Oral Masses in Dogs, What Every Vet Needs to Know with Dr. Stephanie Goldschmidt

Oral masses in dogs are common. Ignoring them is not an option.

Dr. Stephanie Goldschmidt — Board-Certified Veterinary Dentist, Fellow of Oral & Maxillofacial Surgery, and professor at UC Davis School of Veterinary Medicine — joins us for a comprehensive, clinically practical conversation on canine oral cancer.

We cover the full picture: biopsy, imaging, staging, surgery, radiation, chemotherapy, prognosis, palliative care, and when referral is the right call. Dr. Goldschmidt also addresses why even a mass that looks alarming may have treatment options — and why the ones that look benign should never be dismissed.

This episode is essential listening for primary care veterinarians, veterinary technicians, and anyone whose patients include dogs. Packed with clinical pearls you can apply immediately.

Topics covered: canine oral tumors, oral cancer diagnosis in dogs, veterinary dentistry, biopsy techniques, oral mass staging, surgery options, when to refer in veterinary medicine, palliative care for pets, and veterinary oncology.

Referenced Research

The diagnostic yield of preoperative screening for oral cancer in dogs over 15 years, part 1: locoregional screening

https://pubmed.ncbi.nlm.nih.gov/37863103/

The diagnostic yield of preoperative screening for oral cancer in dogs over 15 years, part 2: distant screening

https://pubmed.ncbi.nlm.nih.gov/37770015/

#VetPodcast #CanineOralCancer #VeterinaryDentistry #OralMassInDogs #VetOncology #DogCancer #VetEducation #VetCE #WhenToRefer #SmallAnimalMedicine

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Transcript

SPEAKER_01 0:05

Hi everyone, and welcome back to the Positive Veterinary Dentistry Podcast, where we bring you real-world conversations about the future of veterinary dentistry and oral surgery. I'm your host, Benita Altier, licensed veterinary technician, veterinary technician specialist in dentistry. Today's episode is one that I think every veterinary professional has encountered, struggling with. Oral tumors and our veterinary patients, and more specifically, how do we truly understand what we're dealing with? How do we avoid making assumptions too early? And how do we guide our clients with confidence, even though we don't have all of the answers yet? Because this is one of our biggest themes and struggles, we're going to explore this today in more depth so that we can get some cutting-edge information from an expert in the field. So, today I'm honored to welcome Dr. Stephanie Goldschmidt. Dr. Goldschmidt is an assistant tenure track professor in dentistry and oral surgery at the University of California at Davis. She completed her residency at the University of Wisconsin-Madison, where she also earned her undergraduate degree in animal science. She received her veterinary degree from the Royal School of Veterinary Studies at the University of Edinburgh in Scotland, and then went on to complete a rotating internship at the Veterinary Medical Center of Long Island. Following her residency, she spent five years as a clinical assistant professor at the University of Minnesota. She's also completed a fellowship training in both oral medicine at Penn Dental School and oral maxillofacial surgery at the University of California, Davis. Her subsequent specialty is subclinical, excuse me. You have so many credentials. There's a lot of specialties here. I often describe you as an overachiever. Okay. Her subspecialty, clinical and research focused, is oral oncology with a particular interest in improving treatment paradigms using their gymnostic agents. So, Dr. Goldschmidt, welcome to the show. Thank you for having me over here. Yeah, so excited to talk to you today. It's been a while since we worked together in person, but when we've taught classes to veterinarians out there in the world, it's been really fun to get to know you and to experience your level of expertise, knowledge, and your teaching style. You're such a great teacher and have so much to bring to the profession. I'm really excited to have you here today so that we can work together to bring light to this topic that I know you're really passionate about. I let my guests always pick the topic that they want to talk about because we all have our passion projects and you've done a lot of research in this field at UC Davis and otherwise. And also being an oral maxillofacial surgeon, have a lot of expertise and treatment options that can potentially extend the patient's quality of life. So before we get started, I always at my podcast here have a question. My last guest left for my next guest. So the last guest was Dr. Sandra Manfred Moretta, and she asked you, What is your favorite maxillofacial surgery to perform? And why is that your favorite procedure?

SPEAKER_00 3:25

Oh, I knew she was gonna ask this. My favorite is an exoneration case, which means like a big caudal maxilectomy, and then removing all of the contents behind the eye. Why it is my favorite is because it's technically challenging just because of the anatomical limitations of the area, but also because a lot of people like assume these dogs are going to do so horribly with such a big surgery, and like I get to see them do really well and have a high quality of life and be cancer free for a surgery that a lot of people used to say was like not doable or uncuttable.

SPEAKER_01 4:00

So that's why I do you feel like that surgery has become not commonplace because I know this is only performed at your level with your level of training and expertise in oral maxillofacial surgery. But do you think that this is becoming more common at your level to perform such a seemingly undoable surgery?

SPEAKER_00 4:21

I do. And I think that what's shifting is like a lot of people used to be like, oh, we can't do it. It the dogs, it's not fair, the quality of life is so poor. And then now that more of us are doing it and other people are seeing it, and they're like, oh, this dog got up the next day and ate breakfast and is playing and eating and doing great, it's starting to shift like what is possible and what like it's always very hard with oral cancer surgery. We always need to balance the ethics that just because we can doesn't mean we shouldn't, right? Um, but I think that now we're seeing that these surgeries they do so well, so more people are.

