Feline Stomatitis

FELINE CHRONIC GINGIVO-STOMATITIS/MUCOSITIS and CAUDAL STOMATITIS/MUCOSITIS:

Feline Stomatitis is a painful condition that we at ADOS encounter on a fairly regular basis.  Feline Chronic Gingivitis/stomatitis/mucositis (FCG-STM) may actually consist of a number of syndromes with the common presenting clinical symptom being severe inflammation of the gingival (gingivitis) and oral mucosa (stomatitis or more properly mucositis) toward the back of the mouth.  Mucositis is a more proper term than stomatitis.

At this time, STM is considered an atypical immune response to one or more unknown etiologic agents, which probably include feline calicivirus (FCV) and maybe feline herpesvirus (FHV).  88% of affected animals shed both of these viruses.  Once present in the body, each of these two viruses cannot be eliminated.  They become permanent residents in the oral cavity.  Therefore, this is considered an incurable problem that may hopefully be controlled.  It is not understood why many felines that harbor these viruses do not develop FCG-STM.

The normal immune system does not eliminate these viruses from the body.  They become permanent residents in the oral and nasal cavities.  They may never cause problems, however, in some cases they provoke the abnormal immune response that results is FCG-STM symptoms over time.   The presence of  plaque bacteria can create similar immune reactions surrounding  the teeth and may secondarily exacerbate the caudal oral cavity (FGC-STM) condition.  Feline Bartonella has been incriminated by some as the cause of this disease.  If it is present, it is probably as an opportunistic infection and likely not the primary reason for the oral inflammation.

The classical “stomatitis” lesions are at the back of the mouth where the upper (maxillary) dental arch extends downward to meet the lower (mandibular) dental arch.  For the sake of communications, we like to refer to this area on both sides of the mouth as the arches.  Inflammation in this area is called caudal stomatitis or caudal mucositis.   Severe inflammation in the areas where teeth are located is termed gingivitis and gingivo-mucositis if the inflammation extends beyond the gums to involve the adjacent alveolar mucosa.  The severe inflammatory reaction of the gingiva and alveolar mucosa is also considered an atypical immune response and plaque bacteria may be a factor here.  The more severe the inflammation is in the caudal arch areas, especially if it extends to involve the lateral tongue and dental arches, the poorer the prognosis for long term control.  You may consider treatment of this chronic inflammatory disease, in most cases, to be a life-long process.

FCG-STM is considered to be a chronic, incurable disease; however, there are a variety of treatment options available that may help control symptoms and improve the quality of your pet’s life.  Clearly, not all FCG-STM patients are alike.  Some patients respond to periodontal treatment, some to antibiotics, some to steroids and antibiotics, some to extractions, and some to nothing at all.  In many cases where there is initial control, however, worsening often occurs over time.  Depending on the individual case, medication dosages or the medications themselves may need to be adjusted or changed.  Eventually, there may be nothing that effectively controls  symptoms.  Remember that any medication can have side effects.  For this disease, the use of medications that may have some risk is a better alternative than living with this disease.

Classifying cases:

  1. Initial treatment (fresh cases):
  • Periodontal treatment
  • Extraction of teeth with Feline Resorptive Lesions and periodontitis
  • Anti-inflammatory agents
  • Antibiotics
  • Antiseptic oral rinses
  • Nutritional support

2. Non-responsive (refractory) cases:

  • Premolar-molar (or full-mouth) extractions. 60-80% of cases improve a significant degree or resolve following premolar and molar extractions
  • Some cases require removal of the incisors and canine teeth as well
  • Long-term medical management may be necessary

3. Alternative treatment options with variable results:

  • Cyclosporine-A
  • CO2 laser therapy
  • Interferon (Omega)
  • Stem cell therapy

Treatment Options:

