients. Look for these articles in the current issue of Pet Quarterly: Allergy Relief; Overcoming Oral Tumors: Trusting Dr. Google; Diagnosis: Hypothyroidism.

Visit us on the web at

www.psi-inc.net

A lso in this issue: • Are your clients relying more on Dr. Google than on you? Dr. Jed Schaible takes a look at the ramifications of Internet self-diagnosing and offers hands-on solutions to help steer your clients back to your team. Take advantage of his suggestions for improving your website on pg. 9.

• On pg. 15, veterinary dentist Dr. R. Michael Peak offers an informative overview of oral tumors. Check out his suggestions for treatment options and test your knowledge by reviewing the pictorial of benign and malignant tumors.

The Team is an educational resource published by Purchasing Services Inc., St. Petersburg, Fla. Comments are welcome at info@petquarterly.com

• With signs that can range from lethargy to abnormal heart rhythm, canine hypothyroidism is often hard to pinpoint. Read up on Dr. Michael Canfield’s overview on pg. 23.

Best wishes for a wealth-enhancing holiday season.

Visit us on the web at www.psi-inc.net © Copyright 2012. All rights reserved.

The Team magazine does not make any representations as to opinions or facts as presented. Reproduction of contents in any form is prohibited without prior written permission of the publisher.

Postmaster: Send address changes to: The Team, 2951 34th Street South St. Petersburg, FL 33711

Sincerely,

Dennis A. Nelson, DVM Vice President, Operations Purchasing Services Inc.

www.psi-inc.net | the Team | Fall 2012 1

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Parasites & Dermatology

Allergy Advances A new breakthrough in allergy treatment—sublingual immunotherapy—holds promise for treating challenging cases.

If you are in small animal practice, you probably see allergic dogs and cats at least weekly, if not daily. With estimates of up to 10 percent of office visits focused on allergic pets, these patients may comprise a significant and rising portion of your caseload. That’s great for business, but the diagnosis and management of allergic disease can be challenging for the practitioner, the pet owner and the itchy, uncomfortable pet. In fact, tens of millions of animals suffer from allergies, but only a small fraction are properly tested, diagnosed and treated.

The good news is that by taking advantage of advances in allergy technology, you and your team can build a thriving allergy practice and help alleviate your patients’ discomfort. >>

www.psi-inc.net | the Team | Fall 2012 3

Parasites & Dermatology

Initial Steps Before testing for allergies, it’s important to rule out other conditions that could cause itching, such as parasites (fleas, lice, mites and intestinal parasites), skin infections (bacterial, yeast and fungal) and metabolic diseases.

Allergy should always be considered in pets with unexplained hair loss, recurrent ear infections, or signs of excessive self-grooming.

Allergic patients are often managed with a combination of antihistamines, fatty acids and shampoos. These products can provide relief, but it may be limited or temporary. Steroids also provide short-term relief, but prolonged use can have serious side effects.

Immunotherapy Options To date, the safest, most effective treatment for dogs, cats and horses with allergies is immunotherapy, which has been found effective in approximately 60 percent of patients.

Allergen-specific immunotherapy, or ASIT, is a treatment modality whose success depends on accurate determination of the patient’s specific sensitivities, by either intradermal or serum IgE testing.

offers two options. Formulated with proprietary technology and developed through years of trials in hundreds of dogs, ALLERCEPT® Therapy Drops are the latest innovation in immunotherapy from Heska Corporation. Therapy Drops are administered sublingually and offer a more palatable solution for many owners whose pets are suffering from hard-to-control allergies and for which subcutaneous Therapy Shots are not a viable option (because of owner or pet aversion to shots, shot failure or anaphylaxis).

Sublingual drops are administered twice daily for the duration of therapy.

Then, extracts of the identified allergens are mixed together and administered to the patient. The goal is to desensitize the patient by starting with very tiny doses and gradually building up to very large doses.

Immunotherapy can be delivered through subcutaneous injections or new sublingual drops.

If you have arrived at a diagnosis of atopic dermatitis and selected immunotherapy as the appropriate treatment, Heska Corporation

Effective Alternative Allergy drops have been used around the world in humans for more than 50 years, and numerous studies validate both their safety and effectiveness.

In fact, the World Health Organization has endorsed sublingual immunotherapy as a viable alternative to injection therapy in humans.1 The Cochrane Collaboration, an international organization dedicated to reviewing healthcare treatments, recently concluded that allergy drop immunotherapy significantly reduced allergy symptoms and the

New immunotherapy drops offer a more palatable solution for pet owners who may not be comfortable administering subcutaneous shots.

A small hook on the dispenser pump fits over the pet’s lower teeth, directing the solution under the tongue area.

4 Fall 2012 | the Team | www.psi-inc.net

need for allergy medications.2 Sublingual immunotherapy works via many of the same mechanisms as injectable immunotherapy. However, in humans, additional mechanisms demonstrate that sublingual immunotherapy may be effective even if allergy shots are not.

