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An Updated Approach to Chronic Feline Gingivitis Stomatitis Syndrome

An Updated Approach to Chronic Feline Gingivitis Stomatitis Syndrome

34 VP JULY 2012 An updated approach to chronic feline syndrome (www.avdc.org) as: “Inflammation of surface and elsewhere in the practice by a factor of 2:1. In the same the mucous lining of any of the mouth. case survey, the Maine Coon and structures in the mouth; in clinical use Not all cases of FCGS present in Siamese breeds do appear to have the term should be reserved to the same manner. A wide range of more affected individuals than any describe widespread oral severity of initial signs does commonly other. (beyond gingivitis and periodontitis) occur. Some cats respond well to In a survey of nearly 5,000 cats in that may also extend into sub-mucosal routine periodontal therapy and 12 practices over a 12 week period, 34 tissues (e.g. marked caudal mucositis improved hygiene alone while others cases of chronic FCGS were identified extending into sub-mucosal tissues will respond poorly to any treatment. and no breed bias was identified may be termed caudal stomatitis).” The implication is that some cats (Healey, 2007). Paradoxically, the condition is often have a very low threshold to the • Environmental factors. Colony cats present in the absence of significant trigger factors(s) whilst others have a or those in multi-cat households accumulation of on the teeth. higher threshold approaching the level appear to be more commonly affected The syndrome can be seen at three for normal cats. Most intractable cases early in life. Increased stress levels plus Figure 1. distinct times in a cat’s life. Firstly, (87%) improve with elective tooth the close proximity of other cats around the time of kitten vaccinations, extraction and a few cases (13%) do allowing transmission of viruses and THE condition currently, and most oral inflammation can occasionally be not respond to any treatment (Hennet, other micro-organisms are held to be commonly, known as Feline seen. Whether this is an immune 1997; Girard and Hennet, 2005; significant factors. Chronic Gingivo-Stomatitis (FCGS) response to vaccinal elements or the Hennet, 2010). • Plaque bacteria. The oral bacteria is a relatively common and eruption of deciduous and present in matrix drives frustrating problem to the small consequential increased levels in dental Clinical signs the inflammatory response in normal animal practitioner. In a study of plaque is not known. Many, but not all, cats present with individuals. Cats that appear to be nearly 5,000 cats by 12 practices, A second period to see an increase dysphagia and pain due to extensive plaque intolerant show a variable the prevalence of FCGS was 0.7% in oral inflammation levels is when the oral inflammation and ulceration of threshold to the bacterial load of the (Healey, soft tissues. In some cases it can be mouth displaying an abnormal and 2007). NORMAN JOHNSTON hard to understand how the individual non-specific level of inflammation. Many outlines a logical method of eats or functions normally with such Specific bacteria, as seen in cases prove to investigation and treatment of extensive oral inflammation. , have been be extremely this relatively common and Inflammatory lesions may involve reported in these cats and Pasteurella frustrating frequently frustrating problem – some or all of the oral soft tissues. and species are more highly with a based on the known evidence Most cases present with inflammation represented than others. Around half confusing base and ulceration of the tissues lateral to the cats seen by the author harvested number of the palatoglossal folds in addition to pure cultures of Pasteurella multocida different treatments in current use. permanent teeth erupt. Lastly, and the gingiva and mucosa overlying the (Dolieslager, 2011). The purpose of this article is to bring most commonly, FCGS is seen later in cheek teeth. Other oral tissues such as together a logical method of life with a mean age of seven years. the pharynx, tongue and the Viruses investigation and treatment for these This syndrome must be considered mandibular salivary glands can • Feline Calici Virus. Many papers cases based on the known evidence as part of a full oral cavity also be affected in severe cases. report a level above 70% of base where possible. examination. The presence of other Commonly reported signs include: chronically affected individuals with The syndrome is characterised by problems concurrently, such as tooth • anorexia and/or dysphagia; signs for over six months showing persistent and severe inflammation and resorption lesions (TRs), frequently • severe halitosis; positive testing to virus isolation ulceration of the oral soft tissues. adds to and confuses the picture. • weight loss – chronic or acute; following oropharyngeal swabbing for Many times this includes the tissues It has been known for some time • lack of (or an inability to) groom; Feline Calici Virus (Knowles, 1989; lateral to the palatoglossal folds that carriage of Feline Calici Virus • a reluctance to eat hard food; Thomson, 1984; Harbour, 1991). The (Figure 1) in addition to the gingiva, (FCV) is a co-factor in the induction • submandibular lymphadenomegaly – significance of this within the pharyngeal and lingual mucosa. or progression of the complex. The nodes often dramatically increased in syndrome is not known. Stomatitis is defined by the relationship between calici infection size and painful when palpated; It is possible that the virus American Veterinary Dental College and FCGS appears strong with 70- • variable, sometimes minimal, damages cell membranes allowing 90% of chronic stomatitis cats testing accumulation of plaque and calculus; easier antigenic penetration by other Norman Johnston, BVM&S, DipEVDC, positive compared with 20% of • teeth may be missing, affected by agents. However, other co-factors are DipAVDC, MRCVS, RCVS Recognised general population cats (Knowles, TRs or suffering from furcation required before this virus can cause Specialist in , 1989; Harbour, 1991). exposure and excessive mobility after disease as FCV carriage in the cat graduated from Edinburgh in 1976 It has also been reported that the recession of the periodontal tissues. population is around 20-30% and owns a dedicated referral dental relationship between FCV and FIV (Knowles, 1989; Zicola, 2009). and oral surgical practice near Edinburgh. He is a diplomate of both appears strong but the association Aetiology One research study (Hennet and the American and European between the two has never been This is a complex multifactorial Boucrault-Baralon, 2005) considered Veterinary Dental Colleges and a established for FCGS cats (Knowles, condition and there is no simple that chronic palatoglossitis lesions, as Fellow of the Academy of Veterinary 1989 and 1991). aetiological agent for the syndrome. opposed to buccostomatitis lesions, to Dentistry. He has been a registered Many cats also present with a Certain factors are thought to have an be more specifically associated with RCVS Specialist in Veterinary Dentistry hypergammaglobulinaemia (Harley, effect but the most commonly held calicivirus carriage. since 2002. He is a past president of 1999; Harley, 2003). This implies B view is that these cats suffer from an • Feline Immunodeficiency Virus (FIV) the European Veterinary Dental lymphocyte proliferation and therefore immunological over-reaction to low infection may have a role in producing College, the British Veterinary Dental no humoral immune response levels of oral antigens – dental plaque oral lesions by predisposing the cat to Association and also a past chair of depression. It is probable that affected mainly. Factors involved are: secondary infections. Both FIV and VETTrust, an educational veterinary cats are intolerant to even small • Breed. Mixed breed cats make up the FeLV may contribute to an aberrant charity based in Scotland. quantities of bacterial plaque on the majority of cases seen in the author’s immune response to oral antigens but VP JULY 2012 DENTISTRY 35 a recent study (Dolieslager, 2011) • Bacteriology (O): for both aerobic assessment of showed a group of FCGS cats to have and anaerobic bacteria – a high information by the 4% prevalence for positive FIV and proportion of cats tested show pure owner regarding FeLV which is similar to the UK cat cultures of Pasteurella multocida appetite, grooming, population as a whole. However, this is (Dolieslager, 2011). comfort and activity. not the hyperimmune response that • Biopsy (O) of affected areas – The remaining eight characterises the main syndrome. necessary to eliminate neoplasms (e.g. criteria require the • Dental disease. The presence of any sqamous cell carcinoma, , clinician to score concurrent dental disease is important. etc.) and other immunopathologies; separate areas of soft Either periodontal disease, TRs or very important if lesions not tissues from zero to both can have an exacerbating effect symmetrical. 3. on the syndrome. • Dental chart and full mouth dental Zero signifies radiographic survey (E) to assess normal tissue. One is Diagnostic testing periodontal status of teeth, for mild A standard diagnostic approach is quality and locate broken root tips or inflammation or advocated for all cats affected. Some those with resorptive lesions. ulceration, two for of this can be considered optional in moderate and three some cases and some are essential. Management and treatment for severe. Severe These tests are marked appropriately The main aim for the clinician is to inflammation or as “O” or “E”. restore the balance between the ulceration shows • Full general and dental history: immune response and the oral antigen spontaneous bleeding including recent and past treatments burden. In effect this means zero while moderately for the mouth (E). tolerance of both existing