Patient Information
Patient Name: Stewie
Patient Age & Gender: Feline, 5 years old, male, neutered
Species and Breed: Domestic shorthair, orange tabby
Patient’s Symptoms:
Problem 1: Stomatitis – pain, swelling and redness of entire mouth, extending into throat.
Problem 2: Hyperesthesia.
Problem 3: Skin thinning, tearing and pain as a result of steroid treatment for stomatitis.
Problem 4: Alopecia from previously treated wounds.
Problem 5: Immune system dysregulation as a result of diseases and treatments. Treatment for one problem creates complications and/or worsening of another problem.
Medical History
Problem 1: Stewie initially presented with a mild case of stomatitis in 2009 and was treated with Depo Medrol every two to three weeks. His stomatitis continued to worsen despite steroid treatment, dietary changes, antibiotics and homeopathic treatment. Buprenorphine was added in 2010 with gradually increasing doses (up to 0.02 mg/kg SQ three times daily). Gabapentin was tried but with no effect.
His owners were concerned that anesthesia and extractions would be too risky based on his overall health. The decision was made to perform a dental in November 2012. All upper teeth were extracted. He had a very difficult recovery and no improvement in the stomatitis. By April 2013, Stewie’s mouth was fully inflamed, he was losing weight and refusing to eat, and he had developed severe mass lesions on the tongue and tonsils. The owners were considering euthanasia because of Stewie’s poor quality of life and constant pain
Problem 2: In 2010, Stewie developed hyperesthesia and was treated with amitriptyline. Doses started at 5 to 20 mg weekly and increased to 10 mg daily. Stewie was observed biting and chewing at his skin.
Problem 3: The long-term use of Depo Medrol resulted in tissue-paper thin skin, which tore easily. Four times, Stewie tore open his skin by simple grooming, including two large areas of skin torn off his flanks. Three times, these injuries were treated with trips to the emergency room for suturing and drain. Unfortunately, drain placement within the thin skin resulted in further skin tearing. At this point, the owners started dressing Stewie in shirts to help protect his sensitive skin.
Problem 4: After clipping for suturing, Stewie’s fur did not regrow (shaved areas). Stewie was extremely thin and cold and required extra care to remain warm.
Problem 5: Each issue complicated and exacerbated the other problems. For instance, each skin tear seemed to increase the hyperesthesia; and Stewie’s attempts to deal with the hyperesthesia created more skin tearing. It was difficult to orally medicate him because his mouth was so painful. Weight loss also reduced his immune resistance. Stewie, who had been a lively and friendly cat, refused to get out of bed, eat or interact with the owners or other cat.
Initial Assessments
- 6-09-09 Felv/FIV Negative/Negative
- 04-09-12 Emergency Clinic Report: Laceration on side
Briefly discussed stomatitis – strongly recommend owner give consideration to full mouth extraction. Extractions are arguably better and safer than life-long administration of steroid. For today – general anesthesia for wound care, clean and close, Convenia injection (to help avoid administering oral medication). Most likely wound will heal fine — but steroid may affect wound healing.
SURGERY REPORT: Suture Wound Level 1:
Skin was extremely thin, translucent — not just at the wound but over the entire cat — wound had jagged edges. Caudal edge of the wound was mildly bruised but elected to not resect this area as it would result in considerable tension — used simple interrupted sutures to try to help relieve tension and advance wound edges. Wound came together nicely but am very worried the skin is too fragile to heal normally.
- 04-08-13 New wound, sutured at emergency clinic, Penrose drain placed.
- 05-31-13: Laboratory Values (abnormals only)
Mini chemistry: Globulins slightly elevated (5.3)
CBC: Leukocytosis (20-22K) and mild anemia (PCV=34%)
- 05-31-13: Bartonella PCR: NEGATIVE
- 05-31-13: Dental with extractions of all remaining teeth except lower canines and incisors biopsy with histopath of oral lesions.
- 05-31-13 Histopathology of oral lesions: “Plasma cell stomatitis, marked, subacute, diffuse. Pathogenesis is unknown but is possibly immune-mediated.”
