tpvets_logo.jpg (2726 bytes)TOA PAYOH VETS
Date:   25 January, 2013  

Focus: Small animals - dogs, cats, hamsters, guinea pigs & rabbits

Squamous papilloma in an older Cavalier King Charles
- How does a vet diagnose & treat such a case?

Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
First written:  26 October 201.  Updated:
25 January, 2013 
Be Kind To Pets
Veterinary Education
Project 2010-0129

The following is my script for the video production

Be Kind To Pets - Oral tumours in A Dog

This video describes the processes of how  a vet diagnoses & treats a case of squamous cell papilloma in an older Cavalier King Charles. These processes form part of the Standard Operating Procedures at Toa Payoh Vets
2.  HOOK
A large strawberry-like lump is spotted
by the young lady owner one day. She informed her father and brought the dog to Toa Payoh Vets
The Patient: Cavalier King Charles, Male, 10 years. Singapore
History: Dog was not active, had difficulty eating. Excessive salivation. Sometimes, blood seen dripping from the mouth. What is the problem with this old dog?

Music & Insert the image into the video: 

An old dog is like part of the house furniture.  Family members, especially children who grow up with him love him very much. But they have not much time for him unlike the time when he was a new puppy (video of Cavalier King Charles puppies at the pet shop being sold).

The older dog is a family member for most Singaporeans nowadays. Visits to groomers regularly, good food, dog treats of various brands and plenty of water available at all times. (video of regular visits to groomers)

The dog's mouth is seldom examined by most dog owners and bad breath is usually tolerated by many Singaporean dog owners.

Dental check ups are not usually done and the rotten teeth drop out. Many owners are not bothered when they see their old dogs dropping teeth. Oral tumours develop in some of these dogs. Their health is no longer a priority as they age.  The older dog is always happy to greet the owner and is a good companion to the senior citizen parents and retirees but many dog owners in Singapore do not have time to send the older dog for dental check up or annual health screening.  (video of dogs in apartments, being walked in Singapore). In 2010-2011, I note an increase in the number of younger Singaporeans seeking dental treatment for their older dogs. The younger generation of Singaporeans is better educated and more concerned about the welfare of the old pets and this is good news for the four-legged companions.

Back to my case.
One sunny day in August 2012, the owners of a male, 10-year-old Cavalier King Charles saw a pinkish lump appearing on the front of the lower jaw covering two of the front teeth. It grew bigger and bigger. The father and his daughter consulted me.

Video of Singapore's blue skies and sunshine, families at the Pasir Ris beach and Toa Payoh Vets

At Toa Payoh Vets, Dr Daniel Sing was on duty. I was present. 
"Is it cancerous?" the owners asked Dr Daniel and me. 
"If it doubles in size within a week, it is likely to be cancerous," I  said.

4.  BODY
4.1  Problem -- Is the dog suffering from a cancerous gum tumour or not? 

"How to find out whether it is cancerous? What can I do to resolve the dog's oral tumour problem?" the father asked. The financial costs must be explained fully before any operation is done.
There are several processes to be addressed to ensure a high standard of veterinary care and as a defence against negligence litigation.
(Video of lawyers and subordinate court)

But the owner must give his consent and that is where personality and financial conflicts come in.

as recommended by the vet professors during undergraduate studies will be adopted by most vets especially the recent graduates. This is the standard practice as taught in the University. A small piece of the oral tumour is cut out and send to the laboratory for analysis of its type - cancerous or benign? If the biopsy shows that it is not cancerous, then, there is "no" need to do any surgery.

But biopsy takes time and involves anaesthesia. Sometimes as long as 7 - 14 days. Not much time is available in this case as the tumour was said to be fast growing. It may be malignant and must be excised within 24 hours.
Some vets do biopsy and find the tumour non cancerous. Some tell the owner there is no need for surgery. Some owners decide that they don't want surgery to remove the tumour since it is not cancerous.

(Video of consequences of not early removal of an oral tumour - images of oral tumours in other dogs)

As the weeks pass by, the tumour grows bigger. Excessive salivation, blood in the mouth, bad breath and difficulty in eating. Bacterial infection. By then, the owner has no choice but to get the gum tumour excised.

CONFLICT NO.2 X-RAYS should be done to find out whether the tumour has invaded the jaw bone and below the gums. Due to economic reasons, this was not done in this case as vet costs needed to be as low a possible.
CONFLICT NO.3 BLOOD TESTS Health screening is strongly advised before anaesthesia and surgery for all patients, esp. in the older dog.

Anaesthetic risks are much higher in old dogs. There is always the possibility that the older dog may die on the operating table. When the owner hears that the dog may die on the operating table, he may decide not to get the surgery done. Some deem the vet incompetent and consulted another vet. A health screening should be suggested by the vet to let the owner knows whether the risks are high or not.

"I advise a blood test to screen the health of the Cavalier King Charles," Dr Daniel said.  The owners must consent to take the anaesthetic risk if they give permission for the surgery as in this case. No surgeon can guarantee no risk in any anaesthesia, whether in people or animal.   

The total WCC  17.8 (Normal  is 6-17)
Neutrophils 81%, Lymphocytes 15%, Monocytes 3.2%, Eosinophils 0%, Basophils 0.4%. The platelets were below normal.

