1. A poorer recognition of the signs of arthritis in cats and therefore lower demand
2. The smaller market and financial benefit to drug companies (dogs visit the vet at least twice as much as cats)
3. The difficulty in giving medications to cats
4. The increased risk due to the prevalence of kidney disease

Now, in 2023 we are witnessing the appearance of a wholly new approach to treatment that might overcome many of these concerns.

These are exciting times, but we also need to be cautious and realistic. You’ll see in this article that it is by no means a silver bullet. However, with Solensia there is real hope for cats that we have a new and effective tool to improve their quality of life.

What is Solensia?

Solensia is a trade name for frunevetmab in Australia. It neutralises nerve growth factor (NGF), which has been shown to be involved in the perception of pain. As a monoclonal antibody, it has the potential to be highly specific to its target, and block it almost completely.

In Australia, Solensia has been registered for the alleviation of pain associated with osteoarthritis in cats.

How Well Does It Work & How Quickly?

In our clinic, we have seen some cats benefit greatly after starting Solensia, but what does the evidence say? The results of a single placebo-controlled study conducted by the parent company are shown here and referenced below.

There are three important things to note here:

1. All arthritis treatments show a caregiver placebo effect, but for this particular product, it is especially large
2. The difference between the two groups is statistically significant for Months 1 and 2, so we are confident that Solensia is helping at least some cats
3. Unquestionably, there will be many others who receive insufficient benefit and require different arthritis remedies

My view is that the large placebo effect is a direct result of the difficulty we have in correctly identifying signs of pain in cats. However, it is also possible that it only brings benefit to a minority. Our own experience is that Solensia can be very effective in some cats, but hard to judge as well.

A further clue that anti-NGF treatments are helpful is in the clearer results we see for the canine equivalent, Beransa.

Based on laboratory studies, a positive response would be expected to appear at around day 6.

Solensia Dosage & How Often

Solensia is given by vets at a dose of 7 mg by subcutaneous injection for cats between 2.5kg and 7kg.. Above this, two vials are needed but I would suspect that most of these cats would benefit more from weight loss. If desired, the dose is repeated every month. It is generally recommended to try at least two doses before deciding whether it is effective enough.

NGF is important for foetal and juvenile development. Therefore, Solensia must not be used in breeding, pregnant or lactating cats, or those less than 12 months of age.

Human Health Risks

Similarly, pregnant women, women trying to conceive, and breastfeeding women should take extreme care to avoid accidental self injection or needle stick injuries. To be safe, it is best that they take no part in giving the injection or even holding their pet.

Just to be clear, a treated cat poses no risk to humans.

Solensia Side Effects

Up to 10% of cats given the injection showed signs of hypersensitivity such as skin itching, hair loss, and dermatitis. When this occurs, it is advised to stop the treatment. The itch does not respond well to normal treatments for dermatitis until the injection is stopped

If you read the comments section below, you will see that it is dominated by reports of adverse skin effects. In our clinic we have indeed seen a few reactions, but not much more than the reported 10%. My view on this is that although the rate here appears much higher, owners with affected cats will be more likely to post than those with no problems.

In other ways, our prior experience with monoclonal antibodies like Cytopoint shows us that they are much safer than traditional drugs like anti-inflammatories. This is because as naturally occurring proteins, they require minimal metabolism or detoxification by the liver or kidneys.

It is therefore likely that Solensia can be used at normal doses in cats with kidney disease, unlike anti-inflammatories which become more dangerous. However, until there are studies of their use with liver or kidney disease, caution is still advisable in these cats.

Solensia appears safe when used in combination with other drugs, and at the time of vaccination. The only concern with using multiple treatments could be that if an adverse effect occurs, you may not be able to work out which one caused it.

How Much Does Solensia Cost?

The cost in 2023 for a single injection of Solensia is around $90. This is in the same region as the higher priced anti-inflammatory drugs.

Our experience so far is that for some cats, it maintains their quality of life when other choices fail. It can also be used when other treatments aren’t safe enough to use and for those cats that owners cannot easily medicate. In summary, we believe is worth a try if costs allow.

Anyone who has an arthritic cat knows that we still aren’t doing enough for them. The development of monoclonal antibodies brings us just one step closer, and just might give us more time to enjoy our lovely old cats.

Therefore, talk to your vet about whether it might be good for your cat.

Have something to add? Comments (if open) will appear within 24 hours.
By Andrew Spanner BVSc(Hons) MVetStud, a vet in Adelaide, Australia. Meet his team here.

These are exciting times, but we also need to be cautious. No treatment will work on every dog, and after initial overexcitement, some new products end up being major disappointments. However, with Beransa there is real hope for dogs that we have a new and effective tool to improve their quality of life.

What is Beransa?

Beransa is a trade name for bedinvetmab, also called Librela outside of Australia. It neutralises nerve growth factor (NGF), which has been shown to be involved in the perception of pain. As a monoclonal antibody, it has the potential to be highly specific to its target, and block it almost completely.

In Australia, Beransa has been registered for the alleviation of pain associated with osteoarthritis in dogs.

How Well Does It Work & How Quickly?

In our clinic, Beransa has quickly become the number one treatment chosen by our vets for new patients with arthritis. This has been based on a number of factors:

1. A very high success rate, interestingly higher than in the trial featured below
2. Minimal to no observed side effects, especially compared with traditional anti-inflammatory drugs
3. A similar cost to other treatments, especially in larger dogs

What does the evidence say? The results of a single placebo-controlled study conducted by the parent company are shown here and referenced below.

They show that around one in two dogs show benefit after a month. Like with all arthritis treatments, there is a large caregiver placebo effect, so it is important to stay as realistic as possible about its efficacy in each patient.

How To Use Beransa

Personally, I believe the study shown here and our clinical experience are enough to recommend trying Beransa in the right dog. However, I also strongly believe that we should not forget the other tried and trusted remedies for arthritis in dogs.

This is especially because Beransa only targets pain, not the underlying disease process. Now make no mistake: treating the pain is the most important thing, but it isn’t everything. If we add the treatments known to slow down the arthritic process, our dogs should have better function in the years to come as well as right now.

