Severe inflammation of the oral cavity in cats can be found in the literature under different names, but the term gingivostomatitis indicates general inflammation of the gingiva and non-gingival oral mucosa, especially at the back of the oral cavity. Although it seems relatively rare, the complexity of the syndrome and its painful nature make it one of the most challenging diagnostic and therapeutic problems in feline medicine.
The cause is still unknown
The etiology of feline chronic gingivostomatitis (FCGS) is still unknown and the disease likely has a multifactorial etiology. FCGS may or may not be associated with concurrent periodontal disease and/or tooth resorption. The more typical cases of chronic FCGS usually start in adult cats, although some cases may develop from juvenile gingivitis. There is a relationship between the age of onset of the disease and the number of cats in the household and this may implicate either or both social stress and increased exposure to infectious agents as predisposing factors, although one study failed to confirm any age, sex or breed predilection. A likely cofactor in the induction or progression of the disease is calicivirus (FCV) and an immune-mediated component (inappropriate immune response to viral infections) is suspected to play a role in FCGS development.
The disease makes cats suffer
Affected cats may paw at the face and show dysphagia and/or reluctance to eat, this sometimes leading to progressive apathy and weight loss. Bad breath (halitosis), salivation, oral discomfort, bleeding from the mouth and lack of grooming are often noticed and enlarged and painful (reactive) mandibular lymph nodes palpated. Oral exam on an awake patient may be very difficult to perform due to severe pain.
FCGS is characterised by persistent and severe inflammation of the oral (sometimes including lingual) mucosa which may also extend into the pharyngeal mucosa and can be present in the absence of significant dental deposits. Clinically, lesions are described according to the location within the oral cavity, where two specific sites are the glossopalatine mucosa and the buccal mucosa overlying the premolar/molar teeth. Lesions are usually diffuse, bilaterally almost symmetrical, proliferative and bleed easily.
What should a veterinarian do to diagnose FCGS?
Laboratory tests may or may not show abnormalities, but it is important to perform them – CBC and blood biochemistry as well as urinalysis should be performed in all cats to be treated for FCGS as a part of pre-anaesthetic exam and to rule-out any underlying systemic diseases that may result in stomatitis (e.g., uremia). Blood test results are often negative for FeLV and FIV, however FeLV and FIV status is recommended to be determined in view of a general prognosis for the cat. Cats with FCGS are likely to shed FCV and FHV-1, hence the vet and the client may decide to determine FCV and FHV-1 virus status.
Detailed oral exam and full-mouth dental radiographic survey performed under general anaesthesia are used to assess status of teeth and bone quality. Extensive and advanced periodontitis, presence of root remnants and tooth resorption are common findings that may contribute to persistent oral inflammation.
Biopsy of affected areas is always highly recommended to rule-out possibility of malignant neoplasms, and, less likely, eosinophilic granuloma complex or autoimmune diseases. Histopathologic studies reveal a predominance of lymphocytes and plasma cells as well as some neutrophils, mast cells and macrophages, as expected with chronic inflammation. However, it is of utmost importance to relate histopathologic result with a clinical picture – too often cats are still treated for FCGS, while they may have “just” periodontitis, traumatic mucosal lesions or other limited oral mucosal lesions.
How do we treat FCGS?
Since the cause of the disease remains unclear, a number of different combination treatments are currently in use, with no treatment regimen demonstrating clear superiority.
The majority of cases seen (especially in older animals) prove intractable to hygiene measures and extraction of any diseased teeth alone and require additional treatment. This should not be delayed unduly by repeated attempts at medical therapy as many cases will improve following elective tooth extraction – elective extraction of all premolar and molar teeth (and canine and incisor teeth, if these are also associated with severe inflammation) seems to be the most appropriate approach. Typically 60-80 % of cats are clinically cured or improved within a few weeks of such treatment. It is important that dental radiographs are examined closely to allow detection and removal of all root tips and bony sequestra during the treatment, as these will interfere with healing, and extraction sites should be closed with soft tissue flaps. The inflamed gingiva can be debulked surgically prior to mucoperiosteal flaps closure to minimize the amount of residual inflamed tissue. Surgical treatment must be supplemented with abundant pain control measures. Antibiotics are usually used for 2-3 weeks after extractions in addition to local antiseptics, but most patients may need medical management beyond this time.
Surgical treatment is still the golden standard of care with any medical treatment reserved for those cases that are refractory to surgical treatment. Medical treatments aim at reduction of inflammation (e.g., corticosteroids), immunomodulation / immunosuppression (e.g., recombinant feline interferon omega, cyclosporine, corticosteroids, stem cells, lactoferrin), inhibition of bacterial growth (e.g., lactoferrin), and interference with viral replication (e.g., recombinant feline interferon omega). None of these treatments has 100% success rate and all of them have potential side effects. It is therefore important to select the most appropriate treatment for each individual patient, while considering the client’s expectations.
Pain medications are mandatory at any step of the treatment as severe pain associated with the stomatitis must be appropriatelly addressed. If several treatments of FCGS have failed (about 5% cats), or the client declines further attempts, it is necessary to address the issue of quality of life and possibly consider euthanasia.
Selected references
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