Studies point to the importance of the abundant and unique type of dendritic cells found in the oral mucosa, which appears to be able to rapidly modulate the immune response in many patients.3

Advantages of Drops Using Heska’s ALLERCEPT allergen-specific IgE test to identify the important allergens, selection of allergens for sublingual treatment is performed in exactly the same manner as for the company’s Therapy Shots.

However, with ALLERCEPT Therapy Drops, the extracts themselves and the formulation principles are quite different than for allergy shots. This leads to two important benefits: First, mold extracts can be mixed with other allergens in the treatment sets, rather than being administered separately. Second, the treatment set does not require refrigeration— an additional client convenience.

Another strong advantage of Therapy Drops is that they are much easier to administer. A small, customized hook on the dispenser pump fits over the pet’s lower teeth, directing the solution under and around the tongue area. Maximum contact with the sublingual oral mucosa is necessary, so the drops cannot be mixed with food or squirted into the mouth and swallowed, as with most oral liquid medication. Dogs readily accept treatments, which are done twice daily, every day, for the entire duration of therapy.

Therapy Drops can also be used in cats. The palatable base aids in the success of long-term oral administration. >>

The Team Approach Veterinarians Learn more about sublingual immunotherapy for the treatment of atopic dermatitis. Heska’s website (www.heska.com) provides research and selfpaced continuing education. After you decide how allergy case management fits into your business, discuss a plan for product pricing, team education and implementation of this new therapeutic option with your practice manager.

Practice Managers Discuss with veterinarians your clinic’s strategy for allergy case management.

Schedule a team meeting to review immunotherapy treatment options.

Determine team member roles in educating clients. Direct the team to the allergy education modules and other resources at www.heska.com.

Technicians With a definitive diagnosis of allergy, collect and process a blood sample for serum IgE testing. Educate clients about administration, re-ordering and compliance. Monitor patient progress during recommended recheck visits.

Receptionists Your role begins once the doctor has recommended and prescribed Therapy Drops. Follow-up calls for re-checks, re-orders and to determine how the patient is responding will be very important to treatment success. Help clients avoid frustration with the process or clinical relapse that might occur if there is an unexpected therapeutic gap, or if the allergy drops are discontinued prematurely.

www.psi-inc.net | the Team | Fall 2012 5

Parasites & Dermatology

Hitting the Mark The ALLERCEPT IgE Test measures only allergen-specific IgE, which reduces the chance of false positives.

6 Fall 2012 | the Team | www.psi-inc.net

Tests and tools to increase your success rate in allergy treatment.

Accurate identification of the allergens to which your patient is sensitive is a critical first step for effective allergen-specific immunotherapy. Immunotherapy treatment based on erroneous test results may include unnecessary allergens or exclude necessary allergens. Heska’s ALLERCEPT IgE Test is the only test to use a patented receptor technology that measures only allergen-specific IgE, thus significantly decreasing the chance of false positives.

Using the ALLERCEPT IgE Test, you get accurate, easy-to-read results with a single blood sample, and immunotherapy recommendations within 48 hours of Heska receiving the test sample.

The ALLERCEPT program provides tools to confidently manage allergic patients, such as: n

S tep-by-step workbooks for both veterinarians and pet owners who want to closely manage allergic patients placed on immunotherapy.

n

T wo different options for administering immunotherapy, the newest of which is an easy-touse pump that dispenses drops under a patient’s tongue.

n

L iterature for pet owners that explains the steps involved in testing and treating their allergic pets, as well as ways to manage a pet’s environment.

Shots or Drops?

Each patient will respond differently to immunotherapy, and some may respond better to one formulation than the other. Because both methods are effective, clients may choose the best method based on their preference for administration and factors such as the pet’s temperament. Many clients find it easy to give injections to their pets, and infrequent administration (only once every week or so) is a plus for those with busy schedules. Pet owners who are needle-shy or have rambunctious pets, however, may prefer the drops, even though they must be given twice daily. If a pet has significant mold allergy, drops may be the best option because the mold extracts can be mixed in with the same treatment set.

With the new availability of ALLERCEPT Therapy Drops, you can look forward to fewer examroom complaints about recurring or continuing pet discomfort,

side effects of certain drugs and general frustration with the difficulty and expense of treating an allergic pet. ALLERCEPT Therapy Drops are an important part of the ALLERCEPT Testing and Treatment program, which was designed to provide both veterinarians and pet owners the tools they need to confidently manage pet allergies. n

Bousquet PJ, Cox LS, Dunham SR, et al.

Sub-lingual immunotherapy: World Allergy Organization Position Paper 2009. World Allergy Organization Journal 2:233-81, 2009.

1

2 Radulovic S, Wilson D, Calderon M, et al. Systematic reviews of sublingual immunotherapy. Allergy 66:740-52, 2011.

Allam JP, Novak N, Fuchs C, et al.

Characterization of dendritic cells from human oral mucosa: a new Langerhans’ cell type with high constitutive FcERI expression. Journal of Allergy and Clinal Immunology 112:141-8, 2003.

