Management of Feline Gingivostomatitis

By Han Chia, VMD

Feline stomatitis or feline chronic gingivostomatitis (FCGS) is a chronic painful disease due to an atypical immune response toward the bacteria in the oral cavity. The most common presenting complaint is oral pain. Clinical signs include, but are not limited to, halitosis, ptyalism, prehension difficulties, pawing at the muzzle, hissing/growling at food, inappetance/anorexia, and hemorrhagic salivation. Common physical examination findings are ulcerative or proliferative inflammation at the caudal mucosa. Fortunately, only 0.7% to 12.0% of feline patients suffer from this disease; however, limited treatment options and various response rates cause headaches for veterinarians.1 herpesvirus-1, feline immunodeficiency virus, feline leukemia virus, and various bacteria and non-infectious factors have been implicated as contributors to FCGS.2-4 Recently, a multi-factorial etiology has been proposed, which increases the complexity of this frustrating disease.

Typically, FCGS is diagnosed based on the clinical appearance of the lesion. Both gingivitis and mucositis are typically present. It is important to note that gingivitis alone is not FCGS. Differential diagnoses for ulcers in the oral cavity include juvenile periodontitis, oral squamous cell carcinoma, uremic ulcer, eosinophilic ulcer, and autoimmune diseases. Oral biopsy is indicated if the lesion is not consistent with the typical location of FCGS, and/or it is unilateral.

Unfortunately, there is no known prevention for this disease as the exact etiology remains unknown and is likely multi-factorial. The treatment options are typically divided into surgical and medical management.

Surgical Management

Medical Management

Medical management should only be considered after the patient fails to respond to surgical management. Medical therapies focus on immunosuppression or immunomodulation and may become life-long. The typical treatments are corticosteroids and cyclosporine. Corticosteroids are used for short-term control of inflammation due to concerns for adverse effects from long-term use. Cyclosporine is the most common medication for treating refractory FCGS. The recommended initial dose is 2.5mg/ kg PO q12h to reach a therapeutic blood level greater than 300ng/ml.6 This medication is costly and requires intensive monitoring of complete blood counts and renal values, but most feline patients tolerate it well long-term.

The etiopathogenesis of FCGS has been investigated extensively, but the causation has yet to be determined. Many infectious pathogens such as feline calicivirus, feline

Surgical management should be the clinician’s first line treatment, and it typically involves either full mouth or partial mouth extractions. Researchers hypothesized that through removing surfaces [teeth] in the mouth that retain bacteria, the total bacterial load within the oral cavity decreases. Studies revealed 60-80% of cats showed resolution or substantial improvement of clinical signs or oral inflammation after extraction and did not require further medical management. About 20-30% of patients showed minimal response and required continue medical management after extraction, and about 5% of patients had no response.1,5 It can take weeks to determine whether a positive response is seen. If the clinical signs fail to resolve after surgical management, medical management is recommended.

Interferon and stem cell therapy have also been proposed for medical treatment for refractory stomatitis.7-9 However, Feline recombinant interferon omega is available in the United States only through the Food and Drug Administration Compassionate Use Program and is imported on an individual basis. Stem cell therapy is still undergoing research.

In addition, CO2 laser therapy has shown promising positive outcomes for refractory stomatitis cats. The goals of CO2 laser treatment are removing proliferative tissue, reduction of bacterial load, and inducing fibrosis of inflammatory tissue.10 Multiple treatments are typically required for patients to show significant improvement. This treatment should be used as an adjunctive treatment and not a sole treatment.

Goals of Treatment

Overall, FCGS is a very challenging disease. Early diagnosis and aggressive surgical treatment have the highest potential to achieve remission. Medical management strategies are options for refractory stomatitis but are limited. Maintaining good quality of life is the most important objective when considering the treatment options. Unfortunately, there is a small portion of the feline population that will not respond to medical or surgical treatments. Humane euthanasia should be considered if the patient is exhibiting significant levels of uncontrollable pain and displays evidence of poor quality of life.

References:

1. Winer JN, Arzi B, Verstraete FJM. Therapeutic Management of Feline Chronic Gingivostomatitis: A Systematic Review of the Literature. Frontiers in veterinary science. 2016;3:54-54.

2. Berger A, Willi B, Meli ML, et al. Feline calicivirus and other respiratory pathogens in cats with Feline calicivirus-related symptoms and in clinically healthy cats in Switzerland. BMC veterinary research. 2015;11:282-282.

3. Druet I, Hennet P. Relationship between Feline calicivirus Load, Oral Lesions, and Outcome in Feline Chronic Gingivostomatitis

(Caudal Stomatitis): Retrospective Study in 104 Cats. Frontiers in veterinary science. 2017;4:209-209.Niemiec BA. Unusual forms of periodontal disease. In: West Sussex, UK: John Wiley & Sons, Inc; 2012:91-104.

4. Fernandez M, Manzanilla EG, Lloret A, León M, Thibault J. Prevalence of feline herpesvirus-1, feline calicivirus, Chlamydophila felis and Mycoplasma felis DNA and associated risk factors in cats in Spain with upper respiratory tract disease, conjunctivitis and/or gingivostomatitis. Journal of feline medicine and surgery. 2017;19:461-469.

5. Jennings, M. W., Lewis, J. R., Soltero-Rivera, M. M., Brown, D. C., & Reiter, A. M. (2015). Effect of tooth extraction on stomatitis in cats: 95 cases (2000–2013), Journal of the American Veterinary Medical Association, 246(6), 654-660.

6. Lewis JR, Tsugawa AJ, Reiter AM. Use of CO2 Laser as an Adjunctive Treatment for Caudal Stomatitis in a Cat. Journal of Veterinary Dentistry. 2007;24(4):240-249.

7. Arzi B, Mills-Ko E, Verstraete FJM, et al. Therapeutic Efficacy of Fresh, Autologous Mesenchymal Stem Cells for Severe Refractory Gingivostomatitis in Cats. Stem cells translational medicine. 2016;5:75-86.

8. Hennet PR, Camy GAL, McGahie DM, Albouy MV. Comparative efficacy of a recombinant feline interferon omega in refractory cases of calicivirus-positive cats with caudal stomatitis: a randomised, multi-centre, controlled, double-blind study in 39 cats. Journal of feline medicine and surgery. 2011;13:577-587.

9. Hung Y, Yang Y, Wang H, et al. Bovine lactoferrin and piroxicam as an adjunct treatment for lymphocytic-plasmacytic gingivitis stomatitis in cats. The veterinary journal (1997). 2014;202:76-82.

10.Lewis JR, Tsugawa AJ, Reiter AM. Use of CO2 Laser as an Adjunctive Treatment for Caudal Stomatitis in a Cat. Journal of Veterinary Dentistry. 2007;24(4):240-249.

About the Author: Dr. Chia attended the University of Pennsylvania where she earned her Doctor of Veterinary Medicine degree. She completed a rotating internship at Carolina Veterinary Specialists in Charlotte, North Carolina and a dentistry residency at the Center for Veterinary Dentistry and Oral Surgery. Dr. Chia is passionate about all areas of veterinary dentistry and especially interested in periodontal disease, oral masses, stomatitis, and dental education.

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