SPEAKER_01 4:55

All you need to do is have some case examples where you see success. And I have always said the animal's gonna choose to live, they're gonna choose life. And if we have the ability to give that to them and we can, like why not? And just seeing their behavior in that they just want to play, they just want to eat when they just want to be feeling well and wanting to interact with their owners and families. So that's amazing that you're able to do things like that and medicine and veterinaries specifically has come this far for these patients. I would love to see more information about that because I didn't even realize that's something that we're doing in vet medicine. Yeah. Yeah. So when we think about general practitioners and what they've been taught in veterinary school and what they've encountered out there in the real world, from the research that I've read that you helped to publish in JAVMA, we may really be under-treating all oral tumors and not working them up as we should early on, given the most current information that you have. So, what should a general practitioner be thinking when they see something in the mouth that they're suspicious of? What should their first steps be without making assumptions based on the way the tumor appears visually? And what do you think that they should be thinking?

SPEAKER_00 6:23

Yeah, so I think a big misstep is that we look at something and we're like, oh, it's benign or oh, it's nothing. So definitely a biopsy is essential. I have been tricked before where something looks really boring and is a fibrosarcoma. So the order of when you do the biopsy, I think depends on the conversation with the client, right? Some clients say, I want to get a biopsy or cytology, which can be diagnostic sometimes. It often is not, the mouth doesn't exfoliate that well. It's not wrong to try, but to get an initial answer so that they can then say, okay, I want to stage or not stage. Once we know a tumor is malignant, staging is a non-negotiable because it's really gonna change how we treat these clients, the amount of time we're gonna get with surgery or other treatment and how they make those decisions. So staging in general at a GP level definitely should include chest x-rays. That's gonna definitely let us know if there's anything scary happening in the chest, and then checking the lymph nodes from the mouth. The way that it drains the lymph nodes is a little unpredictable. So it can sometimes go to either side. It can also sometimes go to deeper lymph nodes. But I would say a great baseline is both mandibulars, which we can palpate easily. So getting chest x-rays, mandibular cytology can give us a good first line picture of what's happening. And it depends on the client. Some say, I don't want to do a biopsy if there's chest meds. So you do your x-rays first. Some say, I don't want to spend the money for x-rays and a workup if we found out it was genable hyperplasia. So some want to do biopsy first. And I think it's just laying it out for everyone and seeing which way they want to go. But a big problem that I think I see the back end is for years they said, Oh, it's nothing, it's nothing, it's nothing. Wait till it's huge, and now we've missed our window, or maybe there's still a window, but it's so much higher morbidity. So I think underlying the importance of a diagnosis early to clients is really important.

SPEAKER_01 8:24

And we don't want to get to the point where we have to send a patient to you for a really radical caudal maxillary surgery. I know it's your favorite, but we don't want to get to that point. And from reading your published works, it really seems making assumptions really leads us down the wrong path. So a couple of things that stuck out to me was one, just because it's small doesn't mean it's nothing, right? And then two, because it's large doesn't mean it's something really bad, right? So there's just so much more information that we need before we can decide. And also looking for spread to the lymph nodes or elsewhere, we definitely don't necessarily just depend on palpation of those lymph nodes because that doesn't really, it can also deceive us as well. So, where do you think some of those types of things could help drive a practitioner to, I guess, be more thorough right up front and to use the right words to get the client to understand specific steps that would be ideal versus them just saying, well, I don't think it's anything or it's small, let's wait and see what happens. Because that clients always gonna err on not spending money or not putting their pet under anesthesia, right?

SPEAKER_00 9:46

Yeah, totally. I think that's something that someone once told me when I was early in my career was like, clients are gonna do what you suggest is the better option. So, like when you come in the room and you're like, oh, I see this mask, but it's probably nothing, but we should biopsy it. Of course, they're not gonna want to biopsy it now, right? Like you just told them that you don't think it's anything. So I normally go in and I say we see this oral mass in the mouth, we can see things that are benign or malignant. I think this is most likely benign, but the only way for us to know and to properly give prognosis and treatment recommendations is to get a sample. And that is what I would strongly recommend. And like you mentioned, we know that 40% of palpably normal nodes harbor metastatic disease. So normally once you tell an owner that, like, because the first thing they'll say, oh, I want to sample the lymph node, oh, but they weren't big, right? And then I just explain to them, yes, but like we know that palpably normal nodes are very likely to harbor metastatic disease, and that would vastly change our prognosis and maybe means that you don't want to treat or you just want to palliate. So it's a very important piece of information to have and definitely could change our treatment plan. The other thing we talked a lot about in that paper, which I feel like it's a good time to bring up now, is even when a tumor is benign, like the odoncigenic tumors, the amyloblastomas, we do still recommend screening, we call it, instead of staging, because these dogs are old and often we'll pick up other incidental things. So, especially on the abdominal ultrasound, we recommend that for every patient. And we're really not looking for Mets. We're looking for is there a muco seal? Is there another tumor that might prevent us from wanting to do a maxlofacial surgery? And the likelihood of finding that is low. So 9% to be exact, but that's one in 12 dogs, right?