In particular, I encourage all dog owners using Beransa to at least continue the Hills j/d diet and regular pentosan injections. Both are extremely safe and can slow the degenerative process.

Beransa Dosage & Frequency

Beransa is given at a dose of 0.5 – 1 mg/kg by subcutaneous injection. It comes in a variety of vial sizes to cater for dogs of different weights. If desired, the dose is repeated every month. It is generally recommended to try at least two doses before deciding whether it is effective enough.

NGF is important for foetal and juvenile development. Therefore, Beransa must not be used in breeding, pregnant or lactating dogs, or those less than 12 months of age.

Human Health Risks

Similarly, pregnant women, women trying to conceive, and breastfeeding women should take extreme care to avoid accidental self injection or needle stick injuries. To be safe, it is best that they take no part in giving the injection or even holding their pet.

Just to be clear, a treated dog poses no risk to humans.

Beransa Side Effects

Reactions such as swelling and heat may occur at the site of injection, but these seem rare. Hypersensitivity reactions are also possible but appear more common in the cat form of this drug, Solensia.

Our experience with monoclonal antibodies like Cytopoint shows us that they are much safer than traditional drugs like anti-inflammatories. This is because as naturally occurring proteins, they require minimal metabolism or detoxification by the liver or kidneys. However, until there are studies of their use with liver or kidney disease, caution is still advisable in these dogs.

Beransa appears safe when used in combination with other drugs, and at the time of vaccination. The only concern with using multiple treatments could be that if an adverse effect occurs, you may not be able to identify the cause.

How Much Does Beransa Cost?

The cost in 2023 for a single injection of Beransa is between $100 and $130 depending on the size required. This is in the same region as the higher price anti-inflammatory drugs.

Beransa or Librela may not be a silver bullet, but just having another option is a great blessing. Our experience so far is that for some dogs, it maintains their quality of life when other choices fail. It can also be used when other treatments aren’t safe enough to use.

Anyone who has an arthritic dog knows that we still aren’t doing enough for them. The development of monoclonal antibodies brings us just one step closer, and just might give us more time to enjoy our lovely old dogs.

Therefore, talk to your vet about whether it might be good for your dog.

References

Corral, M. J., Moyaert, H., Fernandes, T., Escalada, M., Tena, J. K. S., Walters, R. R., & Stegemann, M. R. (2021). A prospective, randomized, blinded, placebo-controlled multisite clinical study of bedinvetmab, a canine monoclonal antibody targeting nerve growth factor, in dogs with osteoarthritis. Veterinary anaesthesia and analgesia, 48(6), 943-955 Full Text

Kronenberger, K. (2023). In dogs diagnosed with osteoarthritis, how safe and effective is long-term treatment with bedinvetmab in providing analgesia?. Veterinary Evidence, 8(1) Full Text

Have something to add? Comments (if open) will appear within 24 hours.
By Andrew Spanner BVSc(Hons) MVetStud, a vet in Adelaide, Australia. Meet his team here.

New treatments have made the control of stomatitis within the reach of more cats, and we may be on the cusp of even greater things.

What Is Stomatitis?

Stomatitis, or more correctly gingivostomatitis, is inflammation of the mouth not directly associated with the teeth. The definition is important: many cats who are said to have stomatitis really have gingivitis and periodontitis. While still severe, these cats will respond to standard dental treatments and subsequent good oral hygiene.

Stomatitis on the other hand, is a poorly understood disease which likely represents malfunction of the immune system. It is said to affect anywhere between 0.7 and 12% of cats depending on how you define it.

The most common locations for stomatitis are at the back of the mouth at the opening to the throat (often called the fauces) and on the inside of the cheeks. Sometimes the tongue or oesophagus are also affected.

The Causes Of Stomatitis

Here is what we know about feline gingivostomatitis:

• Cats with stomatitis almost always also have regular tooth and gum disease, but not vice versa
• The risk of it developing goes up by 70% with each additional cat in the house (but removing them afterwards will not help)
• Affected cats are more likely to carry the calicivirus cat flu virus, and if they cure they will clear the virus
• The gums of affected cats contain more cytotoxic (killer) T cells than normal cats
• The risk increases with age

The best theory is that long-term immune stimulation in the mouth leads to the development of an abnormal, runaway immune response. This is certainly what I see: cats who develop stomatitis often have had more regular gum disease for years before it starts.

The Signs Of Stomatitis

Most of the signs of gingivostomatitis are due to severe pain. These include:

• Drooling, excess salivation and a dirty face
• Hissing or backing away during eating
• Extreme pain on opening the mouth
• Reluctance to eat hard food (though it is amazing how some cats will manage to keep eating)

Cats will also have a foul smell from the mouth, but this is true for all oral diseases. Diagnosis is usually straightforward but if the lesions are not symmetrical, a biopsy is a good idea to rule out cancers.

Treatment Of Stomatitis In Cats

Due to the slowly developing nature of the disease, most cats have tried some or all of the following by the time stomatitis develops:

• Regular dental cleaning
• Antibiotics
• Corticosteroids, especially prednisolone

These will all help to some extent, often quite well at the beginning but the effect reduces with time. Most cats end up needing a lot more treatment. The most important of these is pain control.

No matter what else we do, we need these cats to be comfortable, both for welfare reasons and so they look after themselves better. Drugs used are a combination of meloxicam, buprenorphine and gabapentin. In particular, buprenorphine (which is normally an injectable) works very well just by dripping it in the mouth.

However, even this is usually not enough.

Tooth Removal For Stomatitis

The best hope for a cat is that removal of their teeth will help. This is such a major hurdle to cat owners that I can spend six months trying to convince some to do it. But just look at these figures:

• 28.4% of cats are cured
• 39% are substantially improved
• 26.3% have minor improvement
• 6.3% do not respond at all

To the question of “how will they eat?” I answer that the pain is what is stopping them, not whether they have teeth or not. Commercial foods mean that cats don’t really need teeth anyway. All they need is to be happy.

