33d ago

Feline Stomatitis Notes

Feline Stomatitis—Feline Chronic Gingivostomatitis (FCGS)

Basics Overview

  • Inflammatory response affecting the oral cavity in cats.

  • FCGS oropharyngeal inflammation classification by location:

    • Alveolar mucositis (alveolar stomatitis): Inflammation of alveolar mucosa (mucosa overlying the alveolar process and extending from the mucogingival junction without obvious demarcation to the vestibular sulcus and to the floor of the mouth).

    • Caudal mucositis: Inflammation of mucosa of the caudal oral cavity, bordered medially by the palatoglossal folds and fauces, dorsally by the hard and soft palate, and rostrally by alveolar and buccal mucosa.

    • Glossitis: Inflammation of mucosa of the dorsal and/or ventral surface of the tongue.

    • Stomatitis: Inflammation of the mucous lining of any of the structures in the mouth; in clinical use the term should be reserved to describe widespread oral inflammation (beyond gingivitis and periodontitis) that may also extend into submucosal tissues.

Signalment

  • Cats.

  • Purebred breeds predisposed: Abyssinian, Persian, Himalayan, Burmese, Siamese, and Somali.

Signs

  • Ptyalism.

  • Halitosis.

  • Dysphagia.

  • Anorexia and/or prefers soft food.

  • Weight loss.

  • Scruffy hair coat from lack of grooming.

  • Erythematous, ulcerative, proliferative lesions affecting gingiva, glossopalatine arches, tongue, lips, buccal mucosa, and/or hard palate.

  • Gingival inflammation commonly completely surrounds the tooth, compared with gingivitis, which usually occurs on buccal and labial surfaces.

  • May extend to glossopharyngeal arches as well as palate.

Causes & Risk Factors

  • Cause unknown; bacterial, viral, and immunologic etiologies suspected.

  • Significant findings of feline calicivirus; however, calicivirus load does not correlate with degree of inflammation or prognosis of positive therapy.

  • Immunosuppression from feline leukemia virus (FeLV) or feline immunodeficiency virus (FIV) can also lead to poorly responsive infections; most affected cats are negative for FeLV. Concomitant FIV infection is not uncommon.

Diagnosis

Differential Diagnosis
  • Periodontal disease.

  • Oral malignancy.

  • Eosinophilic granuloma complex.

CBC/Biochemistry/Urinalysis
  • Elevated globulin: polyclonal gammopathy secondary to antibody production following bacterial invasion into periodontal tissues.

  • Leukocytosis and eosinophilia may be present.

Imaging
  • Intraoral radiographs to evaluate periodontal disease and tooth resorption.

Diagnostic Procedures
  • Biopsy (especially unilateral lesions) to rule out neoplasia—primarily squamous cell carcinoma.

  • Calicivirus, Bartonella, and oral bacterial culture and sensitivity testing not recommended.

Treatment

  • Prognosis for cats whose lesions do not include caudal oral mucosa is better than those affected by caudal stomatitis.

  • Initial therapy for early cases of alveolar mucositis involves dental scaling above and below gingiva and treatment (extraction) for teeth affected with grades 3 and 4 periodontal disease and/or tooth resorption.

  • For cases of focal vestibular and alveolar mucositis, extraction of locally affected teeth in proximity to lesions usually results in resolution.

  • For cases of moderate to marked caudal stomatitis, extraction of all maxillary and mandibular teeth (including root fragments) or those distal to canines (if no clinical evidence of disease affecting canines and incisors) resulted in resolution of inflammation in ~60% of cases without further need for medication, with ~20% of cases requiring control with medication, and ~20% refractory.

  • To aid extractions, create a gingival flap in all quadrants for exposure; after completely elevating all roots, use high-speed drill with water spray to create trough of bone where roots were, removing most of keratinized gingiva, periodontal ligament, and periradicular alveolar bone; before suturing, “smooth down” alveolar margin to remove sharp edges with round or football-shaped diamond bur.

  • CO2CO_2$$CO_2$$ laser has been effective as treatment adjunct during initial care, especially in cases of moderate to marked caudal stomatitis; laser helps to remove some of inflamed tissue and bacterial load; laser is set to 4 W of continuous energy; after shielding airway from laser energy with moistened gauze, inflamed areas can be rastered; relasering recommended monthly for 3 months if inflammation persists.

  • If patients do not respond to extraction of teeth distal to canines, consider trial of prednisolone 2 mg/kg every other day to control the inflammation, or remove all teeth; when extracting teeth, pay meticulous attention to removing all dental hard tissue; take intraoral radiographs before and after surgery; postoperative application of fluocinonide 0.05% (Lidex Gel) to gingival margin may help healing.

  • Refractory cases with extensive proliferative lesion in caudal oral cavity and pharynx warrant more guarded prognosis.

Medications
Drug(s) of Choice
  • Medication and other therapies have been used with limited long-term success; lack of permanent response to conventional oral hygiene, antibiotics, anti-inflammatory drugs, and immunosuppressive drugs is typical; medications should not be regarded as primary method to control oropharyngeal inflammation.

