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Feline gingivostomatitis

Carl Gorman BVSc MRCVS

Key words: Laser, gingivitis, gingivostomatitis, feline, oral

 

(The advice on laser treatment of this condition is applicable to all types of gingivitis in cats and dogs.)

Feline gingivostomatitis (FGS) is a complex disorder which is very common in domestic cats.  It may also be known as chronic gingivostomatitis, or oral mucositis (as adopted by the American Veterinary Dental College).  It is painful and potentially debilitating.  It can be challenging to manage because of its complicated aetiology and pathogenesis.  As a consequence, it is a frustrating disease for both owners and veterinary professionals.  The difficulties in successfully treating FGS can leave many cats suffering long term pain, poor appetite, poor coats through inadequate grooming, and may cause a breakdown of the relationship between cat and owner. (Fig 1)

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Fig 1       Poor coat and body condition may be seen in cases of gingivitis and stomatitis

Due to the complicated nature of the disease, it is important to try to determine the causes in each case where possible.  Good communication with clients is vital to ensure that they appreciate the potential profound effects on their cat and to manage their expectations.  Bringing about improvement in FGS may be a lengthy and costly process.

Incidence

The incidence of FGS is just under 1% in the UK cat population.  Males and females are equally likely to be affected.  Gingivitis may commonly be seen at three stages in a cat's life - when they are young kittens (vaccination age), when the adult teeth are growing through (5-6 months of age) and then when they are older (averaging 7 years old).  The first two incidences tend to be short lived, whether they need treatment or not.  The later developing syndrome is the more persistent one.

Clinical signs and diagnosis

Cats affected by FGS may have inflammation of some or all of the mucous membranes.  Red, raw tissue may be found on the gums, under the tongue, inside the cheeks and affecting the tissue at the rear of the oral cavity (caudal mucositis, formerly often known as faucitis).  (Fig 2) Sometimes there are 'kissing lesions' - inflamed swollen areas where teeth come into contact with gum tissue on the opposing jaw.  These may develop into proliferative masses on the gums.

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Fig 2       Caudal mucositis, sometimes referred to as 'faucitis'

Affected cats may display:

  • halitosis
  • salivation (often foul smelling, and sometimes tinged with blood)
  • pawing at their mouths
  • backing away from food
  • fragile gums which bleed easily (Fig 3)
  • pain
  • weight loss (though many cats maintain their body weight)
  • unkempt coats through reduced grooming
  • swollen submandibular lymph nodes
  • varying degrees of tooth lesions (but some cats may appear to have normal teeth, while other cats with extensive resorptive lesions do not suffer with gingivitis)

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Fig 3       Bleeding gums

Diagnosis is not difficult; although oral injury, eosinophilic granuloma and oral neoplasia should be ruled out.  Inflammation of the oral tissue extending beyond the immediate vicinity of the teeth is normally enough to make the diagnosis.  (Fig 4), (Fig 5).

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Fig 4       Gingivitis is inflammation of the gum tissue adjacent to the teeth

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Fig 5       In gingivostomatitis the inflammation extends beyond the vicinity of the teeth

Histopathology is rarely necessary, unless there is a suspicion of neoplasia.  (Fig 6) Pathology will show infiltrates of lymphocytes and plasma cells.

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Fig 6       Suspicious masses should be biopsied to differentiate from gingivostomatitis lesions

Aetiology and pathogenesis

While there are many potential underlying causes of FGS, it is now generally accepted that the actual disease process is caused by an inappropriately severe immune response to plaque (the biofilm of bacteria which forms on teeth).

The majority of cats affected by FGS shed calici virus, and it is assumed that the virus is an important factor in the disease. Recent work has shown that almost all cats with caudal stomatitis (also sometimes called faucitis) are calici virus carriers.   Cats infected with FeLV and FIV are more likely to develop FGS.

Bartonella henselae is a gram-negative bacteria which is the cause of cat scratch disease in people.  About 80% of FGS affected cats have positive serology to Bartonella, though it is uncertain whether this is a direct cause of FGS.  The organism can be persistent in the blood and can interfere with immune responses, so it may be a factor.

Nutrition, bacterial infection, plaque and tartar and food allergies may all play a part in FGS.

