Surgery recommended: diagnosis - gingival hypertrophy; possibly epulides. - Hedgehog Central – Hedgehog pet care & owner forum
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Old 09-02-2014, 01:49 AM   #1 (permalink)
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Default Surgery recommended: diagnosis - gingival hypertrophy; possibly epulides.

Vet visit #2, at 2 years, 8 months. (Vet visit #1 was at 1 year, 5 months.)

Standard checkup exam - however, gingival hypertrophy (possibly epulides) has been diagnosed and surgery is recommended ASAP. The vet has recommended not waiting for any significant period of time; i.e., the surgery should be scheduled now.

I won’t make a final decision until: (a) Blood panel and urine testing results are returned later this week. (b) I am able to research the prognosis of the diagnosis; if not to academic / professional opinions, at least garner some anecdotal / experiential information. (c) I have clarified that the estimate for the procedure is complete. It is supposed to be all-inclusive as an estimate, but I am concerned that expensive follow-up costs may not be reflected in provided documentation.

The gingival hypertrophy (or possbily epulis / epulides) diagnosis was a total surprise, but that’s what check-up exams are for. We were discussing cost estimates and timelines (i.e., as in how serious a situation and affordability) and though she hadn’t described it as a crisis, the recommendation of immediacy concerns me. It leaves me wondering what was left unsaid.

Epulides are technically (so far as I can tell) a tumor, often benign. Hedgehogs are, however, I have been led to believe, highly prone to aggressive, cancerous, oral tumors; a top killer along with other cancers, kidney issues, and obesity. From what I can tell, there is a lot of descriptive overlap in presentation of symptoms between excessive gum tissue growth (and its various names) and epulides. She did say that she was NOT leaning toward a cancerous tumor based on her experience of having seen so many (in other animals). However, only testing of removed material can determine for sure.

Also, though an experienced medical professional with some level of expertise with exotic animals (i.e., generally uncommon pets), she has limited experience with African hedgehogs specifically. Though members of this forum generally seem to lack academic / medical expertise, this resource can be rich with information of anecdotal experiences and insights.

What have people here experienced regarding gingival hypertrophy (one of many terms for excessive growth of gum tissue) or epulides? Rate / likelihood of surgical success? Recurrence rates? It is my understanding the condition is continual, that even after successful surgery with maximum trimming of excessive material, the condition itself is highly likely to continue and future surgery for the same issue may be required. The vet was quite vague to this point - mentioning that the condition could recur. Six months was mentioned as tending toward worst case. Of course, at 2 years, 8 months, lifespan is a factor also. Sure, a lot of hedgehogs see their fourth birthday, but my (entirely anecdotal) opinion is that 3 years, 9 months is an approximate average lifespan for a well cared for African hedgehog. There are whole lot more memorial posts mentioning an age of 3-years-and-some-months than four-years-and-some-months.


What are your experiences with cancer rates, prognoses, and mortality rates for these diagnoses? I truly don’t know if the vet knows the answer. My impression is that she sincerely feels this is the best course of action and that she truly expects testing results to not indicate cancerous cells - but my impression is also that she is a bit far out on a limb and guessing (which of course she isn’t going to say).


The procedure will essentially utilize a cauterizing scalpel. (Also called an electronic scalpel; a bit euphemistic.) Excess gum growth will be sliced away and the tissue behind the cut will be cauterized. This will likely be a highly stressful procedure for Sophie and I would expect some considerable pain for a yet to be determined period of time.

In my experience doctors (and nurses) are notoriously unreliable at providing complete information (facts), and equally adept at cherry-picking opinions and/or choosing slippery or ambiguous language rather than providing truly honest assessments. (They aren’t gods - I’ve no expectation of a perfect diagnosis or perfectly executed procedures with zero problems. Also, sh.. happens. That’s life.

However, it would be nice to be able to trust that I am receiving complete and honest opinions. With a doctor in the family, and a nurse in the family, and having dated a nurse, and having been in the unfortunate position of exercising medical powers of attorney for the care of family members, I’ve learned to be skeptical and disbelieving at all times. These are highly educated people. They are masters of choosing truthful words and phrases that don’t necessarily quite tell the truth (or shape it rather creatively) that people need to make truly informed decisions or to shape realistic opinions.