3

Approximately 15%

of itchy pets have atopic dermatitis and are candidates ® for ALLERCEPT

Key Points n

While working with allergic pets

can seem daunting, advances in allergy technology and a systematic approach will aid you in building a thriving allergy practice. n

The ALLERCEPT Testing and

Treatment program from Heska is designed to provide both veterinarians and pet owners the tools they need to confidently manage pet allergies and provide long-term relief from allergic symptoms. n

Therapy Drops are an innovative

solution for many owners whose pets are suffering from hard-tocontrol allergies, and for which subcutaneous Therapy Shots are not a viable option. n

The drops are easy to administer, with just two pumps under the tongue twice per day and convenient room-temperature storage.

What makes ALLERCEPT® Allergy Assessment and Treatment Program the answer?

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General Wellness

Competing with

Dr. Google How to combat the business drain from clients attempting to “diagnose” their pets online.

By Jed Schaible, VMD, MBA, CVPM

We all know that veterinary visits are down, despite an increase

in pet ownership in the United States.

The Banfield State of Pet Health 2012 Report statistically and scientifically validated what we, as veterinarians, have been reporting anecdotally for years. The study showed that there has been a steady decline in pet health and wellness over the last five years—a trend attributed to a poor economy, changes in pet owners’ perceptions of veterinary care and pet owners attempting to use the Internet (“Dr. Google”) as an alternative to veterinary care.

Alarming Increases Over the last five years, many chronic conditions have continued to increase at alarming rates. The report highlights double-digit increases in diabetes, kidney disease, arthritis, heart disease and hypothyroidism. Ear infections and dental disease are on the rise, and preventable diseases such as flea infestation, intestinal parasitic infection and obesity also showed elevated levels.

Veering from Veterinarians Despite these declines in pets’ health, pet owners are less likely to seek veterinary care for chronic diseases and less likely to recognize symptoms of chronic illnesses, the Banfield study found after polling more than 1,000 dog owners and more than 1,000 cat owners in the United States. Shockingly, only 36 percent of dog owners and 28 percent of cat owners said they would take their pet to see a veterinarian to manage an existing condition or disease. >> www.psi-inc.net | the Team | Fall 2012 9

General Wellness Pet owners are also skipping regular preventive exams. “By far the most important finding, from a pet health perspective, is the misperception by many pet owners that regular medical checkups for pets are unnecessary,” said Ian Spinks, president of Bayer Animal Health North America. Clearly we, as a profession, have to better communicate the value of wellness exams and services to pet owners.

You may be thinking, “This study probably doesn’t apply to my clients because my practice is not a Banfield practice.” Elizabeth Lund, DVM, MPH, PhD, and senior director of research at Banfield, was contacted to determine if the pet owners surveyed were general pet owners or Banfield clients.

The pet owners chosen by the market research firm, Kelton, and polled for the study were chosen randomly and were not pulled from a Banfield client list. Unfortunately, this means that these findings likely

A 2012 study found that only 36 percent of dog owners and 28 percent of cat owners said they would take their pet to see a veterinarian to manage an existing condition or disease.

do apply to your practice, your clients and your team.

Delayed Diagnoses With less wellness care and more visits to “Dr. Google” instead of a real veterinarian, pets are presenting to veterinarians with more advanced illnesses, due to a delay in pet owners seeking care for their pets. In a 2011

Bayer Veterinary Usage Study, 39 percent of pet parents surveyed reported that they look online before consulting a veterinarian when their pet is sick or injured.

“The first place pet owners go for pet health information is the Internet, plain and simple,” says Mark Stephenson, DVM, president and CEO of LifeLearn, Inc.

Key Points n

T here has been a steady decline in pet health and wellness over the last five years—a trend attributed to a poor economy, changes in pet-owner perceptions of veterinary care, and the trend of pet owners attempting to use the Internet as an alternative to veterinary care.

n

T o improve compliance, it is more critical now than ever that your practice maintains an effective website that offers professional, up-to-date pet health information.

n

B e proactive in driving clients to your website for health information in order to compete with other online medical resources that delay clients bringing in their pets.

n

L ifeLearn’s ClientEd Online Library is an alternative to a do-it-yourself resource library and can be integrated with your current practice website.

n

C onsider taking the financial decision out of the equation by offering preventative healthcare plans that allow clients to be compliant without having to approve incremental fees associated with wellness services.

Winning Websites Improving your practice website to compete with Dr. Google is a good place to start getting more clients on board with regular wellness care. “To improve compliance, offer professional, up-to-date pet health information,” suggests Stephenson.

Here are some strategies to keep clients coming to your website and to your practice: n Add Resource Links. If your practice does not currently subscribe to a platform that provides client education online, create a resource library section with approved pet health content and/or website links. Link to sites that are friendly to veterinarians and provide pet owners the medical resources they desire. Examples are VIN’s VeterinaryPartner.com and LifeLearn’s MyPetED.com. If you want your clients to consider pet insurance, include a link to PetInsuranceReview.com. n Add Internal Links. Use Google Analytics to determine which posts or pages drive the most traffic to your website, then make sure that your resource library is accessible from those pages. An easy way to be sure that clients are finding your resources is to have a link to your resource library in a sidebar and in the header of each page on your site (i.e. “Pet Health Resources”). n Link from Blogs. If you are posting a blog or news article, consider linking to articles in your resource section when you use disease terms. Not only will this help your clients find your resource library, but also this practice has search engine optimization benefits. For example, if you talk about canine diabetes in the body of an article, the words “canine diabetes” should link to an article about canine diabetes on your site’s resource section or somewhere else you approve. n Host a Photo Contest. Drive clients to your website by posting content that is specific and dear to them. For example, you can

swap out your stock photos for real photos of your patients—clients will be appreciative and will share the website with their friends.