dental inflamed tissue will • General health assessment (E). disease and of bacterial plaque. bleed if gently • Full examination of head and neck stimulated with a (E). First-line treatment – all cats cotton bud. The • Scoring the oral soft tissues using the First-line treatment is for all affected mouth is given a Stomatitis Disease Activity Index cats and must be performed first. The score out of 30. Figure 3. (SDAI) sheet (Figure 2). Scoring the aim is to reduce the antigen burden Repeat scoring at mouth at each visit allows the clinician and assess if the oral soft issues are each recheck (Figure and the owner to establish the severity able to return to a normal state using 4) provides valuable information with resorptive type. Teeth affected by type of clinical signs and assign them a normal or enhanced hygiene measures regard to success of treatment and 1 resorption should be removed score from that day. It takes only a few with the emphasis on regular and on- acts as a powerful motivator for often conventionally. Teeth affected by type minutes but provides very useful going plaque reduction. demoralised owners. 2 or type 3 lesions may be suitable for prognostic information. Pre-op antibiotics – possibly • Scale and polish teeth. Every case amputation depending on • Routine Haematology (O) and advisable for some cases pre- starts by improving basic hygiene. The radiographic diagnosis. Biochemistry (E) screening for operatively to control excessive first principle of reducing the oral • Initiate . Chlorhexidine underlying systemic disease. One study inflammation and improve the soft antigen burden requires this step to be use twice daily will provide excellent (Hennet, 1997) reported 10% of tissue before and after surgery. taken first. post-op plaque control. Finding a affected cats with chronic renal failure. These antibiotics should preferably • Dental radiographs. Full mouth suitable product for cats can be a Any underlying systemic disease may have a good spectrum of activity for dental radiographs provide very useful problem. One suitable product is significantly affect the prognosis or the Pasteurella species. information with regard to the health Bright Bark & Meow from Keystone safety of anaesthetic protocols and It should be noted that many cats status of teeth and surrounding . Industries (wwww.krpvet.com). This other drugs (e.g. long term NSAIDs). appear to be clindamycin resistant Missing teeth may actually have paste should be wiped inside twice • Virus testing: for FIV, FeLV; oral (Dolieslager, 2011). retained roots and would be significant daily or brushed if the cat will allow it. swab for FCV (E). in the context of this condition. Oral disinfection with a suitable Dentistry • Treat diseased teeth. In almost all chlorhexidine product twice daily is • Dental chart and cases, this means extraction. Teeth one of the most important and Stomatitis Disease affected by advanced periodontal effective measures available. Activity Index disease due to recession of gingiva and • Re-assess case in 7-10 days. (SDAI) score sheet. A bone are best removed. Similarly, teeth 1. If better: continue chlorhexidine dental chart is an affected by TRs ( twice daily and review in four weeks essential record lesions) should be removed at this and subsequently as required. Note (Figure 3) of the stage using a technique suitable for that more frequent scaling and mouth. Use of a chart discourages shortcutting of examination. The SDAI score sheet (Figure 2) requires an objective assessment of eight different areas of soft tissue and provides a numerical score for the case. This is very useful in providing a prognosis and motivating owners. The top two criteria signify an Figure 2. Figure 4. average of 36 DENTISTRY VP JULY 2012 polishing intervals will probably be Consideration should be made as to five days post-op. In some of an evidence base for many necessary – perhaps 3-4 per annum. to whether surgery should or could be circumstances it may be necessary to treatments used for this condition and The need for professional dental performed in one session. If teeth are use a convalescence diet immediately also agreed that feline recombinant cleaning is signalled when the daily use excessively mobile, or otherwise easy post-op such as Hill’s a/d, Royal Canin interferon omega is most effectively of chlorhexidine is failing to control to extract, one session is preferable. Feline Recovery RS Diet or Nutri-Plus used in the group of cats which are the inflammation adequately. On the contrary, if the surgery is gel (Virbac). FCV positive and are long-term non- Use of a disclosing solution challenging, it may be best to utilise responders to extraction. This (www.drshipp.com – product code two sessions from consideration of Other anti-inflammatory or consensus statement remains under 429) at each visit helps demonstrate both patient comfort and recovery and immunomodulation therapies review and is intended for