SPEAKER_01 11:34

And if it's your dog, it's 100% if it's your dog. So we have to think about that, I think, with every single patient, because we can think, well, statistically, this is their baby, and we don't want to take a chance and we don't want to minimize the impact that would have on them and their relationship with their pet or just being able to have their pet in their life or their pet having a life that's good quality.

SPEAKER_00 11:58

Exactly. And that's how I approach it is I I offer them the Ferrari, which would be regardless of what type of tumor it is, anything that is truly a tumor, and we're going to be doing a surgery, benign or malignant, full essentially screening. So making sure we're not picking up anything else incidental that might preclude us from wanting to move forward. And we know that when we do all four, like we do a head CT, we chest the lymph nodes, the chest and the belly, there's a one in four chance we'll find something. So it makes a huge difference for these patients. And when we explain that to our clients, I I know we have a biased population that I get to see, but everyone has been like, that makes total sense, right? And want that information to make the best decision we can.

SPEAKER_01 12:43

And I think in most general practices, a lot of these imaging modalities and the ability to get this information is pretty readily available now. 20 years ago, 15 years ago, that might not have been the case, but I think most people do have the ability to do quite a bit of this in hospital and also have referral practices that could do these things not too far away, which helps a lot if the client's willing to go for this. But the client hears the word tumor or a mass, they may be panicking because they're thinking cancer, oh no, we're gonna have to make a euthanasia decision. Like their mind just probably jumps to the worst of the worst thing. So as a general practitioner, we probably have to really pre-prepare what we're gonna say to someone because as you mentioned, someone saying, well, that's probably nothing, that's our hope internally. But when we say that out loud, I think we're really minimizing the sense of urgency to that client that, you know what, this could have been percolating in the mouth for a long time. And because of the fact that we don't anesthetize these animals frequently enough, we often find something while they're under anesthesia for something else or when they're under anesthesia for a routine dental procedure. So it's an incidental finding. I can't tell you how many patients over the years that we were anesthetizing for dentistry and we found something in there that no one could have seen other than when we got them completely anesthetized. So we we want to be as I think taking this as our one opportunity to get aggressive enough with the pre-work that if it's nothing, then great. But if it's not, why take that chance, right? Of just putting it off, which is always everyone human nature. We want to put off something, especially if it's scary. So abdominal ultrasound, lymph node aspirations, and then chest rads. And in your world, you have cone beam CT as well. But what about dental radiographs or intraoral radiographs? What uh type of role does that play when it comes to looking at these types of masses, whether they're teeny tiny, something that we barely notice, or something even fairly large?

SPEAKER_00 15:14

Yeah, I think that it's a at the time of biopsy, it is great to have a dental radiograph, especially if we're deciding between an odontigenic and non-odontogenic tumor, or even within the odoncigenic tumor realm, there are certain ones that don't eat into bone at all. So knowing that and giving your pathologist that information is very helpful. I think it also helps with talking about the urgency for the client. So you see a little nothing gingival mask, but you say, hey, we're gonna see what it is, and you take an x-ray, and now there's also bone lysis. Now you have more credence to say, hey, this looks like it's something more scary. We know from people that bone lysis is extremely painful. Like these are all the reasons we need to think about either treating with radiation or surgery once we know what it is, or talking more strongly about what palliative care looks like. So I think having dental radiographs, if that's something you can do at the time of biopsy, okay.

SPEAKER_01 16:10

And if we're going to be putting them under anesthesia, then obviously if they're under a general anesthetic, we could definitely take the radiographs and like you said, giving that information to the histopathologist along with the other uh samples and information. I always tell people to make sure to take photographs of the mass, to use calipers or even your explorer probe instrument, because your probe has one millimeter markings on it to get dimensions besides photos, radiographs, dimensions. Is there anything else that you recommend that people do when it comes to preparing to send a biopsy to the histopathologist?

SPEAKER_00 16:55

Yeah. Well, one, that's actually like please, please, please take a photo, Bonita said that's so helpful. But also the size. So, like, especially for melanoma, for example, we actually have data that for every centimeter larger a melanoma is, there's a 30% increase in the hazard of death. So knowing the size of that melanoma and any tumor, but melanoma more than anything is super prognostically impactful. So a T1 staged clean melanoma with surgery can get two to three years. Once we get to like a stage two, it's over two centimeters, it like drops to about a year. So it's a huge difference just with that increase in size. So that's really important when we're talking to the client. The other thing I would strongly recommend to not do an excisional biopsy. So taking that tumor in entirety, it like feels very rewarding. But the problem is often if it truly is malignant, you're leaving cells behind. And because we can't totally see where it was or what was left over, our next surgery can actually be much challenging and larger because it was taken in entirety. So taking just a punch in the middle is usually the best way for surgical claims.

SPEAKER_01 18:07

That's great advice. And that's something I've definitely heard in the past. And I think that the tendency is to want to look at a mask just visually inspecting it and thinking, oh, I think I could remove the whole thing, realizing that you should not, for those reasons, go ahead and just get a biopsy, do your staging, and figure out what exactly you're dealing with and whether this is something that should be accomplished in your hands versus referral to someone who has more imaging modalities like cone beam CT and additional surgical experience like yourself.