A great way to collect photos is to host a photo contest on your business’s Facebook page. In order to avoid the headaches associated with programming and managing a Facebook photo contest, consider outsourcing the contest via WildFire App, a company that can host a sophisticated contest on your Facebook page at a low cost (WildfireApp.com). n Offer Refills Online. Increase your traffic by providing a web form that allows clients to conveniently refill prescriptions. Since you have control over the message that appears after they submit the form, consider saying, “Thank you for submitting your refill request. We will be contacting your shortly.

Consider browsing our Pet Health Reference Center.” By creating a dedicated email for prescription refills that can be checked periodically, a web form will very inexpensively give clients a reason to visit your site, and they learn that you have resources relevant to them. n Add a Search Function. If you have pet health articles on your website, consider adding a search function so that clients can easily find them. If your articles are buried deep in your site and the navigation is difficult, clients will ditch your website for Dr. Google and a better user interface for finding content. n Reference Your Site in Discharge Instructions. If you aren’t providing written discharge instructions, you are missing a huge opportunity to increase your website traffic. In your discharge instructions, provide links to your website for additional information.

For example, in discharge instructions for home treatments for otitis externa, a link to an article on your website with instructions on how to clean the ears would drive traffic. An engaging video would be ideal for that page, as well. >>

Risky Research In human medicine, physicians are facing the same challenges from Dr. Google. Online selfdiagnosis led to a 25 percent misdiagnosis rate and a 50 perent rate of self-medicating with an incorrect or unnecessary drug or treatment, according to a recent UK study with a sample size of 1,000 women. Not surprisingly, the study also found that attempts at online self-diagnosis led to a delay in attaining a correct diagnosis and treatment by a licensed physician, leading to inferior medical outcomes.

www.psi-inc.net | the Team | Fall 2012 11

General Wellness If these strategies seem too challenging, time consuming or expensive, consider a comprehensive solution such as LifeLearn’s ClientEd Online Library that integrates with your practice’s website, thereby creating a trusted online resource for clients and reinforcing the bond between the veterinary team and the client. The service allows veterinary practices to customize handouts with clinic

and client/patient information and print or email articles to clients. The best aspect of having an integrated library is that pet owners don’t have to leave your website, so they’re less likely to visit another site with advertisements for competing veterinary services.

Just having a website is not good enough anymore. Your website has to be engaging enough to compete with third-party medical

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resources. Such sites often provide misinformation that delays clients from bringing their pets to you— a delay that often means poorer health outcomes for your patients.

Preventive Packages Lastly, you may find that no matter how much you educate clients about the importance of wellness exams, these efforts may never lead to compliant purchasing behaviors.

Consider taking the financial decision out of the equation by offering preventive healthcare plans that allow clients to purchase bundled wellness services for a monthly fee. This lets them be compliant without having to approve incremental fees throughout the year.

For more information about these plans, see the article “Marketing Preventive Health Plans” on pg. 15 of the Summer 2012 issue of The Team. n Jed Schaible, VMD, MBA, CVPM, is an expert in digital marketing, search engine optimization and social media. Jed is the Director of Market Communications at Purchasing Services Inc. For veterinary marketing tips and more, follow Jed on Twitter: @JedSchaibleVMD

For More Information To access the full text Banfield State of Pet Health 2012 Report, scan the QR code above with your Smartphone or head to bit.ly/ stateofpethealth. Speaking of QR codes, are you using them on your print marketing materials?

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Dental Health

Managing Oral Tumors How to treat oral tumors in dogs and cats and help manage owner fears.

By R. Michael Peak, DVM, DAVDC

The word “tumor” can be frightening to pet owners whose pets present with oral swelling, because the term invokes visions of malignant cancers. However, you can reassure your clients that not all oral swelling are tumors, and not all tumors in dogs and cats are malignant. In fact, 50 percent of canine oral tumors are benign and typically not life threatening.

Let pet owners know that some malignant oral tumors, if diagnosed and treated early, can be successfully removed with surgery, while others respond favorably to radiation or chemotherapy. In cats, most oral tumors are malignant (usually squamous cell carcinoma), and clients should be educated that early detection is the key to effective treatment.

Early Diagnosis Means Better Odds Early recognition, accurate diagnosis and tumor staging are vitally important and significantly affect the patient’s prognosis. Important criteria to determine include tumor type, size, location, bone involvement and evidence of metastasis.

In general, the smaller a tumor is when diagnosed, especially if it is malignant, the better the prognosis and the more likely the mass can be removed surgically. Even small masses that may appear insignificant should be biopsied. The earlier the diagnosis, the easier oral tumors are to treat and the better they respond.