If I go ahead with the surgery, Sophie’s vet (my primary contact person) will not be the one performing it. Evidently, Dr. xxxxx is the exotic pet surgeon. I’ve never met this person, but my take is that they are ‘officially’ in charge of Sophie. Dr. xxxxx has handled Sophie to this point possibly because Sophie didn’t ‘need’ Dr. xxxxx specifically; or possibly because of my detailed correspondence with her personally, which makes her the only qualified person to talk to me about Sophie on most points if they have an interest in her data history as well as past and current care routines, and/or behaviors. I’d certainly prefer to correspond and work primarily with Dr. xxxxx because I think we have a pretty good understanding of what we each bring to Sophie’s care. I lack medical knowledge (a big negative) but she seems to take me mostly seriously as an owner that is sincerely interested in understanding as much as possible about pretty much everything and that I make an active effort to learn what I can wherever information can be found. (Or maybe she is extraordinarily polite and putting up with me with a high level of patience. Most vets would probably have easier days if they didn’t have to deal with owners. Ha!

On the other hand, my own personal doctor doesn’t even pretend to give a **** about hearing any question I have. It’s safe to say that Sophie is getting far more considerate care from her doctor than I am getting from mine - and I’ve got my own medical issues.

……………………………………..
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They called me with an estimate for the surgery and I asked for a PDF file with notes. I mean, the number is the number, but a phone call doesn’t cut it - I want to see and understand approximately how it breaks down. The PDF was promptly sent and it has a pretty good line item estimate.

Surgical estimate:
http://www.serenebreezes.com/Sophie-...an-edit-b.docx

$30 each for two tiny shots of painkiller. Surely that is very profitable!

The surgeon’s time is the most variable factor, which I absolutely expected, and it is less than I was afraid it might be.

Despite telling me that her teeth showed minimal wear, minimal tartar, and minimal I-forget-the-word-she-used, they have a line item for cleaning so I was kind of surprised to see that. I certainly have no objection. It’s probably a good idea; as long as they are in there they should do everything. Maybe when she said ‘minimal’ she meant “Excellent for a 2 year, 8 month old hedgehog but that a cleaning should still be done.” The cost for that, by itself, is quite low, though there are other related line item costs, so that piece of the entire teeth cleaning treatment will be about $80 of the total cost.

I do see two line items each for General Anesthesia and Surgical Monitoring. I wonder if they are going to put her out twice.? Once for the surgery and separately for the cleaning.? I have made an inquiry about this. One General Anesthesia charge is pretty high - the same as what was charged for last week’s complete exam I think. It allows for her to be knocked out for up to a certain amount of time; up to 30 or 45 minutes or something like that, though I think it is something they have some discretion with on fees if they like you.

The other General Anesthesia fee is only $28, which is why I’m thinking that this is back to back procedures but she will be officially knocked out separately for each one.? The cleaning probably goes pretty quickly, which is why the anesthesia fee is so low. It’s a big difference between $28 and $92 for the anesthesia charges.

Is it common to do two knockouts in short order during one visit?

There is considerable excess gum growth to be removed. It’s also pretty delicate I’d guess, which is probably why the surgeon’s time is hard to predict. Certainly I want them to remove absolutely all the excess growth they can / should. If it needs to be done and can be done, then it needs to be done right and I’d rather they take extra time.

There is a Surgical Monitoring fee of $15 for each General Anesthesia. This is where someone is in charge of ‘constantly monitoring’ Sophie while she is knocked out. I’d consider this more of a sub-line-item for the anesthesia. I don’t know enough about veterinary charges / billing to know if it would fall in the class of an ethically dubious junk fee or if it is reasonable. (More and more businesses have junk fee scams where they charge line item fees for which the customer gets no value whatsoever in return.)

Histopathology is a big word for ‘testing the removed material and determining if it is cancerous’ (and/or whatever else they look at with those kinds of tests).

Metacam is a very minor painkiller that I would give Sophie by oral syringe; about two days’ worth I’d guess from the estimate.?

I would expect either a ton of stress running, or zero running, for who knows how long afterward. She will be in a fair bit of discomfort.? I have also inquired about that; why so little Metacam is on the estimate.? When she had cystitis way back when, Sophie was on Metacam for a full week simply to see if it would help give relief to potential pain. This will be real pain from a fair bit of cauterized skin inside the mouth. Evidently a cauterizing scalpel is a big step up from ‘the old days’ - no stitches, no open wounds, no packing wounds . . . but still! It looks like only a coulple of days’ worth of Metacam is on the estimate.?