  • Antibiotics:

    • Clindamycin 5 mg/kg q12h

    • Metronidazole

    • Amoxicillin

    • Ampicillin

    • Enrofloxacin

    • Tetracycline

  • Corticosteroids:

    • Prednisone 2 mg/kg initially daily, followed by every other day

    • Methylprednisolone acetate 2 mg/kg q7–30 days may also help control inflammation.

  • Gold salts: Solganal 1 mg/kg IM weekly until improvement (up to 4 months), then every 14–35 days.

  • Chlorambucil: 2 mg/m2m^2$$m^2$$ PO every other day or 20 mg/m2m^2$$m^2$$ every other week.

  • Bovine lactoferrin: 40 mg/kg applied to oral mucous membranes.

  • Interferon: alpha or omega 30 IU/day 7 days on, 7 days off, indefinitely.

  • CO2CO_2$$CO_2$$ laser to decrease inflamed tissue.

  • Cyclosporine: 2 mg/kg BID.

Follow-Up Patient Monitoring
  • Recommend 2- and 4-week postoperative examinations to determine success of surgical procedure.

  • Soft diet should be encouraged for 2 weeks postoperatively, though some cats may not accept any dietary changes well.

Prevention/Avoidance

  • N/A

Possible Complications

  • Wound dehiscence; inappetence, refractory caudal inflammation.

Expected Course and Prognosis

  • Caudal mouth extractions have been shown to greatly improve large percentage of patients; full-mouth extractions sometimes warranted.

  • Refractory cases with extensive proliferative lesion in caudal oral cavity and pharynx warrant more guarded prognosis.

Miscellaneous

Associated Conditions
  • Lymphocytic plasmacytic stomatitis.

  • Stomatitis.

Abbreviations
  • FeLV = feline leukemia virus.

  • FIV = feline immunodeficiency virus.

Internet Resources
  • https://avdc.org/avdc-nomenclature

Suggested Reading
  • Bellows, JE. Feline Dentistry. Oxford: Wiley-Blackwell, 2010.

  • Druet I, Hennet P, Relationship between Feline calicivirus load, oral lesions, and outcome in feline chronic gingivostomatitis (caudal stomatitis): retrospective study in 104 cats. Front Vet Sci 2017, 4:209. doi: 10.3389/fvets.2017.00209

  • Wiggs RB, Lobrise HB. Veterinary Dentistry: Principles and Practice. Philadelphia, PA: Lippincott-Raven, 1997.


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Feline Stomatitis Notes

Feline Stomatitis—Feline Chronic Gingivostomatitis (FCGS)

Basics Overview

  • Inflammatory response affecting the oral cavity in cats.
  • FCGS oropharyngeal inflammation classification by location:
    • Alveolar mucositis (alveolar stomatitis): Inflammation of alveolar mucosa (mucosa overlying the alveolar process and extending from the mucogingival junction without obvious demarcation to the vestibular sulcus and to the floor of the mouth).
    • Caudal mucositis: Inflammation of mucosa of the caudal oral cavity, bordered medially by the palatoglossal folds and fauces, dorsally by the hard and soft palate, and rostrally by alveolar and buccal mucosa.
    • Glossitis: Inflammation of mucosa of the dorsal and/or ventral surface of the tongue.
    • Stomatitis: Inflammation of the mucous lining of any of the structures in the mouth; in clinical use the term should be reserved to describe widespread oral inflammation (beyond gingivitis and periodontitis) that may also extend into submucosal tissues.

Signalment

  • Cats.
  • Purebred breeds predisposed: Abyssinian, Persian, Himalayan, Burmese, Siamese, and Somali.

Signs

  • Ptyalism.
  • Halitosis.
  • Dysphagia.
  • Anorexia and/or prefers soft food.
  • Weight loss.
  • Scruffy hair coat from lack of grooming.
  • Erythematous, ulcerative, proliferative lesions affecting gingiva, glossopalatine arches, tongue, lips, buccal mucosa, and/or hard palate.
  • Gingival inflammation commonly completely surrounds the tooth, compared with gingivitis, which usually occurs on buccal and labial surfaces.
  • May extend to glossopharyngeal arches as well as palate.

Causes & Risk Factors

  • Cause unknown; bacterial, viral, and immunologic etiologies suspected.
  • Significant findings of feline calicivirus; however, calicivirus load does not correlate with degree of inflammation or prognosis of positive therapy.
  • Immunosuppression from feline leukemia virus (FeLV) or feline immunodeficiency virus (FIV) can also lead to poorly responsive infections; most affected cats are negative for FeLV. Concomitant FIV infection is not uncommon.

Diagnosis

Differential Diagnosis

  • Periodontal disease.
  • Oral malignancy.
  • Eosinophilic granuloma complex.

CBC/Biochemistry/Urinalysis

  • Elevated globulin: polyclonal gammopathy secondary to antibody production following bacterial invasion into periodontal tissues.
  • Leukocytosis and eosinophilia may be present.