Diagnostic Approach Your initial diagnostic approach to oral tumors should include an anesthetized oral exam of the mass.

In general, tumors that are pedunculated or push teeth out of their normal position tend to be benign. Masses that show bone lysis or invade soft and hard tissue without disrupting the normal location of teeth tend to be malignant.

Determine the tissue involvement (i.e., whether it is on a stalk, or pedunculated, or dispersed broadly throughout the soft tissues).

Carefully measure the dimensions of the tumor in three dimensions. Take dental radiographs of the associated teeth and bone. Carefully examine regional lymph nodes—perform fine needle aspirate if any are palpable, as well as mass biopsy.

In general (these are not hardand-fast rules), tumors that are pedunculated or that displace teeth from their normal position tend to be benign, while masses that show bone lysis or invade soft and hard tissue without disrupting the normal location of teeth tend to be malignant. Good biopsy techniques

will help give an accurate diagnosis. Adequate sample size and sample location are helpful to get a representative sample for histopathologic exam—remove a 0.5 centimeter to 1 centimeter cubed sample from the middle or most representative area of the tumor and take care not to incise into normal tissue.

Be sure to take samples after all other dental surgery has been completed and change out instrumentation to avoid potential iatrogenic spread of tumor cells.

If possible, take digital photos of the mass before and after biopsy sampling. Provide a copy of the photos to the pathologist along with a detailed description of any >> www.psi-inc.net | the Team | Fall 2012 15

Dental Health radiographic abnormalities and regional nymph node aspirates.

Once the mass is evaluated histologically and the tumor type is determined, perform further tests if necessary to see the full tumor extent and to determine whether there are any signs of metastasis. These tests can include chest radiographs, abdominal radiographs/ultrasound, CT, MRI and regional lymph node removal for more complete examination.

After the tumor is staged (according to the World Health Organization Tumor Staging classification1), discuss treatment recommendations/options with pet owners regarding prognosis, extent of surgery (if indicated) and quality of life following surgery.

Treatment Options Dogs are susceptible to several types of benign oral tumors, from focal fibrous hyperplasia (overgrown normal gum tissue) to odontogenic tumors (originating from the tooth structure) to non-tooth-origin tumors such as papillomas (small tumors caused by >>

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The Team Approach Train your whole practice team to provide the best care for patients with oral tumors.

Receptionists Recognize the concern pet owners have whenever they find a tumor and empathize with them. Refrain from using words such as “cancer” or “malignant,” but encourage pet owners to have any abnormal swelling evaluated fully by the veterinarian. Try to keep in mind relevant cases that had positive outcomes and relay them to clients.

Technicians Look carefully in patients’ mouths for any abnormal swellings. Keep in mind that even small masses that seem insignificant should be biopsied. Earlier diagnosis and treatment typically results in more positive outcomes.

Veterinarians Be aware that many oral tumors can be malignant and that all tumors start out small, so biopsy of small masses is important. Early diagnosis and treatment positively affects

prognosis. Measure the tumor, take dental x-rays to evaluate for bone involvement, and aspirate any palpable regional lymph nodes for cytology.

Practice Managers Schedule a staff meeting to review oral tumors. Discuss the importance of early detection and treatment.

Review with dental technicians and veterinarians the need for biopsy.

Review records to be sure biopsies are being carried out for all oral masses.

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www.psi-inc.net | the Team | Fall 2012 17

Dental Health

Identifying Oral Tumors Can you identify key types of oral tumors and masses/swellings in dogs and cats?

Take a photographic tour to examine the various types.

Benign 1. Focal fibrous hyperplasia (previously called gingival hyperplasia)

Mild gingival overgrowth between teeth #303 and #304 was confirmed histologically as focal fibrous hyperplasia.

Gingival overgrowth on the vestibular surface of #108 was read histologically as focal fibrous hyperplasia. Note the mass is pedunculated on a stalk at the gingival margin.

2. Peripheral odontogenic fibroma (previously called fibromatous epulis)— some of these mineralize internally and may be called “ossifying epulis.�

Gingival mass at the rostral maxilla, encompassing #101-#203. This mass was histologically confirmed as an acanthomatous ameloblastoma. The mass was removed with clean margins, which carried an excellent prognosis. Although shown in the maxilla here, these masses are common at the rostral mandible around the canine and incisor teeth. Acanthomatous ameloblastomas have not been shown to metastasize, but can invade locally into alveolar bone.

4. Plasma cell tumor/plasmacytoma

Left mandibular swelling in a 15-monthold Golden Retriever. Radiographs reveal multiple radiodense particles within the swelling. Histopathology confirmed this mass as a compound odontoma. Treatment involved gingival flap surgery to expose the lesion, extraction of #305-#307 (inclusive), removing the particles, curetting the bone and closing the gingival flap.

7. Cysts (dentigerous, radicular, etc.)

Rostral mandibular mass and vestibular gingival mass adjacent to #309/#310, which were read histologically as plasmacytomas.