SPEAKER_00 18:44

And I will say that for an oral tumor, we don't want to be using cone beam CT. We want to be using real CT with contrast. So not cone beam CT. So real CT with contrast. Yeah, just because cone beam can only see bone. So we want these to have something that you can give IV contrast and see the sauce tissue extent of the mass as well.

SPEAKER_01 19:06

That's great. And that's more likely going to be in a university setting to have a full cone beam or a specialty.

SPEAKER_00 19:14

Yeah, I would say any referral practice usually will have a full contrast CT if they have multiple specialists on hand. Some standalone dental practices will only have cone beam, but most of them have the ability to refer out for a true contrast CT. That's great.

SPEAKER_01 19:30

Also, when we think about the biopsy, when we think about who we send that biopsy out to, are there any specific histopathologists that you feel should be consulted regarding biopsies of masses in the oral cavity versus where someone might send their regular biopsies for masses on the body?

SPEAKER_00 19:52

Yes, that is a great point. And there are specialists in oral pathology. My personal favorite is Cindy Bell, who runs SOBA or the specialty oral pathology for animals. She does tend to be a little overworked. So I do try to reserve like very challenging masses for maybe her to get a second opinion. For just general oral pathology, there are also some great oral pathologists at the main places, like IDEX and Antech. They both have oral pathology teams. You just have to ask for it specifically. So, like Melissa Sanchez, Alex Harvey, Barb Powers, they're all great oral pathologists as well. Normally, if it is a fairly easy mess, it anyone can diagnose it. But if it is something more challenging, definitely asking for that oral pathology team can make a big difference in figuring out what it is and then stratifying your treatment.

SPEAKER_01 20:45

Great information. And a lot of veterinary practices use those reference labs. And those would be the people that they need to specifically try to designate for that particular biopsy, especially if they're really concerned that it could be something more aggressive or difficult to diagnose, I would assume.

SPEAKER_00 21:07

Yeah. And I think it's very easy. Like I think when you send it in, you just check like I want this to be looked at by the oral pathology team. And I I could be wrong, so I don't want to misspeak, but I don't think there is an additional charge. I think it just streamlines it to that team to make sure they're the ones looking at it.

SPEAKER_01 21:22

Yeah, that makes sense. We want the people that are really in tune to oral pathologies. Now, with dogs specifically, what can appear to be something really concerning, but is actually benign? Like what type of tumors do we see that actually look really scary but are not actually that concerning?

SPEAKER_00 21:46

So, what I would say is that would be like the camp of the odontogenic tumors. So within the oral cavity, we are a little bit unique that we can have these tumors that come off the teeth themselves called the odontogenic tumors. Used to be called epili, but we largely kind of try to get away from using that word because it really confers that they're totally benign. But some of them can get extremely large and destructive. The most common one that kind of can look the most destructive and the scariest would be the amyloblastoma. So it can eat into bone quite aggressively and also become very largely cystic, but it can start by looking like a little gingival nothing. And then once it gets into bone, get really large. So sometimes when you see them on imaging, you're like, holy smokes, this is so aggressive, so enormous. However, because they don't carry any metastatic potential, even with surgery, they can be cured. So a lot of times we'll see people dissuading, oh, you have this horrible tumor. But because it's an amyloblastoma, if they would move forward with surgery, we can cure these patients, even if it's really big. A similar type of odontagenic tumor would be the peripheral odontogenic fibroma or the POF. They don't eat into bone at all. So that's where dental radiographs could be helpful. But I have seen them when they're ignored, get extremely large and look like a fibrosarc, right? And this is one of those things where a biopsy would tell us this is not a fibrosarcoma. We can cure this dog with surgery. And for POFs, we don't even need a margin. It literally is just removal of the mass itself, and they can ride off into the sunset.

SPEAKER_01 23:25

Which is what we want them to do, ride off into the sunset, happy, happy dogs. Are these odonogenic tumors often occurring in younger dogs? Or what age group do we often see these?

SPEAKER_00 23:37

Both POFs and amyloblastomas we tend to see in middle-aged dogs, but both have been reported in young dogs as well. The odontogenic tumor we see primarily in young dogs are odontomas, which are the type of odontogenic tumors that make teeth. So they're very cool to see. And we see them usually in dogs less than a year. I have seen amyloblastomas though in one or two-year-old dogs. So it's not unheard of, but in general, we tend to see more around the like six to nine-year-old range. Okay.

SPEAKER_01 24:07

So we want to be screening these dogs all the time throughout their life, but we do know specifically that there's some oral tumors that could pop up at certain age groups, leading us towards that particular diagnosis or at least having an idea how to stage that patient or potential treatments for that patient based a little bit on how old they happen to be. With some of these tumors that we see in the mouth of a dog, is there any specifically that you would say often tend to look like nothing, but are a lot more concerning just based on visual inspection?

SPEAKER_00 24:46

Yeah, I would say the biggest masquerader would be squame. A lot of times they look like ulcerative lesions. So, like you have this non-healing wound or an ulcer on the palate and it's just not getting better, not getting better. I would be worried that it potentially is a carcinoma and definitely want a biopsy that.