Initial Diagnosis
- Severe stomatitis with inflammation of gingiva – unresolved by partial mouth extractions
- Lingual and tonsillar lesions
- Hyperesthesia
- Very thin skin which tears easily
- Pain
- Anorexia
- Weight loss
- Lethargy, depression
- Chronic steroid use
Treatment Information
Laser treatment began after Stewie’s wound on his left hip was sutured on 04-08-13. The skin over the Penrose drain began to tear. Laser treatment helped calm this area and healing improved. When Stewie tore open the skin over his tail by grooming himself, on 05-15-13, we chose to treat the wound with lasering and bandaging rather than sutures. This large wound healed amazingly quickly and fur began to regrow.
Laser treatment was expanded to include previously sutured areas where fur had not regrown. Those areas also regrew normal fur after treatment.
Stewie had another dental with extractions 07-31-13. Christine lasered the extraction sites while he was still under anesthesia. His recovery from this dental was significantly easier than from the dental in 11-2012.
Laser Make & Model: Companion Therapy Compact Laser CTC-12
Frequency of Treatment: Treatment frequency varied. During periods of severe stomatitis inflammation treatment would increase to twice weekly. During periods of wound management frequency could be daily depending on severity. For maintenance periods, while stomatitis was well controlled, treatment was performed weekly.
Protocols Used: I used a variety of built-in protocols: Stomatitis – Open and Closed, Wound, and Dermatitis. I also included the patient characteristics; Average weight, Medium coat length, Medium coat color and Medium skin color.
Mode: Stomatitis; Open = CW, Closed = CW, Wound; 2×3 = CW, Dermatitis; 2×3 = CW
Power: Stomatitis: Open = 3 W, Closed = 4 W, Wound; 2×3 = 2 W, Dermatitis; 2×3 = 2 W
Treatment Time: Stomatitis; Open = 1 minute 33 seconds, Closed = 2 minutes 15 seconds, Wound; 2×3 = 2 minutes 27 seconds, Dermatitis; 2×3 = 2 minutes 27 seconds
Total Energy Delivered: Stomatitis; Open = 186 joules/cm2, Closed = 360 joules/cm2, Wound; 2×3 = 196 joules/cm2, Dermatitis; 2×3 = 196 joules/cm2
Areas Treated: Mouth/gingiva, upper and lower jaw for stomatitis. Bilateral hips, lumbar spine during multiple wound management treatments and later to assist in hair regrowth.
Approximate Size of Area Treated: Stewie’s new wound was approximately 2” X 3” = 38 cm2
Other Treatment Details: Small contact head was used for treatments, generally held one inch from patient. If patient would tolerate it, laser was applied directly to hair when treating outer jaw.
Any Other Treatments Used: Originally, the laser treatment was performed to address a large open wound that did not appear to be suturable. The area involved was too large with very thin skin. Placement of sutures and a drain would have likely resulted in the skin tearing even more. The wound was lasered on days 0,2,4,6,7,8,9 and then started stretching out to once/week. On day zero (05-15-13) and day 7 (05-22-13), Stewie was sedated so the wound could be clipped and cleaned. A telfa pad coated with Calendula cream was placed over the wound, and clothing plus an Elizabethan collar were used as barriers to further injury.
The telfa pads were replaced daily. This wound healed extremely well and the fur grew back immediately, in contrast to areas that had been previously sutured. Laser treatment was added to previously healed wounds and we saw the fur return to those areas. Buprenorphine and antibiotics were given SQ.
Assessment Used
Subjective by Dr. Jerri Smith:
- The skin healed remarkably well. See photos above!
- The stomatitis is significantly reduced because of the extractions but still recurs. We are able to manage it with laser treatment every 7-14 days and occasional Buprenorphine. Stewie may still need to have the remaining incisors extracted, as some are loose. He no longer needs steroids however which has resolved the thin skin problem.