publication the location and quantity of dental also operator fatigue. Many drug therapies and combinations in due course. plaque. Given that dental plaque is have been advocated previously for Our own studies over five years invisible unless stained, disclosing Operative management of elective this condition. This is probably due to indicate that not only is interferon very solution is a powerful motivator in extractions the consistent lack of success with helpful in reducing inflammation and establishing excellent dental hygiene. Multiple extractions require planning most of them. Most of these regimes have improving comfort levels, it often also 2. If no better: move to elective with regard to technique, no proven efficacy. allows practices to drop other less extraction of cheek teeth as soon as instrumentation, analgesics, antibiotics Some of these treatment regimens effective treatment regimes. possible. Studies over the last 15 years and nutrition pre- and post-op. Some are based on very low number case • Transmucosal oral use. Interferon (Bellei, 2008; Hennet, 1997; Girard, cats may benefit from being reports, anecdote or small given per os is believed to work by 2005) consistently show the benefit of hospitalised for 2-3 days if owners are uncontrolled studies. Given that some initiating a cytokine cascade when it this procedure with 50% of cases unwilling or unable to administer of these drugs are highly toxic in cats, comes into contact with mucosal cells requiring no further treatment to medication per os. familiarity with the drugs and their side to provide an immunomodulatory resolve their signs and a further 37% • Analgesia. Morphine is a very effects is vital. effect over a long period of time. The needing low levels of inflammation powerful premedication for severe The internet also provides many cascade then has distant effects. support but are markedly better than pain at 0.1mg to 0.2mg/kg im or sc. owners with information which may or A 10mu vial is reconstituted and before. every 6-8 hours. Beware of dysphoria may not carry any reasonable validity. injected into a 100ml bag of sterile • Repeat scale/polish. For juvenile in cats (and also hyperthermia post-op) Beware of this and apply good science saline. Ten fractions of 10ml are patients it is important to avoid when high levels are used. Regional to any proposals that sound as if they withdrawn into individual bottles, permanent anatomic changes in the analgesia using lidocaine, mepivacaine are too good to be true. which are then frozen. When frozen first two years of life. If the immune or bupivacaine is also effective in a they have a reported shelf life of one system is substandard in the early multi-modal regime. Feline recombinant interferon year. The first 10ml fraction is used to months, the provision of excellent Some authors advocate a omega (Virbagen, Virbac) give a dose of 1ml per os per cat per hygiene can help considerably. combination of these agents – for A number of studies have reported day resulting in a daily dose of 100,000 Although little calculus may be visible, example, a 1:3 ratio of lidocaine and using interferon and long-term follow- units of interferon. continued inflammatory changes in bupivacaine. Carprofen or meloxicam up appears to indicate that it exceeds This fraction can be refrigerated either the whole of the gingiva or the is useful in addition to, but not instead the potential of other treatments for normally and will have a shelf life of marginal gingiva is an indication to of, opiates. this condition (Southerden, 2006; three weeks. The owner continues to repeat the surgical cleaning – especially Buprenorphine is considered good Camy, 2010; Gracis, 2010). give 1ml per day using alternate sides of hand curettage subgingivally. This may for moderate to severe pain in cats at Results in a recent study of 39 cats the mouth until all the fractions are mean professional scaling and 1ml per 15kg every six hours. Owners indicate that feline recombinant used. Ideally, treatment lasts for 100 polishing every three months. can administer this analgesic very easily interferon is an effective treatment days but longer may be required in by mouth if dispensed in prefilled 1ml particularly in the group of cats which some cases. Second-line treatments syringes for up to five days post-op. are FCV positive and are non- After three months, the progress Elective extraction of teeth An alternative regime in the hospital responders to elective extraction should be reassessed using the This is now firmly established, by both would be to use an injectable opiate or (Hennet, 2011). Stomatitis Disease Activity Index peer-reviewed publication and dental a Fentanyl patch. A consensus statement written by a (SDAI) scoring system (Figure 2). specialists, as the logical option to take • Antibiotics. As the primary condition group of European specialists Cats can be re-swabbed for calicivirus if first-line treatment (see above) alone