SPEAKER_01 25:22

You know, then we get to the hopefully the veterinary and the general practitioner realizes a draining fistulus thing underneath the eye is often dental origin, right? So hopefully we're heading down the right path. But now we're dealing with something maybe more sinister.

SPEAKER_00 25:36

Yeah, I've seen a number of fibrosarcomas in this location in particular, where they didn't respond to antibiotics, they didn't respond to antibiotics, and then they let it go for months and months and months. And then by the time we see them, they're very large. And what's tricky because we don't see anything in the mouth, right? I just because we don't see a mass effect in the mouth doesn't mean it's not a cancer. So anytime something like is fishy, like it's a non-healing wound, it's not responding as we would expect, that's always like perks up my ears that like we definitely should biopsy this and see if we're missing something. And that's why our normal medical treatments aren't working. Right.

SPEAKER_01 26:14

That's a big red flag. If things aren't healing and it seems like what you did made sense at the time, but what's going on, right? We need to get more aggressive on figuring that out versus waiting, because especially with these animals, their little lives are so sped up, things can rapidly change. And we think a month or two is nothing in our lifetime, but for them, it could be a really big make or break situation, waiting too long to get to the bottom of it.

SPEAKER_00 26:42

And we hear all the time from patients like who come here, oh, I wish I'd caught it earlier. Oh, like, what do you think? I was nervous about this thing. And so I think if there's anything suspicious, it's always better just to get a sample of it. If the worst case scenario is that you find out it's nothing, that's a pretty good scenario to be in. So I think it's actually just phrasing it to the clients more in that light of, hey, let's just make sure and wonderful if it's nothing, right? Like then we can not worry about it rather than waiting, waiting, waiting till it declares itself.

SPEAKER_01 27:16

Yeah, good news is good news. Yeah. So I always heard about there was some specific oral tumors that would displace teeth or move teeth out of the way, and some where they don't do that. So can you explain a little bit better for me? Like, why would an oral mass cause teeth to move out of the way versus stay in place?

SPEAKER_00 27:38

Yeah. So the the thought process behind it is that like slowly growing masses like POFs, which don't cause bone lysis but will grow, can slowly move a tooth versus aggressive oral mass that is extremely lytic will eat into the bone and then the tooth will be mobile. It's a little bit of like an old wives' tale, but I will say that it is normally the pattern we see. So it is true. Like if a tooth is moved, it probably is something that happens slower. I just, I don't think it totally means they're benign or not, because I've seen a fibrosarcoma also move teeth, but it means that there's a mass that is growing that isn't eating the bone away versus if teeth are mobile, the bone is being eaten away, which usually means it's happening faster, more aggressively.

SPEAKER_01 28:23

Exactly. And this is where dental radiographs can really start to show us even subtle changes to see teeth being moved slowly out of place. And that that's concerning because generally speaking, teeth move into the place they're going to be and stay there and don't start drifting or moving or anything like that in veterinary patients, right?

SPEAKER_00 28:45

Yeah, if a tooth is moving at all, that's not normal. Um in humans, our teeth move with time. We have different fibers than dogs, and so in dogs, even when teeth are extracted, teeth shouldn't shift. So if a tooth is shifting, it means something is growing or pushing it. If it is happening slowly, it it might be that it is not a fibrosarcoma. It might be more of a POF, but it's definitely a reason to look for imaging.

SPEAKER_01 29:10

Teeth in dogs are a natural retainer, basically, right? When they are in occlusion versus with people, we have different occlusal forces as well, which can cause that to happen if teeth are extracted and now there's a gap, right? So very fascinating between humans and in dogs. When we think about whether they are pigmented masses, are there anything specific that you have as like other red flags or indicators that we should be more considering something versus something else with pigmentation of masses?

SPEAKER_00 29:44

Yeah, I mean, really the only mass that's going to be pigmented is a melanoma. There is this thought that actually amelanonic or unpigmented melanomas are worse. We don't actually necessarily know that. It's actually the opposite, which is interesting. Like if there's something that's very dark and very pigmented, it means that the melanocytes are well differentiated, which actually means it's a little bit less aggressive than one that's not doing that pigment. But there's no good studies that show that the amelanotic ones are worse, but we know the very well-pigmented ones are better. If you see a pigmented, a truly pigmented mass, it probably is a melanoma. But something that always gets me down in the dumps is someone sees a little pigmented mass, they tell an owner, it's a melanoma, it's a horrible prognosis, don't do anything. But in reality, if it's a small melanoma that we caught early, it's well differentiated, like those well-pigmented ones, stage is clean, and we do surgery, they could get 800 plus days. So they can still do well with intervention. So don't put them in this doom and gloom category right away. Kind of give them the information that these are highly metastatic, but you know, do you want to see if it has spread? Do you want to move forward with thinking about treatment? But definitely any well-pigmented mass within the mouth, it's most likely a melanoma, and you definitely should get biopsy to confirm that and talk to the owner about next steps.