Status of original problem list as of 11-12-13:
- Severe stomatitis with inflammation of gingiva – now mild stomatitis
- Lingual and tonsillar lesions – resolvedHyperesthesia – very mild to non-existent
- Very thin skin which tears easily – completely resolved
- Pain – occasional mild oral pain because of stomatitis – treated with laser and Buprenorphine
- Anorexia – resolved
- Weight loss – resolved
- Lethargy, depression – resolved
- Chronic steroid use – resolved
Stewie’s Weight:
Date lbs kg Comments
05-23-10 12.5 5.7
06-14-11 15.5 7.0
04-09-12 13.8 6.3
11-14-12 14.1 6.7
03-15-13 11.4 5.2
04-06-13 11.1 5.0
04-08-13 11.0 5.0
04-23-13 11.0 5.0
04-26-13 10.9 5.0
04-30-13 10.7 4.9
05-04-13 10.9 5.0
05-10-13 10.8 4.9
05-17-13 11.6 5.3 With clothing
05-19-13 11.8 5.3 With clothing
05-24-13 11.6 5.3 With clothing
05-31-13 10.1 4.6 At dental, no clothing
06-06-13 11.1 5.2 With clothing
06-28-13 11.4 5.2 With clothing
07-02-13 11.6 5.3 With clothing
07-16-13 11.8 5.3 With clothing
09-05-13 12.1 5.5 With clothing
09-24-13 12.6 5.7 With clothing
Owner Assessment: Stewie now looks and acts like “Stewie” – a friendly, healthy cat with normal lifespan expectations. He wears clothing now because he likes it and he has his own Facebook page!
Results
Stewie’s response to laser treatment has been incredible. His skin has healed completely from all tears and all of his fur has regrown.
By improving the quality of his skin and decreasing his somatic pain, his owners felt his improved quality of life justified further extractions and biopsies of his oral lesions. Laser treatment following his oral procedures allowed the gingival, tonsillar and lingual lesions to heal.
By removing most of the remaining problem teeth and following up with laser treatment for post-extraction healing, Stewie’s appetite returned, he began to eat normally and put on weight. We were able to significantly reduce pain medication and completely eliminate antibiotics and steroids…
Because the stomatitis issues were resolved, the use of steroids was eliminated and Stewie’s immune system returned to normal. As a result of his healed skin, the hyperesthesia has almost completely resolved so the amitriptyline is only given once to twice weekly.
Discussion
Originally, our Companion Laser was used to address a large open wound that did not appear to be suturable. The rapid healing was so remarkable that we now use it on any type of dermatologic injury, as well as for otitis and inflamed masses. We routinely treat post-surgical incisions and extractions with the laser.
Stewie is one example of our use of the Companion Laser for treatment of stomatitis. We now routinely use the laser on oral lesions before and after extractions. One of our clients is a Feline Leukemia positive cat whose stomatitis was so severe 15 months ago, he wasn’t expected to survive more than a few weeks. We began treating him with Depo Medrol and the laser. His general health improved so much that he eventually had all but his canine teeth extracted. He gets mild inflammation of the canine gingival area and we treat it with the laser. He has gained weight and now acts like a perfectly normal healthy cat.
Laser treatment is very helpful for acute pain from orthopedic or trauma injuries. We routinely use the laser on IVDD cases, bite wounds and following surgery or dental extractions. One of our clients is a male Great Dane. During his neuter, a prophylactic gastropexy was performed. He was quite painful post-operatively. His owner, a pediatrician, felt that his pain level decreased significantly after laser treatment.
We also recommend the laser to treat chronic inflammation of osteoarthritis. Laser treatment helps reduce the amount of medication needed in many pain/trauma cases. One client was ready to euthanize her cat because he was almost paralyzed. Laser treatment on his hips, spine and knees improved his quality of life significantly and he continues to do very well. Another client has a geriatric Newfoundland with severe osteoarthritis. When Christine arrived for Marley’s third treatment, the owner was crying tears of joy. She had taken the dog for a walk earlier that day and was amazed to see Marley running around the park and playing with her other dog. Previously, Marley had growled in pain when the puppy approached her or when the owner petted her.
The efficacy of treatment with the Companion Laser was originally an unknown to us. Our interest in alternative treatment methods and pain management lead us to purchasing this laser. The results we’ve seen have been so incredible that we automatically recommend it as either a primary or adjunct treatment for any case that involves joint pain, dermatologic problems and stomatitis.
References
1) Companion Laser Training website: Training and Webinars
2) Multiple references in VIN (Veterinary Information Network) on the use of laser treatment for pain management and alternative treatment methods.
3) Veterinary Economics: August 2013, Volume 54, Number 8, dvm360.com. Pages 19-20. “What’s New and What’s Nibbling Away at your Net Profit?”
4) Veterinary Medicine: September 2013, Volume 108, Number 9, dvm360.com. Page 428. “Osteoarthritis in your Senior Cat”,