is a hyperimmune reaction to mixed reported to the 19th European carriage in the oropharynx at this time. is insufficient to provide resolution of oral antigen, antibiotics by themselves Congress of Veterinary Dentistry in A cat that was previously positive the inflammation (Bellei, 2008; give minimal success. In the peri- 2010. The statement discussed the lack requires three consecutive negative Hennet, 1997; Girard, 2005). If the operative period, they will guard Preliminary results of an interferon therapy in a long-term tissues fail to respond by reduction of against opportunist infection and are study of 29 cats (2009 to 2012) inflammation and improvement in often best started pre-operatively. The • Breed: cats presented with FCGS were CDSH 62% and pedigree 38%. comfort to the best hygiene we can selected drug should have good • Age: mean age at presentation was 6 years 7 months with 60% male/n and provide within 2-4 weeks, elective activity in bone and on anaerobic 40% female/n. surgical extraction of all the cheek bacteria. • Calici: 69% of cats tested positive for FCV on first presentation (virus teeth should follow without delay. Clindamycin and/or potentiated isolation on oral swab). Owners and many veterinary surgeons are the drugs of choice in • Of those cats FCV positive, only 13.8% became FCV negative after INF are often reluctant to take this step. most cases. Many Pasteurella species treatment Elective surgical extraction of are resistant to clindamycin but post- Success rates were measured using the SDAI score sheets. whole cheek teeth quadrants should extraction it is a good choice as bone • A successful outcome was considered to be an SDAI score of 5 or less at not be undertaken lightly as there are has been exposed. revisit. several complications that may be • Feeding. Nutritional assistance may • A cure was defined as an SDAI score of 2 or less. associated with it. be necessary short or medium term. In • Improvement was defined as a 50% reduction in initial SDAI score. (Bear in 1. The underlying bone may be very severe cases it may be necessary mind that a “normal” cat with moderate gingivitis would score around 4 on sclerotic and poorly vascularised. to consider pharyngostomy feeding in an SDAI sheet). 2. The roots may be ankylosed to the some cases and assisted oral feeding in • FCV negative cats (n=9): 100% scored <5 (successful outcome) at 3 alveolar bone. hospital in others. If fluid intake is month revisit; 6 cats (66%) in this group scored less than 2 at 3 months 3. Teeth already affected by TRs (type sub-optimal, this should be addressed revisit. 2) may have roots in an advanced state also. • FCV positive cats (n=20): 15 cats (75%) scored less than 5 at 3 month of destruction with no true Most cats do better at home if the revisit; in this group 8 cats scored <2; 5 cats (25%) improved but did not morphology. For type 1 TRs the teeth owner is able to provide active help. score <5. Their SDAI scores were less than half at 3 month recheck from may be fragile and hard to extract Favourite soft foods (pilchards in original presentation. without flaps. tomato sauce) are necessary for three VP JULY 2012 DENTISTRY 37 results with virus isolation techniques recommend the use of any of these Definition of oral and oropharyngeal Inflammation to be considered truly negative. agents in the management of FCGS Source: American Veterinary Dental College Nomenclature Committee • Initial intralesional use. The syndrome. The potential side effects (www.avdc.org/nomenclature.html) consensus statement from 2010 and a can be significant and excessive use of subsequent study (Hennet, 2011) immunosuppressive doses can be a Oral and oropharyngeal inflammation is classified by location as: indicated that intralesional treatment is problem long term. Gingivitis: inflammation of gingiva not necessary to initiate therapy. Periodontitis: inflammation of non-gingival periodontal tissues (i.e. the

• Subcutaneous injections. This CO2 laser surgery periodontal ligament and alveolar bone) method of administration has been There are insufficient data to Alveolar mucositis: inflammation of alveolar mucosa (i.e. mucosa overlying described previously (Southerden, recommend the use of CO2 laser use the and extending from the without 2006) but according to subsequent routinely in the management of FCGS obvious demarcation to the vestibular sulcus and to the floor of the mouth) research it appears to be substantially syndrome. The consensus group felt it Sublingual mucositis: inflammation of mucosa on the floor of the mouth less effective, and markedly more may have a possible role with Labial/buccal mucositis: inflammation of /cheek mucosa expensive, than transmucosal adjunctive pain control. Caudal mucositis: inflammation of mucosa of the caudal oral cavity, administration for treatment of FCGS. One single cat case study bordered medially by the palatoglossal folds and , dorsally by the hard