Only the teeth at the back (premolars and molars) need removing in most cases. Leaving the canines and incisors means cats look and act much the same, and the procedure is shorter. However, at Walkerville we still often do only one side of the mouth at a time.

Close to 70% of cats who have their teeth removed will still need some form of medical treatment at least in the short term.

Newer Stomatitis Treatments

The real problem comes for the few cats who don’t respond to tooth extraction. If this happens to you, please don’t regret having the teeth removed; the next treatments are very unlikely to work on their own.

Cyclosporine is an immunosuppressant that helps in around a half of these cases, especially if blood levels are measured. Those that cure can usually be weaned off the drug, whereas others may need to stay on it for life. You can learn more about cyclosporine here.

Interferon Omega injections have a lower response rate (similar to prednisolone) but give a small chance of complete cure.

Mesenchymal Stem Cells given intravenously are the newest hope, and are showing good results in early trials. A seemingly effective product is close to release in the USA.

If no other treatments work, you should never feel guilty about choosing euthanasia. It’s a terrible choice, but also sometimes the only humane and kind thing for the worst of cases. But I hope I’ve helped you see that there’s a lot more than just cortisone and antibiotics, and a real chance of cure for many cats.

Have something to add? Comments (if open) will appear within 24 hours.
By Andrew Spanner BVSc(Hons) MVetStud, a vet in Adelaide, Australia. Meet his team here. The information provided here is not intended to be used as a substitute for going to the vet. If your pet is unwell, please seek veterinary attention.

References

Jennings, M. W., Lewis, J. R., Soltero-Rivera, M. M., Brown, D. C., & Reiter, A. M. (2015). Effect of tooth extraction on stomatitis in cats: 95 cases (2000–2013). Journal of the American Veterinary Medical Association, 246(6), 654-660

Lommer, M. J. (2013). Efficacy of cyclosporine for chronic, refractory stomatitis in cats: a randomized, placebo-controlled, double-blinded clinical study. Journal of veterinary dentistry, 30(1), 8-17

1. Will CBD oil help my dog?
2. How do I buy genuine CBD oil in Australia?

Here I provide answers, assessing CBD oil by the same standards we use for any other medicine. Let’s start with a short explanation.

What Is CBD Oil?

In theory, CBD oil is an extract from the cannabis or hemp plant containing high levels of cannabidiol and very low levels of tetrahydrocannabinol or THC. It may also contain other active ingredients derived from the plant.

The lack of the psychoactive THC means that dogs receiving CBD oil should never appear sedated or ‘stoned’. I have seen enough marijuana poisoning to know how unpleasant it is. Products containing significant levels of THC should not be given to dogs.

Cannabidiol (“cannaba-DYE-ol”) is believed to act on receptors found in the central nervous system and joints, possibly with other active ingredients found in CBD oil. The effect is complex and poorly understood but may involve competitive inhibition rather than activation.

Evidence For Cannabidiol in Dogs

Clinical studies for the use of medicinal cannabis in dogs are only found in epilepsy and osteoarthritis. Other possible uses, such as for anxiety or calming, are not recommended until more is known.

Evidence for the ability of CBD oil to prevent seizures in dogs is poor. There are many ancedotal reports of success, but very little good quality science. Given that conventional treatments for epilepsy work well in the majority of dogs, there is not a strong demand and I will not discuss this use further. Those wishing to try it should talk to their vet.

Evidence for the use of CBD oil to treat the signs of arthritis is stronger. In fact, cannabidiol is actually better supported than some commonly used treatments like glucosamine, green-lipped mussel (GLM), hydrotherapy and cold laser.

Three recent randomised placebo-controlled trials all found that outward signs of arthritis improved when dogs received twice daily oral doses of cannabidiol. Although these studies used only small numbers of dogs, the effects were statistically significant.

Vets reading this can find treatment protocols detailed in the papers linked below.

When To Use Cannabidiol For Arthritis

The conventional treatments for canine arthritis (listed on this page) work well in the majority of cases. However, as dogs age, arthritis inevitably worsens. Eventually there comes a time when these treatments don’t always provide enough relief.

Cannabidiol is probably not strong enough to work on its own, and likely to give only partial relief. Therefore, it is a sensible choice to add to existing therapy, not replace it. But pet owners also need to be careful.

The desperation of vets and pet owners for anything to try has created a demand often filled by less-than-ethical sellers. Much of the current batch of products claiming to be CBD oil in Australia are likely to be ineffective. Not only does this deprive dogs of the help they need, it tarnishes the name of what may actually work if it had a chance.

Note that there is no evidence to support the use of CBD products in cats, and it is not recommended.

Is CBD Oil Legal For Pets?

Vets in Australia can prescribe cannabidiol as a Schedule 4 drug for patients under their care with the following conditions:

1. Cannabidiol comprises 98 per cent or more of the total cannabinoid in the preparation
2. Any cannabinoids, other than cannabidiol, must be only those naturally found in cannabis
3. Owner consent is obtained to trial an unlicensed and potentially harmful treatment
4. There is adequate monitoring of the patient’s response and any side effects

However, the second issue for vets is finding a supplier. There are no locally registered products, and special approval is needed for importation. The easiest solution is to find a compounding pharmacist who offers it, as compounding on an individual basis is exempt from licensing.

I found a supplier by talking to state regulatory authorities and then selected pharmacies. You could do this too for your state.

What Is The Best CBD Oil?

Due to current Australian regulations, only CBD oil sold under prescription is likely to be of sufficient quality. Products available for sale online can only be one of two things:

1. Illegal
2. Containing very little active ingredient

The latter is probably the correct statement. These products are often in the form of treats or oils, and use words like hemp, cannabinoid, cannabis or CBD to describe their contents. They conspicuously avoid saying how much cannabidiol they contain.

Anecdotal reports of success are likely to represent instances of the caregiver placebo effect, which we all suffer.

The Drawbacks Of CBD Oil

There are several reasons why CBD oil containing cannabidiol may not be the best treatment for your dog.