5. Sublingual granuloma

Gingival mass on vestibular aspect of #205 and #206. The radiograph reveals mineralization within the mass. This mass was histologically confirmed as a peripheral odontogenic fibroma with mineralization.

(Photo and radiograph courtesy of Dr. Tony Woodward, DAVDC, Ft. Collins, Colo.)

3. Acanthomatous ameloblastoma (previously called acanthomatous epulis and adamantinoma)

18 Fall 2012 | the Team | www.psi-inc.net

Mass under the left side of the tongue was read as mucosal hyperplasia and granuloma. These are considered nonneoplastic and are usually the result of trauma from the adjacent teeth.

6. Odontoma (compound or complex)

The two photos and radiograph above are of a young male neutered Boxer. The soft blue-tinged swelling just caudal to the left maxillary canine tooth suggests a possible cyst. During the oral exam, the left mandibular 1st premolar was noted to be missing with a soft swelling on the lingual aspect of #306. The radiograph revealed an unerupted #305 and radiolucency that encompassed #305 and the resorbed roots of #306. The associated teeth were removed, cyst lining removed and submitted for histopathology, and the surgical site closed. The histopathology revealed an epithelial lining consistent with a dentigerous cyst.

2. Squamous Cell Carcinoma

The photo and two radiographs above are from a 9-year-old male neutered Domestic Short Hair with left mandibular swelling. There are multilobular areas of radiolucency noted. Surgical exploration, removal of the involved teeth and lining of the defect was performed. Histopathology revealed the lining to be epithelium consistent with a “bone cyst.�

Malignant 1. Malignant melanoma

Photo and radiograph of 9-month-old neutered male Beagle. The irregular area just distal (caudal) to the left maxillary canine (#204) was biopsied and found to be a papillary squamous cell carcinoma. Clean margins were achieved with left partial rostral maxillectomy.

3. Fibrosarcoma

Photo and radiograph of a 9-year-old spayed female Lab mix. The mass was read as squamous cell carcinoma, and the radiograph shows periosteal reaction at the distal aspect of #204. Clean margins were achieved with left rostral partial maxillectomy.

Photo and radiograph of a 13-year-old neutered male domestic short hair. Nonhealing extraction site of the right mandibular first molar (#409) revealed squamous cell carcinoma. The radiograph shows little amount of bone involvement. Since the mass was caught early, clean surgical margins were achieved with right total mandibulectomy.

Photo and radiograph of a 12-year-old neutered male mixed-breed dog. The radiograph shows alveolar lysis around #306/#307. Histopathology revealed this mass to be a malignant melanoma. Clean margins were achieved with left rostral partial mandibulectomy and melanoma immunotherapy. Melanoma can be locally invasive and can metastasize early in the course of the disease.

Photo and two radiographs from a 12-year-old neutered male domestic short hair. The mass was biopsied and found to be a squamous cell carcinoma. Due to the extent of bone involvement, surgical excision was not attempted in this case.

Squamous cell carcinoma (SCC) is the most common malignancy in cats. It can be locally invasive and has the potential to metastasize. In general, the further caudal the mass is, the more guarded the prognosis.

SCC at the tonsils and base of the tongue tend to carry a more guarded or poorer prognosis.

Photo and radiograph of a 13-year-old neutered male Poodle mix with a right mandibular swelling. The biopsy revealed this mass to be a fibrosarcoma. The radiographs reveal extensive bone lysis extending caudally to the mandibular foramen area. Right total mandibulectomy was performed. The mass was noted extending out of the mandibular foramen.

Margins were read as clean, but narrow.

The prognosis in such cases with this tumor type are guarded. The fibrosarcoma is typically slow to metastasize, but very locally invasive.

Photo and radiograph of a 14-year-old spayed female domestic long hair. This mass was read as fibrosarcoma. There was little radiographic evidence of bone involvement, other than widening of the periodontal ligament space at the mesial aspect of #204.

This mass was removed with relatively wide, clean margins. Due to the invasive nature of these masses, even with clean margins, there is still a chance of recurrence. >> www.psi-inc.net | the Team | Fall 2012 19

Dental Health

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viruses). You can treat most of these tumors by removing the mass along with a very small amount of the normal tissue surrounding the mass and any associated teeth.

In some cases, even benign tumors may invade the bone of associated teeth, meaning that some bone removal may be necessary when removing affected teeth. As long as these lesions are detected early, a small amount of bone removal combined with removal of a few teeth should not interfere with the pet’s overall quality of life.

Treatment for oral malignant tumors varies depending on the tumor type, size, extent of local invasion into surrounding tissue and extent of metastasis. This further underscores the importance of oral biopsy, dental x-rays, chest x-rays, abdominal x-rays or ultrasound, and evaluation of the regional lymph nodes that drain the area where the mass is located.

If there is no evidence of metastasis, surgery to remove the mass may be the best chance for a cure. Different oral malignancies require different margins of normal surrounding tissue to be removed to give the best chance of eliminating the tumor completely. You may need to remove substantial amounts of both the upper and lower jaw when removing oral malignancies; reassure pet owners that these patients generally adapt quite well.