SPEAKER_01 31:09

And this can get confusing because sometimes inside the mouth there's these pigmented places, right? And especially owners, they don't often look in their pet's mouth that carefully. So they might think, oh, is that something new? Or has he always had that dark spot right there? So definitely not taking that and just discarding that information. We should be looking at it. But I assume if it's a mast, it's not gonna be just normal, tightly attached gindival tissue or mucus membranes. It's gonna be a different texture or raised or rolled or something else that would clue us into that. We should be looking at it as more of an isolated area versus something that's just part of the normal anatomy.

SPEAKER_00 31:53

Yeah, absolutely. It's normally not, it's very not impossible, but it's very rare for melanomas to be flat, like truly just like a pigment in the mucosa. It's more that like they come out as a mass and they normally do grow quickly. So often they will have some ulceration, some rapid change. There is this kind of subsets referred to as melanos, well-differentiated melanocytic neoplasms. Some call them melanocytomas. So there is this like more benign subset of melanomas, but are rare and tend to definitely be like right around the lips or mucocutaneous junction. They're not normally true oral, but most of them are truly masses. I've never seen a melanoma that's just a new pigmented plaque or flat area. Okay.

SPEAKER_01 32:41

And I assume that caudal melanomas also are more concerning and less often recognized than ones in the rostral part of the mouth.

SPEAKER_00 32:51

Yeah, biologically, they're not worse, right? Caudal is not worse than rostral, but normally we pick them up later. Surgery becomes more challenging, I'll bet not impossible. So definitely something I give the same spiel to everyone. So I never say, oh, you have a caudal melanoma, this is a death sentence. I say you have this melanoma or with likely melanoma, it's got a biopsy to confirm. And then let's, if you want to move forward, let's get all the information from staging. But if you have a T1 or T2 melanoma that truly stages clean, the literature says that we can still do well with surgery. The best, obviously, the smaller the better. But even for T2s, we tell them about a year, but there are some papers where they get two plus years. When we get bigger, bigger than four centimeters or lymph node spread, that's normally when I have more of the conversation of a more guarded prognosis. We're looking more kind of at six months or so. And then we talk about do you want to move forward or do you want to just do palliation? But I think it's a big mistake telling someone right from the beginning when you see something, oh, this is melanoma, it's horrible. We can't do anything. Because for some people, getting two years, they're really happy with that amount of time and they would want to move forward.

SPEAKER_01 34:01

That could be a long time, especially when a larger dog's like yeah. I think reading some of your work as well, there was a large number of dogs in the studies that were larger dogs, like Labradors or retrievers. And we do know that there's some breeds that just seem to be having more than their fair share of these types of tumors. Is there anything specifically that we're working on? I know I remember reading something about a vaccine for melanoma, but these at-risk breeds, is there anything right now in the research that are being worked on to help us predict, treat, or prevent for some of these dogs that are more at risk?

SPEAKER_00 34:44

Yeah, we definitely know that large bree dogs are more predisposed, especially golden retrievers, that we tend to see more oral cancer in them. We are working on it. We are looking at like what are essentially biomarkers of disease that we could catch early. So, what we've been looking at is we've been looking at dogs that have oral cancer and then the kind of surrounding tissue right near it, which we call dysplastic tissue or starting to look a little abnormal, and seeing what is in those dlastic subsets. So, what genetically is happening there? And could we actually use that to do saliva swabs to start pre-screening for dogs? So that's something that we are actively working on here, trying to see if there's a better way for us to pick them up. As far as treatment, there isn't the melanoma vaccine. So melanoma is very interesting because it's what we call like an immunogenic tumor. It's very smart, it's very good at evading the immune system. So essentially hijacking that to try to wake the immune system up. So we call it a vaccine, but it's not really preventative. It's given after to wake up the immune system. It has had mixed results. Essentially, one study showed it's better than sliced bread. One study showed it didn't work. I tell people the only thing that's gonna hurt is your pocketbook. We know it is safe. We just don't know if it actually works. So definitely it's not wrong to give it, but I would give it as an adjunct to another local treatment. I wouldn't give it as a sole treatment. We are actively here working on some of our own immunotherapeutics, similarly for melanoma, to try to wake up the immune system to better fight off cancer. And that's some of the clinical trials we're working on now. So looking at a checkpoint inhibitor, actually, we're about to start it soon, any day now, looking at giving that before surgery. And could we wake up the immune system and do better? But right now, everything's in the works. There's nothing that's really come on commercially that can be used in practice right now.

SPEAKER_01 36:42

Okay. That's good. And it's so reassuring that there's people like you at the university level working on this research to really help us get down to the bottom of how to recognize this and prevent it ideally, but recognize it as early as possible and have some really great treatment options. So right now it sounds like from what we're discussing that the staging is really important and that we don't want to neglect to do the full staging, yeah, if at all possible, so that we can give the pet parents the most information we can so they can make an educated decision on what they want to do with their pet. And that we have to be really careful with our biopsy technique, right? So that we're not going to cause more struggle for a surgeon like yourself to hopefully get a cure through a surgical intervention. Besides surgery, what other adjunct treatments are there out there for some of these cancerous tumors that we really have to be more aggressive about?