1. Availability: you might not be able to find a vet or pharmacy in your area able to supply it
2. Side effects: although it appears well-tolerated, cannabidiol can cause adverse effects including diarrhoea, drug interactions and possible liver damage
3. Cost: CBD oil containing cannabidiol is surprisingly expensive

My experience of using CBD oil is that it will cost the owner of a 25kg dog around $10 a day, or around $4 for every 10kg bodyweight. This is far higher than the costs for other conventional arthritis treatments. If it works, you can try reducing the dose, but we can only hope that the price will come down in the future.

Regulation may be partly to blame for this, but it isn’t wholly a bad thing. The situation in the USA, where CBD oils are easily available, is one of very unreliable drug levels and even some dog products with undeclared THC.

Medicinal Cannabis Protocol

At Walkerville Vet, we are happy to prescribe cannabidiol, but only under the following conditions:

1. The dog is already receiving a non-steroidal anti-inflammatory drug
2. A pre-treatment checkup and baseline blood test is performed
3. A further blood test is done one month later, and check ups are then every three months

We apologise for this conservative approach. It’s quite likely that other vets will be happier to prescribe more liberally.

If you think your dog could benefit from CBD oil, talk to your veterinarian, but also forgive them if they seem sceptical or dismissive. There have been so many pet owners taken for a ride that they may reject the idea. But personally, I think the time is right to take cannabidiol more seriously.

Like we once did for other outlandish treatments that later became our standards. But just a word of warning though: I don’t have a sense of humour for jokes about weed or stoner dogs. That’s what’s holding us back.

Have something to add? Comments (if open) will appear within 24 hours.
By Andrew Spanner BVSc(Hons) MVetStud, a vet in Adelaide, Australia. Meet his team here.

Further Reading

Brioschi, F. A., Di Cesare, F., Gioeni, D., Rabbogliatti, V., Ferrari, F., D’Urso, E. S., … & Ravasio, G. (2020). Oral Transmucosal Cannabidiol Oil Formulation as Part of a Multimodal Analgesic Regimen: Effects on Pain Relief and Quality of Life Improvement in Dogs Affected by Spontaneous Osteoarthritis. Animals, 10(9), 1505. Full Article.

Gamble, L. J., Boesch, J. M., Frye, C. W., Schwark, W. S., Mann, S., Wolfe, L., … & Wakshlag, J. J. (2018). Pharmacokinetics, safety, and clinical efficacy of cannabidiol treatment in osteoarthritic dogs. Frontiers in veterinary science, 5, 165. Full Article.

Verrico, C. D., Wesson, S., Konduri, V., Hofferek, C. J., Vazquez-Perez, J., Blair, E., … & Halpert, M. M. (2020). A randomized, double-blind, placebo-controlled study of daily cannabidiol for the treatment of canine osteoarthritis pain. Pain, 161(9), 2191-2202. Full Article.

She came to me late one night for vestibular disease. And she certainly had all the classic signs:

• a head tilted to one side
• loss of balance and inability to walk
• rapid eye flicking called nystagmus
• even nausea and vomiting

It had been happening for two years, on and off, and she needed more of her medication. Except she really needed a whole lot more than that.

The truth when I explained it was too much for the owner to take. She decided I must be wrong, and I never saw her again. As far as I know, Holly never received the treatment she needed.

To understand why, you need to know why vestibular disease happens.

The Causes Of Vestibular Disease

The vestibular system is the organ that manages things like balance, head position and posture. It has two parts: one in the middle and inner ear (peripheral), and another in the brain (central). Anything that damages these areas causes the signs of head tilt and loss of balance.

Here are some of the more commonly reported causes:

• Middle or inner ear infection
• Idiopathic Vestibular Syndrome
• Drugs or other toxicities
• Head trauma
• Hypothyroidism
• Meningoencephalitis (MUO)
• Tumours
• Cerebrovascular Disease (“stroke”)

So how common are these in everyday dogs? it’s very hard to tell, because most of the data we have comes from veterinary specialists who tend to see more of the rare things.

We looked at the 132 cases of head tilt from our own clinic over the last 15 years. Here’s what we found…

The Causes Of Head Tilt In Dogs

Notice that when you only look at the symptom of head tilt there are another three common causes: neck pain, focal seizure and otitis externa. Neck pain can cause a wry neck, or torticollis, just like people. Focal seizure is a poorly understood but mostly harmless episode. Otitis externa is an ear infection that doesn’t go through the ear drum. Read more about each at the links.

‘Other’ causes included no more than two of: stroke, shaker syndrome, hypothyroidism, MUO, toxicity, head trauma, labyrinthitis, low blood glucose and more that could not be classified. It’s important to note that some of these would also have been strokes and tumours if advanced imaging like MRI were available.

Now, finally we can get back to talking about the most common mistake, and Holly’s story.

Otitis Media vs Vestibular Syndrome

The dog at the start was thought to have idiopathic vestibular syndrome but really she had otitis media. It’s an easy mistake to make, but the results are devastating. One is a painless condition that resolves by itself, the other causes unremitting pain, and only gets worse.

Idiopathic vestibular syndrome generally affects dogs over 10 years of age, comes on suddenly, and usually starts improving within 3 to 4 days. By four weeks most dogs are back to normal except for a slight head tilt in some. It then does not occur again on the same side.

No treatments have been shown to help, although we often give sedatives or anxiety medications to control any distress. The cause is unknown.

Otitis media and otitis interna are ear infections on the other side of the eardrum. Most of the time they started on the outside and spread through a ruptured eardrum.

Middle ear infections cause their signs by direct damage to the vestibular apparatus. They also often damage the facial and sympathetic nerves which travel close by. Therefore, middle ear disease as well as causing balance disorders, often causes a dropped lip from facial paralysis and a half-closed eye with a dilated pupil from Horners syndrome.

Commonly affected breeds are:

• French bulldogs
• Cavalier King Charles spaniels
• Cocker spaniels
• West Highland white terriers

Which are all breeds known for getting ear infections.

Help! My Dog Has A Head Tilt

If your dog has a head tilt, it’s important to know how to tell the benign from the serious causes. Therefore, the first thing to do is get a check up with your vet.