This blood test indicates a bacterial infection. The liver and kidneys were functioning normally.
"OK," the patriarch consented to the surgery.

Antibiotics were given to the dog.

CONFLICT NO.4 IV Anaesthesia

No  Intubation

Anaesthesia. What type? IV anaesthesia, gas anaesthesia or both? IV anaesthesia is shorter acting than gas anaesthesia. Intubation (a breathing tube connects anaesthetic gas and oxygen to the dog) is usually done in dental scaling which will be performed after oral tumour removal surgery.
Chihuahua young. Retained left upper canine tooth extracted. Toa Payoh Vets Early prevention of tooth decay by regular dental scaling. Toa Payoh Vets
(Insert above images of a dog intubated, left and dental scaling, right)

But this dog had a big oral tumour in the front of the mouth, obstructing the insertion of the endotracheal tube.

"No intubation, as we need good access to the gingival tumour and to excise all, if possible. It is growing fast." 

Domitor + Ketamine IV at 25% of calculated dosage for a young healthy dog was sufficient for electro-surgical excision. Dental scaling was done after that.

Cavalier_Squamous_Papilloma_mouth_toapayohvetsThe old dog survived the anaesthesia and that was what mattered most for the owners. It is not always possible for every old dog to survive anaesthesia during surgery. Therefore it is wiser to remove the tumour when it is smaller and when the dog is younger. 

  Informed consent form "This is an old dog. Explain in detail the anaesthetic risks of death on the operating table and operation and post-op complications. An informed consent needed. The form is to be signed by the owner.

In any case, the vet must delivers a dog alive at the end of surgery but no vet can guarantee. Therefore assess the risk and get the informed consent.
The teeth need to be extracted. Dental scaling need to be done. That means surgery will take longer than normal. Isoflurane gas top up anaesthesia to be delivered by an endotracheal tube is needed. 

But this endotracheal tube blocks the operating view. "IV Anaesthesia is the best," I said to Dr Daniel. Will this be effective? Yes if you know how to use the appropriate drugs. The dosage must be just sufficient for surgery but safe for the older dog.  50% of the Domitor & Ketamine IV formula was used in this case. It was effective. No need topping with isoflurane gas in this case. 
CONFLICT NO.6 Histology "Is the oral tumour cancerous or not?" the father asked.

"Nobody can tell from the physical appearance," I said. "The tumour needs to be analysed by the laboratory and the tumour cells can be seen under the microscope if there are any. This is the process of histology.  Do you wish to get the tumour sent for histology?"

It is best to get the owner's permission to send the tumour for histology to check whether it is cancerous or not, as some owners may have a budget or do not wish to spend more money.
Write "AMA" (Against Medical Advice) in the medical report if the owner is not in favour of histology, blood tests or any process advised by the vet. This record serves as evidence to protect the vet in the event of negligence litigation.
4.2  SOLUTION Electro-surgery, not medication
It is unprofessional to give medication to the owner to treat the oral tumour as some owners may insist on having them as an alternative to the high risk of anaesthesia during surgery. It will not disappear.

Cavalier_Squamous_Papilloma_mouth_toapayohvetsElectro-surgical excision including extraction of 3 incisor teeth enclosed by the papilloma. Electro-surgery by Dr Daniel. "Transect at least 2 mm from the tumour and remove the entombed incisors," I said. "However this is not possible in this case. X-rays are not done to see whether the bone is involved to lower veterinary costs for the owner at this time."

  Histology - a microscopic examination of the tumour to check its cells as to whether the tumour is cancerous or not. The owner consented for the gum tumour to be sent to lab for histopathology  (Image of microscope) 

Squamous papilloma with reactive atypia and chronic inflammation. No definite dysplasia or malignancy. (Video of a microscope)

Good news for the owner. However, the papilloma may return as it is extremely difficult to completely excise it. Lab Report:  Squamous papilloma. So it is not an epulis as I thought it would be except that it had various finger-like projections as in a wart.

The owner was happy with the good news. Not cancerous.

5.  CONCLUSION Final Diagnosis from histology The diagnosis is squamous cell papilloma.
The dog goes home 24 hours after surgery. There was no more gum bleeding. 

6.  ADVICES & TIPS Post surgical management 1. POST-OP REVIEWS. THREE-MONTHLY NEXT 12 MONTHS. Owner need to be advised and reminded by the vet but this is seldom done by me. Dog has not returned as at Jan 4, 2013.

2.  Older dogs must be checked by the owner daily and any mouth tumour be removed when it is small. In this case, the tongue covered the papilloma till it became chronically infected and swollen. It could have existed for some weeks without the owner seeing it.

TIPS. Old and unhealthy dogs (>5 years) must be given 25-50% of the calculated dosage of IV anaesthesia for younger dogs to lessen risks of heart failure.
Toa Payoh Vets' Be Kind To Pets video
Veterinary Education for vet students and pet owners
Concept by:
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS

Video and narration by:

Video is at:
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Date of video production:

For more information:
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The video produced by a vet intern is at:
Video: Oral tumour electro-excision in a Cavalier King Charles

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All rights reserved. Revised: January 25, 2013

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