  1. Dental Extractions: In the face of FCG-STM, this is the preferred initial treatment choice.  Other treatments do not work very well until the bacterial loads are reduced (extractions performed).  Although not proven, most experienced with treatment of this disease agree that the earlier extractions are performed in the disease process the better the prognosis seemingly is.  Remember that the criteria for extraction is when we cannot otherwise control infection or pain and this is almost always the case when this disease is present.  About 60 to 80% of cases improve or resolve following premolar-molar extractions.  Success is measured by the response to treatment: reduced or resolved inflammation, the lack of or significant decrease of clinical signs (decreased appetite, pain on open mouth, drooling, pawing at face) and patient’s level of “well being”.  Some individuals respond very well to extractions only, and others do not improve at all.  Most cases fall somewhere in between.  Which teeth, and how many require extracting, depends on the individual pet’s case.  Partial-mouth extractions: cheek teeth (premolars and molars) to full-mouth extractions (incisors, cheek teeth, canine teeth) are usually needed.  If partial-mouth extractions are performed, it should be remembered that eventually the remaining teeth (canines) may need to be removed as well.  With each extraction, all tooth material must be carefully removed.  If root material is left behind, inflammation may not subside.  Extraction of feline teeth is technically very difficult and time consuming.  Depending upon factors such as the individual’s overall health and anesthesia risks, oral surgery (extractions) may need to be staged (work performed in two stages).  In some cases, two shorter anesthetic procedures and recoveries may have less risk than one very long episode.  After extraction sites have healed and sutures dissolved, the need for medical management can be assessed.Most cats do surprisingly well in the immediate post oral surgery/extraction period.  This is the usual case even when full mouth extractions have been necessary.  We typically recommend only offering soft food for a couple of weeks after extraction procedures, but once the extraction sites have healed some cats will prefer to eat hard food, even in cases where they have had all of their teeth extracted.  This is likely because most cat kibble is quite small and can be easily swallowed whole.  As true carnivores, cats are primarily food gulpers and not chewers as humans suspect. This means they have the mechanism for by-passing their teeth when they are diseased or when some or all are missing.  If patients are significantly debilitated from their disease prior to extractions, or if it is assessed that there may be recovery/healing difficulties, placement of a temporary feeding tube may be necessary to by-pass the oral cavity and provide a means of providing nutritional support during the healing process.  Feeding tubes are usually very well tolerated and are much more patient friendly than they may seem.
  2. Oral antiseptics: Can be beneficial in some cases.  Some cats will not tolerate administration oral rinses.  Existing oral pain and poor tasting medications make this treatment option difficult for many clients
  3. Systemic antibiotics: May be used from time to time depending upon the case.  Regular intermittent use or continual long-term use may be inappropriate and can lead to antibiotic resistance.
  4. Systemic steroids (injection or oral): Steroids can be one of the more helpful treatment options.  The dosage varies and how much and how often depends on the individual patient’s circumstances.  Patients on oral steroids can have their dosages tapered down to find the lowest possible maintenance level.  This can greatly reduce the risk of side effects.
  5. Cyclosporin: Another immunosuppressive drug used to impair and inhibit the immune response.  There may be side effects, and dosage levels need to be monitored carefully.  Use of this drug may be more labor intensive and expensive.  This is often our alternative if management with steroids is unsuccessful for some reason.
  6. Laser ablation of the inflamed tissues: Laser ablation may be helpful for some select patients.  This often requires staged treatments, and disappointing results may occur as inflamed tissues tend to regrow to previous levels in a short period of time.  Pain after these procedures can make a patient unwilling or unable to eat. If this occurs, placement of a temporary feeding tube may be necessary to provide nutritional support during the healing process.
  7. Stem cell therapy: Stem cell treatment is currently undergoing research.  Although promising results are being noted, the final results are not yet conclusive and it is too early to call this mainstream.
  8. Miscellaneous Treatments: There are numerous anecdotal reports of different drugs and modalities for treating FCG-STM.  This includes homeopathic medications and Omega Interferon (which is available in Europe, but not in the USA).  Some may be worth attempting, however, results are generally disappointing and one must be careful and selective about trying unproven products and regimens.  Unfortunately, there is no good science that supports many of these products.