A head tilt without vestibular signs is most often going to be caused by an external ear infection. It definitely needs treatment, but as long as this is done it’s a lot less serious.

A head tilt with vestibular signs will have the following breakdown according to our data*:

• 39% Idiopathic Vestibular Syndrome
• 24% Otitis media/ interna
• 10% Tumour
• 27% Other

Here are some clues that your dog does not have idiopathic vestibular syndrome:

• Smell or discharge from the ear
• Repeated episodes
• Any signs of nerve damage
• Gradual (not sudden) onset

Treatment Of Otitis Media

All this matters, because success rates with treatment of middle ear infections depend on how quickly you act.

I saw a case of otitis media just the other day (that’s why the numbers in the graphic and the table are different). I’m not at all worried about that dog. The symptoms had only been present for two days and the infection won’t have established itself yet.

He went on a combination of local treatments known to be safe when the eardrum is ruptured, plus systemic antibiotics. I’ll be amazed if he isn’t right as rain in a week or two.

The other side of the coin are dogs like Holly or Denver here. Dogs with long-standing middle or inner ear infections are usually incurable with medicines alone.

So if you’re interested, click here to read about the surgery that Holly needed, and Denver got. It made a world of difference to his quality of life.

* total number excludes otitis externa, neck pain, focal seizures and 10 cases classified in ‘other’ that had a head tilt only

Have something to add? Comments (if open) will appear within 24 hours.
By Andrew Spanner BVSc(Hons) MVetStud, a vet in Adelaide, Australia. Meet his team here. The information provided here is not intended to be used as a substitute for going to the vet. If your pet is unwell, please seek veterinary attention.

Sometimes when a tooth needs removal, there is plenty of time to explain why. However, most of the time, you get a hurried phone call while your dog or cat is asleep. There really is nothing you can do but trust your vet.

We’ll look at each of the reasons why a tooth might cause enough pain to require extraction.

Trauma

Tooth fracture is most commonly caused by chewing on hard objects such as antlers, fences, stones or even raw bones. While shallow fractures can be tolerated, those that involve the the tooth’s central pulp cavity require urgent care.

You can see a picture of an exposed pulp cavity at the start of our page on What to expect after tooth extraction. There’s also a discussion of costs of removal.

Such a tooth is destined to die, and then form a tooth root abscess. They can be below the eye like the one pictured here, or hidden in the jaw like the xray at the start (green arrows). These teeth always cause severe and ongoing pain, even if your dog appears normal.

General Rule: tooth fracture involving the pulp cavity requires immediate pain relief and either referral for root canal endodontics, or removal. Removal is a practical and low-cost option chosen by most owners..

Tooth Resorption

Tooth resorption is the most common cause of tooth loss in cats, but it’s increasingly being seen in dogs too. Despite being everywhere, we still know very little about why it happens. It occurs when the tooth is invaded by special bone-destroying cells called odontoclasts.

Resorption below the gumline is probably painless. However, when it spreads or starts higher up, it causes painful cavities called odontoclastic resorptive lesions. You can sometimes identify these by red areas where gum is growing into a hole on the tooth.

The xray at the start shows the appearance of Type 2 resorption (red arrow), as seen by a loss of both the internal structure of the root and the periodontal ligament (the dark line on the adjacent good roots indicated by the yellow arrow).

General Rule: part or all of a resorbed tooth must always be removed.

• Type 1 resorption requires complete removal of the tooth including its roots as they remain intact and will not resorb by themselves.
• Type 2 resorption only requires removal of the part above the gum line. Attempting to remove roots in such cases is extremely difficult, as well as unnecessary.

Mobility

Buildup of plaque on the teeth causes infection and damage to the periodontal ligament that holds the tooth in its socket. We call this process periodontal disease (PD).

As attachment is lost, the tooth becomes mobile, or even wobbly. Eventually it causes too much pain to be used.

General Guideline: a tooth should be removed when movement in any direction (other than axial) is greater than 0.5 mm.

Furcation Exposure

PD in multi-rooted teeth, which is most of them, will eventually expose the junction between the roots. We call this the furcation. Once it’s exposed, food and plaque accumulate underneath the tooth and cause painful infection.

General Guideline: a tooth should be removed when a probe can be passed in one side of the furcation and out the other. In other words, when there’s a hole under the tooth.

Gingival Pocketing

The loss of attachment caused by PD also causes pockets to form between tooth and gum (‘3’ on the diagram). Once the pocket gets deep enough, food and plaque accumulate and the pocket gets harder and harder to manage.

General Rule: pockets deeper than 6 mm in dogs, or 4 mm in cats require advanced care. Most teeth like this are removed, and that’s a valid approach given the poor outlook. The ideal is periodontal flap surgery, but this is rarely available outside specialists. A bare minimum is cleaning under anaesthetic at least every 6 months.

Management of the pockets is one of the most important parts of a routine scale and polish. I hope you can see that it’s completely impossible to do with anaesthetic-free dentistry.

There are only two other common situations where tooth removal is indicated. The first is in cats with severe gingivitis and stomatitis, where even healthy teeth are sometimes removed to reduce the disease burden. The second is preventative extraction of puppy teeth that haven’t fallen out by themselves. You’ll find a whole article about this (and pictures!) at the link.

In closing, I can promise you something with my whole heart: your vet would always rather a clean mouth than a dirty one, and a dental procedure without extractions. The advice I give you on cleaning teeth in dogs and ways to keep cats’ teeth clean is designed to prevent you ever being in this position.

The reality is though, that in a long life nearly all pets need at least one tooth taken out. I hope this helps you for when the time comes.

Have something to add? Comments (if open) will appear within 24 hours.
By Andrew Spanner BVSc(Hons) MVetStud, a vet in Adelaide, Australia. Meet his team here.

It’s stressful knowing a dog or cat might lose teeth. The main worry is “how will they eat?” When it happens it is never as bad as feared.

The reason is that nearly all teeth removed by a vet are already causing pain. Therefore, dogs and cats who have had teeth taken out should eat better shortly afterwards. Owners of pets with severe problems also notice their pets are generally brighter and more active.