Imaging

  • Intraoral radiographs to evaluate periodontal disease and tooth resorption.

Diagnostic Procedures

  • Biopsy (especially unilateral lesions) to rule out neoplasia—primarily squamous cell carcinoma.
  • Calicivirus, Bartonella, and oral bacterial culture and sensitivity testing not recommended.

Treatment

  • Prognosis for cats whose lesions do not include caudal oral mucosa is better than those affected by caudal stomatitis.
  • Initial therapy for early cases of alveolar mucositis involves dental scaling above and below gingiva and treatment (extraction) for teeth affected with grades 3 and 4 periodontal disease and/or tooth resorption.
  • For cases of focal vestibular and alveolar mucositis, extraction of locally affected teeth in proximity to lesions usually results in resolution.
  • For cases of moderate to marked caudal stomatitis, extraction of all maxillary and mandibular teeth (including root fragments) or those distal to canines (if no clinical evidence of disease affecting canines and incisors) resulted in resolution of inflammation in ~60% of cases without further need for medication, with ~20% of cases requiring control with medication, and ~20% refractory.
  • To aid extractions, create a gingival flap in all quadrants for exposure; after completely elevating all roots, use high-speed drill with water spray to create trough of bone where roots were, removing most of keratinized gingiva, periodontal ligament, and periradicular alveolar bone; before suturing, “smooth down” alveolar margin to remove sharp edges with round or football-shaped diamond bur.
  • CO2CO_2 laser has been effective as treatment adjunct during initial care, especially in cases of moderate to marked caudal stomatitis; laser helps to remove some of inflamed tissue and bacterial load; laser is set to 4 W of continuous energy; after shielding airway from laser energy with moistened gauze, inflamed areas can be rastered; relasering recommended monthly for 3 months if inflammation persists.
  • If patients do not respond to extraction of teeth distal to canines, consider trial of prednisolone 2 mg/kg every other day to control the inflammation, or remove all teeth; when extracting teeth, pay meticulous attention to removing all dental hard tissue; take intraoral radiographs before and after surgery; postoperative application of fluocinonide 0.05% (Lidex Gel) to gingival margin may help healing.
  • Refractory cases with extensive proliferative lesion in caudal oral cavity and pharynx warrant more guarded prognosis.

Medications

Drug(s) of Choice
  • Medication and other therapies have been used with limited long-term success; lack of permanent response to conventional oral hygiene, antibiotics, anti-inflammatory drugs, and immunosuppressive drugs is typical; medications should not be regarded as primary method to control oropharyngeal inflammation.
  • Antibiotics:
    • Clindamycin 5 mg/kg q12h
    • Metronidazole
    • Amoxicillin
    • Ampicillin
    • Enrofloxacin
    • Tetracycline
  • Corticosteroids:
    • Prednisone 2 mg/kg initially daily, followed by every other day
    • Methylprednisolone acetate 2 mg/kg q7–30 days may also help control inflammation.
  • Gold salts: Solganal 1 mg/kg IM weekly until improvement (up to 4 months), then every 14–35 days.
  • Chlorambucil: 2 mg/m2m^2 PO every other day or 20 mg/m2m^2 every other week.
  • Bovine lactoferrin: 40 mg/kg applied to oral mucous membranes.
  • Interferon: alpha or omega 30 IU/day 7 days on, 7 days off, indefinitely.
  • CO2CO_2 laser to decrease inflamed tissue.
  • Cyclosporine: 2 mg/kg BID.

Follow-Up Patient Monitoring

  • Recommend 2- and 4-week postoperative examinations to determine success of surgical procedure.
  • Soft diet should be encouraged for 2 weeks postoperatively, though some cats may not accept any dietary changes well.

Prevention/Avoidance

  • N/A

Possible Complications

  • Wound dehiscence; inappetence, refractory caudal inflammation.

Expected Course and Prognosis

  • Caudal mouth extractions have been shown to greatly improve large percentage of patients; full-mouth extractions sometimes warranted.
  • Refractory cases with extensive proliferative lesion in caudal oral cavity and pharynx warrant more guarded prognosis.

Miscellaneous

Associated Conditions

  • Lymphocytic plasmacytic stomatitis.
  • Stomatitis.

Abbreviations

  • FeLV = feline leukemia virus.
  • FIV = feline immunodeficiency virus.

Internet Resources

  • https://avdc.org/avdc-nomenclature

Suggested Reading

  • Bellows, JE. Feline Dentistry. Oxford: Wiley-Blackwell, 2010.
  • Druet I, Hennet P, Relationship between Feline calicivirus load, oral lesions, and outcome in feline chronic gingivostomatitis (caudal stomatitis): retrospective study in 104 cats. Front Vet Sci 2017, 4:209. doi: 10.3389/fvets.2017.00209
  • Wiggs RB, Lobrise HB. Veterinary Dentistry: Principles and Practice. Philadelphia, PA: Lippincott-Raven, 1997.