SPEAKER_00 37:45

Yeah. So in general, when we think about local therapy, we're thinking about surgery or radiation. So, radiation therapy, a lot of these are radiation responsive. The biggest thing, like when I give my spiel to clients, is that cells can escape radiation. So when we give radiation, kind of one of the biggest things we worry about is that some cells do not die and the local recurrence rate is potentially higher. And we know that, especially for squamous cell carcinoma. But sometimes for certain melanomas that they're bigger and surgery would be high morbidity, radiation's a better option, right? Because we don't have that same morbidity from surgery. The side effects we think about with radiation would be oral mucositis, like a hot pizza burn. Um, I warned people about a hot pizza burn. And then sometimes they can get some kind of hair changes. Those are the kind of acute side effects, long-term side effects. If that is the outcome that they get, we can get what's called radiation-induced osteonecrosis, meaning some of the bone dies because of the radiation. It's rare, but is possible. Normally happens a year plus after RT. And then we can have some changes to the eyes and some long-term kind of like fibrotic scarring changes. But in general, they do tend to tolerate radiation pretty well. And it's a good alternative if they don't want to move forward with surgery. The kind of chemotherapeutics or systemic medications, those are really only for patients once they've had spread. So that is not a local treatment. It's normally if we already have lymph node spread or chest spread, then that's when we think about adding those on. And it's rare, but sometimes we will give those kind of therapies before surgery to try to shrink down the tumors, but it's definitely a more unusual approach.

SPEAKER_01 39:31

Well, and that could be less scary for a pet parent, too, if they know that this doesn't necessarily mean chemotherapy, right? Because a lot of people think cancer and they think chemotherapy, and they think my pet's hair is gonna fall out and they're gonna be vomiting all the time and they're gonna feel horrible. And I don't want to put my pet through that. But as we talked about earlier, they just want to live, they just want to eat their food, they want to play. So it's amazing to me how well they really tolerate some of these interventions, given what a human might wind up having trouble with these types of treatments.

SPEAKER_00 40:06

And I always tell them, like, they don't look in the mirror. Like the hardest, like the hardest part for us to have a piece of your jaw removed is like the social aspect of it. But they don't have any of that. They don't look in the mirror, they don't have the cosmetic piece of it, and they do amazing. Like the amount that they can adapt to having a piece of their jaw removed and eating the next morning, and they hunt and they play and carry around big sticks, and usually the first kind of five days are the toughest, but then they turn this corner and they go back to their normal quality of life.

SPEAKER_01 40:38

Exactly. They uh probably get more sympathy and more pets and more hugs, right? Because they're like, oh, buddy. Exactly. What's going on with you? And more people paying attention to them. So they probably enjoy that extra TLC. A little extra TLC. One thing I wanted to bring up before we got to the kind of last thing I wanted to ask you about was tumor seeding. So we talk a lot about nerve blocks, and I always talk about if there is a tumor, we don't want to be placing an injectable drug through that tumor to apply a nerve block. So, are there any specific things when we talk about pain management with these pets that we should do or shouldn't do or just be cautious about?

SPEAKER_00 41:23

Yeah, totally. So, what you brought up is a great point. We never want to use an instrument and go through a tumor and go somewhere else, especially a carcinoma. So if you are gonna do a local block, which we always recommend, don't go through the tumor, do a farther block. If you can't get away with a block, better to not do one at all. Similarly, make sure you're changing your instrument. So if you see it on your oral exam, make sure you probe that last. Don't use the same scalpel that you use there anywhere else because we worry about seeding. As far as pain control, these are painful. These are painful because they eat into the bone. Normally, the best things we can do are an NSAD if they can tolerate it. SADs tend to be really good for bone pain. And then you could add on a mantidine or gabapentin as well if you need a backup. But normally the best thing we could do is get rid of that bone pain by surgically removing it or radiating it. If they decide to do neither of those things to deal with the bone lysis, then for more chronic pain, I usually do long-term NSADS, GABAPentin, potentially a mantidine, and then an opioid for true hospice care. So once, like if they've decided they don't want to treat, they just want to medicate, then towards more the end of life hospice care, I will do short-term fentanyl patches so they can be as comfortable as possible at the end.

SPEAKER_01 42:41

Yeah, that's important. We want these guys to be comfortable. And during the surgery itself, do you use controlled rate infusions as well as your nerve blocks? Is that something you would do as well?

SPEAKER_00 42:52

When we're doing the not for a biopsy just because it's too quick. Normally we'll just do a single opioid injection, but for maxolectomies and mandibolectomies, yeah, we always have them on, usually a fentanyl CRI, plus or minus a ketamine CRI, depending how invasive the surgery is. And then we normally keep those on post-op for about 24 hours. We love CRIs for dentistry.

SPEAKER_01 43:14

I feel like they were made for these cases that you have multiple quadrants involved with maybe major extractions and also just dealing with the fact that I definitely learned from you even more about this. Sometimes nerve blocks don't work. Totally. Yeah. I've like, but but why? And sometimes they just don't work. Yeah. They just, yeah. They like you said, uh metabolic alteration of the tissues, right, can really interfere with the ability for those nerve blocks to work for our patients. So we have to have other potential ways of dealing with not only interoperative pain, post operative pain, but then maybe even longer term when it comes to these patients having some major surgery. Yeah. So one word that was coming up in your literature that I was unfamiliar with. With is therapy. Theragnostics. Yes. So explain this to the audience just so we can have a better understanding of what that means and how that applies.