Even dogs who end up without teeth will eat dog food better than they did before as long as the food is kept small enough.

Pain Relief

The greatest advances in pet dentistry have been in the provision of adequate pain control. Nowadays, nerve blocks are standard and animals should experience little or no pain. These are routinely combined with anti-inflammatory medications both at the time and afterwards at home.

Whether one or 20 teeth require removal, complications are rare and you can expect a fast recovery. A course of antibiotics may also be given depending on the need.

Eating After Dentistry

Most animals will eat a small dinner on the evening of surgery, and continue eating afterwards without problems.

You will get specific feeding instructions from your clinic depending on which teeth were removed. Sometimes it’s better to eat soft food , especially when stitches are present. Other times small kibble is preferred to prevent food getting impacted in the healing areas.

How Long Does It Take For A Tooth Extraction To Heal?

Uncomplicated tooth extraction sites will heal in approximately one to two weeks. Common reasons for delayed healing are remnant tooth fragments or food becoming stuck in deep sockets.

Stitches, if placed, should also dissolve in one to two weeks without issue. There may be a small amount of bleeding, but if your dog or cat is happy and eating, it’s no concern.

Options In Tooth Extractions

Like whenever we discuss the cost of veterinary care, there will be choices. That’s why you can divide tooth extractions into three basic situations:

1. Where extraction is the only option
2. Where extraction is the low cost choice compared with ongoing maintenance
3. Where extraction is appropriate but specialist care could save the tooth

Vets skilled enough to perform advanced dentistry are still rare enough that there might not be one close to where you live. Costs for referral to a dental specialist quickly run into the thousands.

As valuable as the service is, no-one should feel that they have to go to a specialist. Especially when there are still far too many animals that get no treatment at all.

The Cost Of Tooth Extractions

Costs in general practice depend on the time and difficulty involved. I’ve previously published the costs of routine teeth cleaning here, and I would add the following amounts as a rough guide:

• For a single small tooth, add $200
• For a large tooth requiring sutures, add $500
• For many teeth, add $600 to $1000

These prices include pain relief and antibiotics if needed, but are only estimates.

Often the only clue to teeth needing removal is bad breath. Please contact your vet if you suspect your dog or cat has dental problems. All it takes is a checkup to know for sure.

Related: How Vets Decide When Teeth Need Extraction

Have something to add? Comments (if open) will appear within 24 hours.
By Andrew Spanner BVSc(Hons) MVetStud, a vet in Adelaide, Australia. Meet his team here.

These cats are in severe distress from having cold, hard, painful hind legs and pulmonary oedema. They also often have pre-existing heart disease.

The first cat I saw, I treated as I’d been taught and he made a rapid and full recovery. As far as I know he went on to live a good life.

The problem is that this experience was an outlier, only I didn’t know it. It meant that for many years afterwards I’d see other cats with ATE give their owners a positive outlook and attempt to treat them.

I say ‘attempt’, because they always did badly, even though I used the same treatment. There’s almost nothing worse for a vet than trying to treat a suffering patient only to realise three days later you should never have put them through it. We want to avoid that at all costs.

My mistake was prioritising my personal experience over the science. Here’s what it says:

Treatment of Aortic Thromboembolism In Cats

Four large studies look at success rates for the treatment of cats with ATE

• 33% survival with a medial survival time of 51 days (46 cats)
• 37% survival with a medial survival time of 11 months (100 cats)
• 39% survival with a median survival time of 6 months (44 cats)
• 31% survival with a medial survival time of 4 months (127 cats)

In looking at these results, we have to keep in mind two things. Firstly, these cats were treated in 24 hour intensive care referral centres, not private clinics. Secondly, how important it is to look at long-term survival data, not just how many get out of hospital.

Now you know that these terrible rates of success exist despite the best of care, you will hopefully see why I now only offer two options to cat owners facing ATE:

1. Emergency referral to a specialist centre, with a clear warning of the poor prognosis
2. Humane euthanasia

In my opinion, given the suffering, anything else is inhumane. This is just my view, and if your vet feels differently, I cannot argue. It’s a judgement call.

Though I suspect I am not alone, judging by a recent paper. Of 250 cats with ATE seen in general practice, the decision between vets and owners was euthanasia for 153 of these. When you look at the rest you can see why: only 30 of the remaining cats were still alive one week later, and their median survival time was only 3 months.

But if you’re reading this because your cat’s unwell, don’t give up yet. ATE is not the only cause of a cat’s back legs suddenly not working, or dragging the back legs. Get to your vet ASAP and get a proper diagnosis before making any decision.

So what about the positive information you read on online forums?

The Outlier Effect

When you search online about your dog’s or cat’s illness, you’ll quickly find forums, full of well-meaning advice. Some of it is undoubtedly useful; after all, these are real experiences from pet owners sharing what you’re going through.

However, some is extremely misleading. The outlier doesn’t know they’re an outlier, and even I was guilty of that despite knowing better. Outliers are also more likely to be the ones wanting to share their experiences, whether good or bad.

I use forums too. I find them especially useful when I want to know if something has ever happened, or if anyone has reported the thing I’m seeing. What I’ll never do without checking is use any advice I see, whether on treatment or prognosis. For this we need science.

Blimey, I won’t even use case reports, which are published accounts of a single case. I need to see good outcome data, enough to make an informed decision. I certainly don’t need unrealistic expectations at this most critical time.

In the case of diseases like aortic thromboembolism, using anything except good science is likely to lead to false hope and bad decisions like mine. I’ve learnt my lesson, but if it was so hard for me I can understand why it’s even harder for cat owners.

Have something to add? Comments (if open) will appear within 24 hours.
By Andrew Spanner BVSc(Hons) MVetStud, a vet in Adelaide, Australia. Meet his team here.