In general, the smaller the malignancy and the more forward in the mouth, the easier it is to achieve clean margins, and consequently a higher rate of success.

As you’ll note in the photo sidebar (pgs. 20-21), many oral tumors look alike—the bottom line is to look often, detect early and treat as soon as possible. n Dr. R. Michael Peak specializes in pet dentistry at Tampa Bay Veterinary Dentistry, Largo, Fla. www.thepetdentist.com 1 Verstraete, FJM and Lommer, MJ, Oral and Maxillofacial Surgery in Dogs and Cats, Saunders-Elsevier, 2012, pg. 374.

Senior Wellness

Diagnosing Canine Hypothyroidism Tips for identifying, diagnosing and treating this common condition in senior dogs.

By Michael Canfield, DVM

Hypothyroidism, or deficient production of thyroid hormone, is the most common

hormonal disorder in dogs. It is also the most over-diagnosed hormonal disorder in dogs. Several factors contribute to that, including the fact that a dog’s thyroid levels could be low if screened when ill or if it is receiving medications such as steroids, sulfonamide antibiotics, tricyclic antidepressants, phenobarbital, aspirin or furosemide. Additionally, thyroid supplementation in a dog with normal thyroid hormone production will actually result in decreased thyroid hormone production via negative feedback on the thyroid glands.

If you determine that a senior dog in your practice has indeed developed hypothyroidism, be sure to prepare the pet owner for the lifelong care and management that this condition will require.

Q: What causes the disease?

A: Primary hypothyroidism

is the most common cause of thyroid failure in adult dogs.

There are two types of primary hypothyroidism that predominate in dogs: lymphocytic thyroiditis and idiopathic atrophy, both of which result in circulating thyroid hormone deficiency. n Lymphocytic thyroiditis results in cellular infiltration of a thyroid gland and progressive destruction of

Hypothyroidism is the most over-diagnosed hormonal disorder in dogs.

>>

www.psi-inc.net | the Team | Fall 2012 21

Senior Wellness the gland. Clinical signs may not be evident until 75 percent of the gland is destroyed. n Idiopathic thyroid atrophy is characterized by loss of thyroid parenchyma. The cellular infiltrate found in lymphocytic thyroiditis is lacking in idiopathic thyroid atrophy.

Neoplastic destruction of the normal thyroid gland by an infiltrative tumor may result in clinical signs of hypothyroidism—thyroid carcinoma

Alopecia

and squamous cell carcinoma are the most common.

Secondary Hypothyroidism results from failure of pituitary thyrotrophs to develop or function, resulting in impaired TSH secretion leading to secondary deficiency of thyroid hormone synthesis and secretion.

Tertiary Hypothyroidism results from a deficiency in the secretion of thyrotropin-releasing hormone by

Rat tail

Seborrhea

Table 1 Metabolic

Dermatologic

Lethargy Mental dullness Weight gain Inactivity Heat seeking

Alopecia at points of friction Symmetrical alopecia Rat tail Otitis externa Hyperpigmentation Pyoderma Seborrhea Myxedema

Reproductive

Gastrointestinal

Abnormal estrus cycle Galactorrhea Testicular atrophy

Diarrhea Constipation

Ocular

Cardiovascular

Corneal lipid deposition Corneal ulceration

Arrhythmias Bradycardia

Hematologic

Neuromuscular

Anemia Hypercholesterolemia Hypertriglyceridemia Abnormal coagulation

Weakness Ataxia Facial nerve paralysis Laryngeal paralysis

22 Fall 2012 | the Team | www.psi-inc.net

the hypothalamus. This has not been reported in dogs.

Congenital Hypothyroidism in dogs has an unknown incidence and is beyond the realm of this discussion.

Iodine deficiency is a rare cause of hypothyroidism, but with the increased use of unbalanced home-prepared diets, we may see an increase in iodine deficiency– induced hypothyroidism.

Serum antibodies against thyroglobulin, T3 or T4 may be present in dogs with thyroiditis, however, dogs with thyroiditis may continue to have adequate thyroid reserve. Although positive antibody titers are not diagnostic for hypothyroidism, positive titers increase the likelihood of thyroid dysfunction.

Q: What are the clinical signs?

A: Common clinical signs

include lethargy, mental dullness, sluggishness, cold intolerance and weight gain. Dermatologic changes often predominate and include bilaterally symmetric alopecia, typically sparing the head and extremities. The hair is often brittle, easily epilated and may take on the puppy-like coat appearance. Coat color fading may occur, and failure of hair regrowth following clipping is common. Table 1 lists many of the clinical manifestations of hypothyroidism.

Q: Are there any age and breed predilections?

A: Hypothyroidism is typically

a disease of middle-aged to older dogs. Golden Retrievers, Doberman Pinschers, Irish Setters, Miniature Schnauzers and Great Danes are at increased risk, although reports vary. Peak detection of antithyroglobulin antibodies is two to four years of age. Table 2 lists the top 20 breeds reported to have the highest prevalence of thyroglobulin antibodies.