SPEAKER_00 44:12

Yeah. So theragnostics are probes that are both therapeutic and diagnostic. So something that, as much as I like to do surgery, what I find very hard is when we go for an oral tumor surgery, we take the tumor, then we take a centimeter up to two centimeters around the tumor to make sure no cancer cells are left behind and we have the best chance of a surgical remission. But that has a lot of morbidity in the oral cavity in particular, especially like a small dog, two centimeters every direction. That's a big surgery. So a lot of my research focuses on how we could better tell cancer from normal tissue in real time by using these kind of probes. But thernostic probes also treat the cancer itself. So they have some sort of anti-cancer killing, but also help us guide in the OR. So that's what most of my current research focuses on.

SPEAKER_01 45:06

That's great because we don't want to have him lose a larger amount of his face if we could just pinpoint where the treatment needs to be applied. So rather than ruining the whole neighborhood, you're actually just hitting the one place, the house where the tumor lives. Exactly. Yeah. Yeah. That's really exciting and neat that you're doing more research into how we can expand upon this concept and really be able to improve staging and margins and targeted therapy for all of our patients that we need to work on. And so it's this isn't just a dog thing, I'm assuming we're talking any animal.

SPEAKER_00 45:47

Yes. Yeah. So we're definitely spending a lot of time also on how we can better treat cats with oral squamous cell carcinoma, which is obviously very challenging for all of us because right now we have no good option, right? So yeah. It's definitely something that we're actively looking at as well. So not dogs only, but dogs and cats.

SPEAKER_01 46:07

Yeah. Exactly. It's just with cats, it's really challenging because often these squamous cell carcinomas seem to pop up out of nowhere and they can tend to be in the back of the mouth and it's not recognized quickly enough, even if there was something that we could do to really help this cat. So that's a really challenging one. But talking about dogs today, it really I think gives us some hope that we do have some really good solid information here that we can use when we're talking with clients. Thank you so much for your scripts and things that you would say to the clients once they present to you at a high level there at UC Davis. Even in a general practice setting, I think it's so incredibly important that we understand the words that we say and what we do really can make or break the situation for that pet. It could be life or death. They could decide that they're just gonna euthanize, even though maybe that wasn't necessarily the option that would have really helped that animal for short term or longer term without really too much heavy lifting, honestly, or at least getting the information to make an educated decision so that these clients aren't jumping to conclusions and their pet has a death sentence and there's nothing they can do. So it's great to remember that. With this conversation, what do you think you'd really like the listeners to take away from this? Any things that you would think are key that you really want to reiterate about what we talked about today?

SPEAKER_00 47:36

Yeah, I think you did a very good job, like just summarizing it. But I think the most important things are don't let assumptions get the best of everyone. I think that coming in and saying we see something, let's find out what it is, let's do a quick biopsy or try cytology to have more information, get the whole prognostic picture and letting people know that there are options for these masses. They don't have to take them, but giving them all the information and then letting them make the decision rather than saying, Oh, it's melanoma, all melanomas die, right? And giving them all that information and going through the staging and going through the biopsy. I think there's so much power in what can be done before they even come to see us, and that having that conversation is so impactful.

SPEAKER_01 48:21

Very important advice and things that the DVMs out there in general practice will really be able to take away. So we're gonna link these two papers, part one and part two, that were published in Javma in the show notes. And if there's anything else that you think would be relevant, we can certainly add that to the show notes as well. They can find you at UC Davis doing all your great work there with the team and doing your research, which will watch for more publications and updated information from your work there at UC Davis to help guide our clinical decision making because that's what this podcast really is about bringing really up-to-date clinical information and relevant topics to general practitioners, veterinary technicians, and teams out there in the world, because we sometimes just don't have a lot of time to dive into the research, but having more of a concise conversation about it today could really help spur on some curiosity to want to learn more and then don't jump to conclusions for these patients so that we can hopefully slow down and get the prognosis figured out and figure out what we're dealing with before we just jump to something really devastating for this patient. And if they're people, right? Yeah. So before we sign off today, you get to leave a question for our next guest. So, did you happen to think of a question that someone like yourself or veterinary technician like myself would be able to answer? I was gonna ask, what is the favorite animal you've ever treated? Okay, what is your favorite animal that you've ever treated? Perfect. So that question will go to the next guest. So watch for that answer. So I have to start listening to the podcast. There you go. So you can listen for the answers and the questions as they come along. Yeah. So thank you so much today, Dr. Goldschma. I really appreciate you being here and bringing your expertise. And for the listeners, thank you for being here to listen to the Positive Veterinary Dentistry Podcast. We really appreciate you listening. Please like, subscribe, and share because we're trying to make sure this information, which we feel is so vital to our general practitioners, gets out into the world. I'm sure you have other veterinarians and friends that would be interested in this information. So please share this episode with them. And until the next episode, keep doing positive dentistry. Listen in, and we'll see you next time. Thank you.