Feline Stomatitis

Judy Rochette, DVM, FAVD, DAVDC How I Treat DENTISTRy West Coast Veterinary Dental Services Vancouver, British Columbia Peer Reviewed

Feline Stomatitis

Oral inflammation is a nonspecific indication of pathology and does not signify whether a patient has stomatitis as a result of an incompetent immune response or an exuberant response to stimulation.

he incidence of stomatitis within the general population of cats, while variable, is generally Tconsidered to be low. 1 Given the much higher incidence of periodontal disease and resorptive lesions recognized today in the pet popu - lation, all causes of oral inflammation should be ruled out or treated until chronically inflamed oral tissues can- not be attributed to a pathology other than stomatitis .

J Perform preanesthetic diagnostics & provide supportive care ® Test all patients for FeLV and FIV, regardless of age ® A false-positive FIV response can result when a cat is vaccinated against FIV ® Conduct serum biochemistry panels and CBC to determine if other causes of immunosuppression might exist ® Other potential causes include diabetes mellitus, disseminated lymphoma, or advanced renal or How I Treat Feline Stomatitis thyroid dysfunction J ® Immunosuppressed animals should not receive Perform preanesthetic diagnostics & provide supportive care antiinflammatory medications, as they can further J Perform diagnostics, assessment, & treatment while patient suppress the ability to control oral infection is anesthetized ® Serum biochemistry panels can assess ability to J If inflammation persists after healing period, extract tolerate anesthetics and may exclude specific remaining teeth therapies J Reassess the patient ® Testing for calicivirus or presence of Bartonella spp J has limited value If extractions were insufficient, administer medications ® A positive response should not influence treatment J Follow up of the oral cavity ® Treat comorbidity if patient shows signs of active bartonellosis, especially given its zoonotic potential 2 ­ Because azithromycin and doxycycline have

CONTINUES

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antiinflammatory effects unrelated to ® If gingivitis does not respond to profes - their antibacterial activity, do not inter - sional therapy and plaque control, early- pret initial improvement as indication of onset stomatitis may be present complete and successful therapy 3,4 ® Nutritional support can be crucial to preoper - For Adult Patients Diagnostics, ative stabilization ® Begin multimodal analgesia as soon as possible ® ® assessment, Place esophageal feeding tube to provide Options include presurgery gabapentin, pre - 20–30 calories/lb/day based on ideal body medication with narcotic and/or α2-agonist, and treatment weight local blocks with narcotic added to increase for stomatitis ® Give preoperative fluid support (IV or via duration and effect, 5 ketamine CRI, antiin - should be esophageal tube), warmth, and analgesics to flammatories during recovery, and narcotics help facilitate recovery for home use (buprenorphine, fentanyl performed  patch) while the J Perform diagnostics, assessment, ® Place esophageal feeding tube (if not done patient is & treatment while patient is earlier) if patient is debilitated anesthetized ® anesthetized. Stomatitis is rarely unilateral or focal ® Initial anesthetic visit: full-mouth radiography, ® Biopsy of the focal area may be warranted; removal of compromised teeth, thorough where inflammation is generalized, biopsy cleaning and polishing, and biopsy of focal tends to be nonproductive except if other inflammation/irregular tissue or if autoim - signs of autoimmune disease coexist mune disease is suspected ® Culturing the mouth is usually unproductive ® Rub moist cotton swab over plaque lesion and For Juvenile Patients roll across a slide for cytology ® Perform radiography of all inflamed areas ® Populations of eosinophils or fungal agents ® Assess for normal numbers of teeth, normal may help direct therapy tooth development and placement, presence ® Rinse oral cavity with chlorhexidine-based of cysts or developmental tumors/abnormal - rinse ities; treat as needed ® Acquire full-mouth radiographs to assess ® Assess for infected dental sac; perform oper - tooth numbers, placement, and health, as well culectomy and administer antibiotics as appro - as quality of alveolar bone priate ® Extract any teeth compromised by tooth ® If there is suspicion that inflammation may be resorption, periodontal disease, fracture, or physiologic secondary to tooth eruption, rinse heavy wear or causing soft tissue contact/ oral cavity with chlorhexidine-based rinse and trauma clean/polish teeth +/- fluoride application +/- ® Thoroughly clean and polish any remaining barrier sealant teeth, +/- apply barrier product ® If excessive inflammation persists after com - plete tooth eruption (may be accompanied by J If inflammation persists after healing feline proliferative gingivitis), same care plus period, extract remaining teeth gingivectomy may be required ® If owner cannot provide regular professional ® Institute ongoing plaque control (home care and daily plaque control, reanesthetize care) with regular reassessment and oral care and perform caudal (or full-mouth) extrac - to arrest this inflammatory tendency tions ­ Low-dose doxycycline therapy may assist ® Take dental radiographs to confirm removal of with initial control, and esterified fatty all tooth material acids may prove to be of value in future ® Even teeth with resorption lesions must studies have roots removed ® Plaque-revealing solutions and methods ® Crown amputation should not be used in may help determine if plaque control is stomatitis cases effective ® Suture all extraction sites with absorbable 5-0