Further Reading

Borgeat, K., Wright, J., Garrod, O., Payne, J. R., & Fuentes, V. L. (2014). Arterial thromboembolism in 250 cats in general practice: 2004–2012. Journal of veterinary internal medicine, 28(1), 102-108

Moore, K. E., Morris, N., Dhupa, N., Murtaugh, R. J., & Rush, J. E. (2000). Retrospective study of streptokinase administration in 46 cats with arterial thromboembolism. Journal of Veterinary Emergency and Critical Care, 10(4), 245-257

Laste, N. J., Harpster, N. K., Harkins, J. D., Stanley, S., Mundy, G. D., Sams, R. A., … & McAllister, P. M. (1995). 2392581. A retrospective study of 100 cases of feline distal aortic thromboembolism: 1977-1993. Journal of the American Animal Hospital Association, 31(6), 492-500

Schoeman, J. P. (1999). Feline distal aortic thromboembolism: a review of 44 cases (1990–1998). Journal of Feline Medicine & Surgery, 1(4), 221-231

Smith, S. A., Tobias, A. H., Jacob, K. A., Fine, D. M., & Grumbles, P. L. (2003). Arterial thromboembolism in cats: acute crisis in 127 cases (1992–2001) and long‐term management with low‐dose aspirin in 24 cases. Journal of veterinary internal medicine, 17(1), 73-83

When Is A Swollen Belly An Emergency?

Dogs with any of these symptoms need to be taken to a vet immediately:

• Vomiting
• Hard, painful abdomen
• Collapse
• Severe lethargy
• Not eating

Now dive deeper…

The picture above shows what a dog’s normal body shape should be.

Could it just be fat? The answer is usually ‘no’. Overweight dogs are so common that they look normal to most people. Therefore, trust your instincts: if the stomach looks odd, it’s almost certainly not just fat.

For example, the pictured dog isn’t fat anywhere else, and the belly hangs down more than it should. Even though he seems well, he’s in a lot of trouble.

Causes Of An Enlarged Abdomen

There are many reasons why the stomach gets bigger than normal. I’ll classify them by the cause of enlargement and start with the most serious. There are two special cases in puppies near the end.

Gas: Bloat

Bloat or GDV occurs when the stomach suddenly twists and blocks the escape of gases. Gastric expansion follows, and without treatment dogs die a rapid and horrific death.

Affected dogs are usually large breeds with obvious distress and a hard, painful abdomen. If your dog is comfortable and eating or drinking, they don’t have bloat. You can read more about the causes and prevention of bloat here.

Sometimes a dog’s stomach swells up with gas for less serious reasons, like overeating. I saw one this week which happened with no obvious cause. These dogs need xrays to tell them apart from life-threatening cases of bloat, and to monitor the stomach size.

Pain: Peritonitis

Abdominal pain makes dogs hold their belly stiff and tight like a drum. We call this splinting. You should always treat this sign as an emergency.

The most common cause is pancreatitis, which you can read about at the link. However, this is indistinguishable without testing from other causes of inflammation or infection, such as:

• Intestinal obstruction from swallowing the wrong thing
• Ruptured or twisted bowel
• Gall bladder diseases
• Gunshot or stake injuries

Blood: Haemorrhage

Internal bleeding can cause the belly to look bigger, however it’s rarely the most obvious sign. These dogs are also usually weak, pale, lethargic or even collapsed.

There are two common causes of abdominal bleeding:

1. Eating rat poison stops the blood from clotting, and although there’s an antidote, most dog owners haven’t realised their dogs ate it until symptoms begin
2. Haemangiosarcoma is a tumour of the spleen whose first sign is often unexplained blood loss

It’s also very possible to have abdominal haemorrhage after any major surgery or injury. Obviously, whatever the reason, bleeding is always a critical emergency.

Urinary Tract Damage

Damage anywhere in the urinary tract can cause urine to leak into the abdomen. The most common reasons for this are bladder stones blocking the urethra, and car accidents.

Like with bleeding, the amount of fluid is mostly small, and other more obvious signs of illness are present, like lethargy, straining or pain.

Food: Overeating

A classic and sometimes serious cause of bloated stomachs is when a dog biscuit bag is left out while you’re not at home. Most dogs will binge on the kibble until they can’t eat any more, then the kibble starts to swell as it takes on water. These dogs often need the vet to induce vomiting to relieve the distress.

In puppies, abdominal distension after eating is quite normal. As long as they are bright and playful, and it goes down in a few hours, there’s nothing to worry about. However, the next cause also needs consideration…

Parasites: Worms

Intestinal worms are a very common and serious reason for a swollen stomach in a young puppy. Roundworms (pictured) often get large and numerous enough to swell the belly and block the passage of food.

Read all about preventing and treating intestinal worms here.

Fluid: Ascites

Many diseases cause the buildup of a clear fluid that we call a transudate. Most of these slowly worsen without any other major signs of illness. Examples might be:

1. Heart disease
2. Caval syndrome from heartworm
3. Portal vein obstruction from tumours
4. End stage liver disease
5. Certain widespread cancers
6. Protein-losing enteropathy
7. Protein-losing nephropathy

The first four happen because the blood pressure in abdominal vessels gets high enough that fluid leakage occurs. Number 5 is simply because fluid often escapes from tumours with a high surface area.

Numbers 6 and 7 are probably the most common. They happen when blood proteins are being lost through the gut or via kidney disease. This leads to a drop in plasma oncotic pressure, which causes fluid to leak from small vessels. The fluid will also often be present in the chest cavity.

Testing is essential to identify and treat the cause. Often all of the following are needed:

• History & physical exam
• Ballottment of the abdomen (percussing one side of the belly and feeling for a fluid wave on the other)
• Blood and urine tests
• Ultrasound exam
• Intestinal biopsy

The most common cause is inflammatory bowel disease as a consequence of protein-losing enteropathy. You can read about that here. As you can imagine, without treating the cause, drainage of the fluid is usually useless.

Fat: Hormonal Diseases

Even though fat deposition is unlikely, there are two diseases in which it is laid down in a way that can look like a swollen stomach. These are:

• Cushings disease, associated with an enlarged liver, pot belly, hair loss and excessive drinking
• Thyroid disease, associated with lethargy and unexplained weight gain 

You can read about tests and treatment for both diseases at the links.