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Table 2 Top 20 Breeds with Highest Prevalence of Thyroglobulin Antibodies n n

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English Setter

German Wirehaired Pointer

Giant Schnauzer n Golden Retriever n

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Husky n Maltese

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Old English Sheepdog

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Rhodesian Ridgeback

Shetland Sheepdog n Siberian Husky n

Tibetan Terrier

Q: How is it diagnosed?

A: Diagnosis may be difficult

because of changes associated with increasing age and the effects of concurrent illness and medication usage on serum thyroid concentrations. A diagnosis should begin with a clinical suspicion of thyroid dysfunction with consistent clinical signs.

Common clinicopathologic changes include a nonregenerative anemia, hypertriglyceridemia and hypercholesterolemia. >>

8

8

www.psi-inc.net | the Team | Fall 2012 23

Senior Wellness The most useful tests in the evaluation of dogs suspected of having hypothyroidism include total thyroxine (T4) concentration, free thyroxine concentration and thyroidstimulating hormone concentration.

T4 concentration is highest in puppies and progressively declines during adulthood. A total T4 serum concentration is an excellent screening test for hypothyroidism.

If the results are normal, thyroid

function is likely adequate. However, if the total thyroxine concentration is low or low normal, additional testing may be warranted. A low free T4 by equilibrium dialysis or an elevated thyroid-stimulating hormone level are supportive of a diagnosis of thyroid dysfunction. It is possible that the patient should be evaluated for concurrent illnesses and medication usage (current/ historical).

Q: How is it treated?

A: Levothyroxine is the treatment

of choice, regardless of the underlying cause. Administration of levothyroxine with food may decrease bioavailability.

Levothyroxine should be administered at a dose of 0.02 mg/ kg (maximum of 0.8 mg) every 12 hours. Some dogs require twicedaily treatment, while others require only-once daily treatment.

However, once-daily treatment only benefits patients with slower metabolism.

Therapeutic monitoring includes evaluation of clinical response to levothyroxine sodium and determination of serum T4 and TSH levels. Serum T4 and TSH concentrations should be determined four to eight weeks after treatment is initiated and two to four weeks following dosage adjustments. T4 and TSH concentrations should be evaluated four to six hours following administration of levothyroxin for patients being medicated twice a day; however, patients treated once daily should be tested prior to dosing and again four to six hours following medication administration.

Q: What is the prognosis?

A: The prognosis for dogs with

hypothyroidism depends upon the underlying cause of thyroid hormone deficiency. An adult dog with primary hypothyroidism that is treated appropriately should have a normal life expectancy, however, the prognosis for a puppy with hypothyroidism (cretinism) is guarded, and the prognosis for a patient with secondary hypothyroidism can be guarded to grave. Fortunately, primary hypothyroidism is the most common. n Dr. Michael Canfield practices dermatology at several locations in Florida including Animal Emergency and Referral Center in Fort Pierce, and Animal Hospital of Regency Park in Port Richey.

24 Fall 2012 | the Team | www.psi-inc.net

TEST YOUR KNOWLEDGE Quiz questions are based on artic les in the current is sues of The Team an d Pet Quarterl ÂŽ y

1 A nationwide study of pets’ health found tha t since 2007: A. Diabetes is up 32 percen t in dogs.

B. Ear infections are up 34 percent in cats.

C. The number of overweigh t cats is up by 90 percent.

D. All of the above 2 What percentages of dog and take their pet to a veterina cat owners would rian to manage an existing disease?

A. 36 (dogs), 28 (cats) B. 43 (dogs), 31 (cats) C. 56 (dogs), 42 (cats) D. 65 (dogs), 53 (cats) 3 Name another possi ble cause of feline or can ine oral swelling.

A. Tumor B. Swollen lymph nodes C. Foreign-body penetratio n into oral tissues D. _____________ 4 True or False: In gene ral, oral tumors that are pedunculated tend to be benign.

A. True B. False 5 What is the most com mon type of malignant ora l tumor in cats?

A. Focal fibrous hyperplasia B. Squamous cell carcinom a C. Odontogenic tumors D. Fibrosarcoma

6 What are two key dif ferences between immunotherapy delivered thr subcutaneous injections? ough drops versus A. Pet owners administer tre atment.

B. It may be used for cats as well as dogs.

C. Mold allergens may be mixed with other allergens in the treatment sets.

D. The treatment set does not require refrigeration.

7 True or False: Adminis tering immunotherapy drops under the tongue is key, because dendritic cells found in oral mucos a help modulate immune response.

A. True B. False

8 Which type of canine hypothyroidism results in cellular infiltration of the thyroid gland?

A. Tertiary hypothyroidism B. Lymphocytic thyroiditis C. Congenital hypothyroidis m D. None of the above 9 What drug is the tre atment of choice for can ine hypothyroidism?

A. Levothyroxine C. Trilost ane B. Methimazole D. Mitota ne 10 True or False: Hypothy rodism is the most over-diagnosed hormonal disorder in dogs.

A. True B. False

Answers:s 1.D, 2.A, 3.Absc essed teeth or www.psi-inc.net | the Team | Fall 2012 25

cysts, 4.A, 5.B, 6.C and D,

7. A, 8. B, 9. A, 10. A

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