98 ...... NAVC Clinician’s Brief / June 2012 / How I Treat suture material using a swedged-on needle ® Should not be given to immunocompro - that dissolves in ~14 days mised patients ® Discharge patient with buprenorphine or ® Perform pretreatment CBC and renal function fentanyl patch tests, as possible adverse reactions include ane - ® Dispense antibiotics if patient shows evidence mia and renal dysfunction of osteomyelitis and/or is immunocompromised ® Cyclosporin A (Atopica, atopica.com; Neoral, ® Antibiotic choice should be bactericidal neoral.com) strongly recommended, as instead of bacteriostatic, liquid instead of bioavailability differs among products pill (unless owner has indicated otherwise) ® Begin at 2–2.5 mg/kg q12h ® Prognosis after extractions: 50%–60% clini - ® Retest renal and CBC values at 3 weeks cally cured, and 30%–40% significantly ® Test blood cyclosporine levels at 6–8 weeks improved with only occasional medication to ensure minimum value of 300 ng/mL for good quality of life 6,7 ­ If blood value is too low, adjust dose to  as much as 5 mg/kg q12h J Reassess the patient ® Prognosis using cyclosporin A after extrac - ® Call the owner 1 day after surgery to ensure tions: large majority of previously unrespon - patient is eating and acting normally sive cats improve; poor response usually Request an ® Adjust analgesic dose or frequency, depend - attributed to idiosyncratic low levels of in-office ing on patient’s behavior cyclosporine absorption and suboptimal blood reassessment ® Request in-office reassessment 7–14 days levels post surgery to gauge healing and level of ® Increased doses allowed improvement of 7 to 14 days inflammation blood levels in most of these suboptimal after surgery ® Revisit in another 14 days if improvement absorbers and corresponding improvement to gauge is poor of oral inflammation 9 healing and J If extractions were insufficient, J Follow up inflammation. administer medications ® If any teeth remain, daily plaque care is essen - ® Start ω-interferon or cyclosporine treatments tial and should include daily brushing, appro - priate dental diet if patient has sufficient teeth Recombinant Feline ω-Interferon to chew kibble-based food, water additives to ® Interferon reportedly has antiviral and anti- control oral plaque, and regular professional inflammatory activity care ® Several protocols for feline ω-interferon are ® In edentulous patients, consider using water available additive (HealthyMouth, healthymouth.com) ® Current literature and ongoing studies sug - for plaque control on other oral surfaces gest low-dose oromucosal administration is (tongue, alveolar ridges) and switching diet most effective with minimal adverse events 8 to novel protein/carbohydrate ­ Protocol includes mixing a 10-MU vial ® Be aware that immunostimulation (allergens, into 100-mL saline, dividing into and vaccines) can trigger stomatitis again then freezing 10-mL vials, thawing 1 vial at a time and administering 1 mL by See Aids & Resources , back page, for references mouth q24h (~100,000 IU) & suggested reading. ® Use of species-specific interferon avoids devel - opment of neutralizing antibodies that mani - fest with human α-interferon

Cyclosporine FOR MORE… ® Alternative treatment if cats are immunocom - See Management Tree on page 101 for an petent and do not respond to extractions or if algorithm on oral inflammation in cats. ω-interferon cannot be acquired

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