Masses & Enlarged Organs

Sometimes a tumour in the abdomen can get so large that it causes the belly to noticeably bulge. These are usually slow-growing benign masses, otherwise they would have caused other signs earlier. Swelling can also occur when organs themselves become enlarged. Perhaps the most important are the liver and spleen. 

Diagnosis requires blood testing and an ultrasound exam. Even large masses can often be removed if there is no evidence of spread.

Uterus: Pregnancy & Pyometra

Lastly and very rarely I have seen owners of a female dog not be aware of a mating 5 to 6 weeks earlier. In older un-desexed females, a uterine infection called pyometra or reproductive tract cancer can also swell the abdomen in a similar way. 

These unplanned events should be a lot less common now that desexing has become compulsory in Adelaide.

I’ll end on a positive note. Despite some of the horrendous diseases mentioned here, most causes of abdominal enlargement that I see are the ones that can be treated, often with just a tablet. Therefore, don’t be frightened of getting the vet to take a look. It’s usually all for the better.

Have something to add? Comments (if open) will appear within 24 hours.
By Andrew Spanner BVSc(Hons) MVetStud, a vet in Adelaide, Australia. Meet his team here. The information provided here is not intended to be used as a substitute for going to the vet. If your pet is unwell, please seek veterinary attention.

• Arthritis, hip dysplasia
• Degenerative myelopathy
• Cruciate rupture or torn ACL
• IVDD & other spinal diseases
• Soft tissue injuries, like ligament, tendon and muscle tears
• Recovery from surgery and wound healing
• Skin conditions and ear infections

But does it work? Is this relief for suffering dogs or just another false hope?

Dog Laser Therapy Studies

I’ve read the scientific literature on cold laser or low level laser therapy (LLLT) in dogs. This is the direct and controlled irradiation of target tissues with Class 3 or Class 4 lasers. Here are the key findings:

Arthritis & Hip Dysplasia

There are no placebo controlled studies on the effect of lasers on arthritis in dogs. Which is a shame, because this is where it’s being used most in practice. Therefore, we have no evidence to guide us either way.

In humans, a 2019 review paper studying knee osteoarthritis found that LLLT reduces pain and disability more often than could be explained by chance alone. This suggests that LLLT could work in dogs since we share a similar disease process. However, it’s also important to note that 2019 consensus guidelines for the non-surgical management of human osteoarthritis strongly recommend against laser therapy, stating “No efficacy, implausible biological mechanism”. 

My personal suspicion is that it will work best for knee-like joints where there isn’t much soft tissue between the beam and the target.

Degenerative Myelopathy

Im sorry, I really wish we could offer something for these dogs. However, there is zero evidence for LLLT and almost zero chance that it will help. The cause of the spinal changes in degenerative myelopathy is poorly understood. It certainly isn’t likely to either respond to laser or be accessible by it.

Cruciate Rupture or ACL Tears

Although unstudied, there is very little chance that laser therapy will make a torn ACL better before surgery. That’s because the main problem is the instability of the joint.

After surgery, there is mixed evidence about whether LLLT helps the recovery. One study found no improvement in stiffness, function, quality of life or load but did find a small improvement in gait at 8 weeks. Two other studies found no difference.

IVDD & Back Pain

Once again there is no evidence in either in dogs or humans that laser therapy will help with spinal disc prolapse or collapse. This is the condition well-known in Dachshunds that you can read about here. The same goes for spondylosis and lumbosacral stenosis.

It is however possible that LLLT will reduce the discomfort associated with these conditions. That’s because a 2017 review in humans found that laser therapy reduced pain in adult patients with musculoskeletal disorders.

Musculoskeletal Pain

The paper above is just as relevant here. It’s quite possible that low level laser therapy may also have uses for chronic sprains, such as we see commonly in older, overweight or very energetic dogs.

Nearly all of these get better quickly with a combination of rest, weight loss and anti-inflammatories. However, there are always a tricky few for which laser would be worth trying.

Surgical & Wound Healing

No studies have yet demonstrated a benefit of laser therapy in wound or fracture healing in dogs. However, wounds that heal badly aren’t very common and most studies used fresh uncomplicated surgical wounds instead. These probably always heal the same regardless.

Studies in rats have shown significant benefits of laser therapy in wound healing. Therefore, it’s reasonable to expect that if we can study the right (or wrong!) injuries in dogs we might see a benefit. An example might be the large amounts of skin loss we see after car accidents.

Dermatitis & Atopy

There is one study of dermatitis in the feet of dogs. It showed equal improvement in both the treated and untreated feet. This, the authors explained as the placebo effect! (Surprised? Read about placebo effects and pets here).

In other words, no real benefit. These days with all the excellent and safe treatments for dermatitis in dogs, there should be no reason to use LLLT except as a last resort.

Dog Laser Therapy Side Effects

The benefit of cold laser therapy in dogs is that it is very safe. With a properly calibrated machine and knowledgeable operator, there is almost no risk of harm.

The only side effect you’re likely to see is a lighter wallet. LLLT machines are very expensive, and therefore treatment costs can add up quickly. If you’re OK with this, dogs seem to tolerate the visits well and adverse effects are rare.

Veterinary Cold Laser Protocols

Protocols vary a lot based on your vet’s preferences and the condition being treated. They could go from once a week for four sessions up to every few days for ten sessions or more. The actual time of laser therapy is usually less than ten minutes.

And will it work? My personal view is yes, but not by much. The strongest evidence lies with joint problems. I would be quickest to recommend it for the dog with arthritis when other treatments aren’t good enough. But I can’t help wondering if a similar effect could be had by gentle warming of the affected joint for a similar time.

If you want to try cold laser on your dog, please ask. We’ll be happy to refer to a local centre where it can be done.

Just having another option is a good thing and I look forward to more good science to help us make a choice. When it appears, you can be sure I’ll put it here.

Have something to add? Comments (if open) will appear within 24 hours.
By Andrew Spanner BVSc(Hons) MVetStud, a vet in Adelaide, Australia. Meet his team here.