The estimate does not include a follow-up visit, which I would consider to be part of the total estimate if it will be needed / required.? I most definitely included a request for clarification on this point because even a minor follow-up visit would probably be on the very high side of $100 - $300 in the blink of an eye; visit charge (for walking in the door); then she’d have to be knocked out again; doctor’s exam fee . . . . I would expect a follow-up to be required for a lot of things, so definitely need to specifically know for sure that the estimate I have is truly complete. A follow-up visit would be a big extra hit; adding, I would guess, on the higher side of 25% - 75% of the surgery estimate to a grand total. But - maybe ‘it is what it is’ and she’ll only need to go back for a follow-up if I think there is a problem.? The vet well knew that I wanted an ‘all inclusive’ estimate and cost range so I’d be surprised for that to be left out. Still, the question needs to be asked.

Certainly I think that Dr. xxxxx trusts me to be on full alert regarding Sophie’s condition; perhaps she is making a follow-up visit discretionary.? She may be saving me some money by not requiring a follow-up visit.? She knows that the total cost is a big concern. Add the surgery estimate to the cost of this last visit and I’m at $760 - $880. That does not allow for the cost of a follow-up visit, which would certainly push the total cost to over $1,000.
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This picture was taken by the vet in June 2013. Not a great picture, but not terrible. (Low resolution image; not a lot of data for me to work with in Photoshop.)
http://serenebreezes.com/Sophie-pix/teeth-1.jpg
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This picture was taken by the vet August 2014. (Much higher resolution; much more data to work with.) The angle is very similar to the image above. It’s not reasonable to assess color differences because the conditions, lighting, and the like, make a big difference. Color should not be considered ‘true’ in either picture and color comparison definitely should not be made. However, the growth of excess gum material appears to completely obscure the teeth and appears to already be folding around and over the teeth.

Only the vet can really say. In retrospect, this aspect of the conversation was pretty vague. I do not have the knowledge to interpret the seemingly apparent differences in these images. Comparing one picture to another, despite being taken from a similar angle, may not give a fully accurate ‘then and now’ look, but there surely does appear to be a lot more gum than teeth in the new picture. Also, the vet is recommending proceeding soon; another reason that I’m thinking that she’s understating severity a bit in her description to me. (Not deliberately necessarily (or at least not entirely), but her understanding and my understanding probably are not quite sync. Of course, that is one of the problems inherent in buying an expert’s time. One can only learn so much within a limited window of time and I can’t be sure that I’m asking the best questions or phrasing them in the best way to maximize what is learned. ‘Asking questions’ is often easier recommended than it is achieved. Time is limited and I lack the experience to cross-examine and counter-question effectively.
http://serenebreezes.com/Sophie-pix/...ertrophy-1.jpg
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A picture from the other side of her mouth:
http://serenebreezes.com/Sophie-pix/...ertrophy-2.jpg


.
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Old 09-02-2014, 09:47 AM   #2 (permalink)
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My Peaches had it. We didn't even discuss surgery but she was 4 years old when she developed it.

There was a medication we gave her that really seemed to help initially. I'll take a look later and see if I have any notes for her still on the computer.

Her teeth would disappear completely in spots and then would appear again. Peaches was a stubborn girl and insisted on eating her hard full sized kibble even though it had to be painful for her and it would make her gums bleed. It took me months to be able to syringe feed her. She was on metacam for most of the last months of her life.

Her gums never turned cancerous, but she did develop a tumour in her head that proptosed her eye and then appeared on the roof of her mouth.

You have not only the financial aspect but what Sophie is going to have to endure and how long her recovery will be to consider and if this is only going to work for a few months, I'm not sure it would be worth it.

I'm on my way out but when I get home I'll see if I can find my notes on Peaches.
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Old 09-02-2014, 09:55 AM   #3 (permalink)
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I was thinking that the two charges for anesthesia was once for the gas to knock her out, then the general for the surgery?

I don't see any supplemental fluid support, my Nara had this during her surgery.

I would inquire about how long the metacam shots last. When my Nara had her surgery (basically a spay-hysterectomy) she was on metacam for 2 or 3 days. She was in considerable discomfort the first night.

My vet gave me a care sheet post surgery for things to watch for. I didn't have a follow up visit, but the vet did call for the next 2 days checking on her. (They call on her birthday too!)

I have no experience with oral issues, you may want to PM Nancy. There's been so MANY people who have experienced oral tumors and cancers.

I am wondering if the Hedgehog Welfare Society has any information/research on oral tumors.

Hoping that all goes well with surgery and hopefully, it won't come back.

ML
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