Management

The diagnosis of FGS will usually be easily made with a physical examination.

When assessing cats, the following examinations to assess health status and causes should be considered:

  • Full blood profile and urinalysis to assess for systemic disease
  • FeLV and FIV testing
  • Examination under anaesthetic including dental x-rays

Tests which are less useful for aiding treatment are:

  • Histopathology (unless neoplasia or eosinophilic granuloma is suspected)
  • Testing for calici virus, herpes virus, Bartonella,
  • Culture and sensitivity

Extraction of all premolar and molar teeth (and of canines and incisors if those areas are affected) should be carefully performed.  Around 50-60% of cats which are calici virus positive will be cured with this treatment, 25-30% will be markedly improved, while 15% won't show a positive response.

Antibiotic treatment should be started.  Clindamycin is a good choice because of its efficacy against oral bacteria and its penetration into bone.  Doxycycline has efficacy against Bartonella and would be a suitable alternative.

Cases which fail to respond well to this treatment should receive immunosuppressive therapy.  Normally this is through corticosteroids - prednisolone tapered after 3 to 4 weeks of daily treatment.  Some clinicians caution against using corticosteroids because of the risk of diabetes mellitus with long term use, the reduction in immune response reducing the cat's ability to clear infective agents and the fact the response to steroids is poorer with subsequent courses of treatment.  Refractory cases may respond to cyclosporine, although cats should be tested for Toxoplasma before starting such potent immune suppression.

Pain relief is an important part of the management of this disease.  Meloxicam is commonly used and is effective for analgesia.  Its anti-inflammatory effects may improve FGS, but anecdotally corticosteroids are more effective.  Naturally meloxicam and steroids must not be used at the same time.

Interferon can be helpful in some difficult cases.  This may be because of its antiviral effect, or because it mediates inflammatory cytokines.  Various regimes have been developed for its use in FGS; through injection, local injection, oral and topical application.

CO2 laser surgery to ablate the inflamed tissue can be very useful where tooth extraction has failed to cure FGS.  More studies need to be carried out into its use and efficacy, but in the author's hands results have been good.  All inflamed tissue should be ablated, which may take more than one treatment to achieve.  Although a large area of oral tissue is being treated, post op comfort appears to be good.

Class IV laser therapy

Laser therapy has the potential to aid management of FGS in several ways.  The treatment reduces pain and inflammation and speeds healing.  (Fig 7)

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Fig 7       A cat receiving laser treatment for gingivitis; treatment can be delivered through the cheeks

Pain perception is reduced by an increased release of local endorphins.  Nerve receptors are rendered less sensitive to pain.  This is an important factor in managing FGS.

Inflammation is reduced by a decreased release of prostaglandins and inflammatory mediators.  Macrophage activity and leukocyte phagocytosis are increased.  Lymphatic vessels are dilated, reducing oedema.

Healing is accelerated by increased angiogenesis, increased release of stimulating cytokines and stimulation of fibroblasts leading to collagen production.

Studies are needed into the use of laser therapy in FGS.  In human medicine research has shown good response to laser therapy in aphthous stomatitis (a condition causing recurring ulcers) and oral mucositis (painful inflammation in the mouth which is common in patients receiving radiotherapy or chemotherapy for head and neck cancers).  A pilot study reported at the Oncology Nursing Society's 40th Annual Congress followed 52 patients deemed at high risk for oral mucositis.  All received preventive laser therapy.  No patients developed oral mucositis.

Practical treatment

The MLS laser has a stomatitis setting, which should be suitable for most cases.  It is not necessary to open the mouth, as the laser will penetrate deep enough through the cheeks to reach the inflamed tissues.

Treatment may be applied in conjunction with any of the suggested treatments above.  Before extraction of the cheek teeth is performed, laser therapy will help with pain and inflammation.  After extractions have been performed the laser will also speed healing.

The laser should not be applied to tumours, so a diagnosis of cancer should be ruled out before proceeding.

A suggested regime would be 3 treatments in week one, 2 treatments in week two and 1 treatment in week 3 and subsequent weeks.  This can be adjusted according to response, and a maintenance regime may be needed.

The same treatment regime can be used for all cases of gingivitis and oral discomfort in dogs and cats.