concluded that the use of a CO2 laser and soft , and rostrally by alveolar and buccal mucosa Corticosteroids assisted recovery of soft tissues after Contact mucositis and contact mucosal ulceration: lesions in susceptible These drugs are used, by some extraction therapy but would not have individuals that are secondary to mucosal contact with a tooth surface bearing practitioners, principally to control been as useful as a monotherapy the responsible irritant, allergen, or antigen. They have also been called inflammation in refractive cases which (Lewis, 2007). “contact ulcers” and “kissing ulcers” have had elective cheek teeth extraction Palatitis: inflammation of mucosa covering the hard and/or soft palate and are not sufficiently controlled by Additive-free foods and additional : inflammation of mucosa of the dorsal and/or ventral tongue feline recombinant interferon. nutritional support surface If their use is justified on welfare It is necessary to ensure good quality : inflammation of the lip (including the mucocutaneous junction area grounds (often described as rescue nutritional support to encourage an and skin of the lip) therapy), the overriding principle must effective immunological response and : inflammation of the bone and bone marrow always be to use the minimum effective post-extraction healing process. Stomatitis: inflammation of the mucous lining of any of the structures in dose rate. Various diets and supplements the mouth; in clinical use the term should be reserved to describe wide-spread This means using a short-acting have been suggested, including vitamin oral inflammation (beyond gingivitis and periodontitis) that may also extend molecule (prednisolone) at the lowest preparations and omega-3 EFAs, but into submucosal tissues (e.g. marked caudal mucositis extending into effective dose rate such as 5mg twice there is no study which has data to submucosal tissues may be termed caudal stomatitis) weekly or 2mg every other day tapering prove a recommendation for any Tonsillitis: inflammation of the palatine tonsil downwards. They can be used in specific product. There is anecdotal Pharyngitis: inflammation of the pharynx conjunction with feline recombinant evidence that use of diets or interferon omega. supplements high in omega 3 EFAs Once this information is available, Dolieslager, S. M. J., Riggio, M. P., Lennon, affects platelet function and can result a treatment plan and prognosis can be A., Lappin, D. F., Johnston, N. W., Taylor, NSAIDs in excessive haemorrhage during considered. D. and Bennet, D. (2011) Identification of If used, the first choice option appears extraction surgery. The role of bacterial plaque is bacteria associated with feline chronic to be meloxicam. Any NSAID needs to The beneficial effect of a recovery crucial, whatever the state of the host gingivostomatitis using culture dependent be prescribed with due regard to the food post-surgery has been immune response. Diligent and culture independent methods. appropriate guidelines for use of long- demonstrated in cats with FCGS professional scaling, polishing and Veterinary Microbiology 148 (1): 93-98. term NSAIDs in cats (Sparkes, 2010). syndrome (Thyse, 2003). subgingival and attention Girard, N., Hennet, P. (2005) Retrospective Some new molecules such as Additive-free and hypoallergenic to existing dental disease underpins Study of Dental Extractions for Treatment robenacoxib may show promise. foods have also been suggested but the any treatment in tandem with of Chronic Caudal Stomatitis in 60 FCV results are anecdotal at best with no aggressive home-care by the owner. Positive Cats. Proceedings 19th Veterinary Cyclosporine known study proving efficacy. Cases failing to respond to simple Dental Forum, p447. There is currently insufficient data from plaque control should be considered Gracis, M. (2010) Controlled study using a published papers to recommend the use Summary for elective cheek teeth extraction and modified 2x2 cross-over design to compare of cyclosporine in the management of Feline Chronic Gingivitis Stomatitis adjunctive treatments at an early date. the efficacy of recombinant feline FCGS syndrome. Syndrome is a poorly defined Those cases still non-responsive but interferon omega and prednisolone in Some data have been published on syndrome of unknown aetiology FCV positive may be helped by refractory feline chronic gingivostomatitis this molecule, as part of a dermatology characterised by focal or diffuse interferon therapy. Proceedings 19th European Congress of study, suggesting four out of eight cats chronic inflammatory response It is important that the owner is Veterinary Dentistry, p192. treated responded and could be involving the gingiva, , and involved at an early stage with Harbour, D. A., Howard, P. E. and Gaskell, maintained on every second day dosing. often the pharynx, tongue and other discussions as to aetiology, treatment R. M. (1991) Isolation of However, other studies have been oral soft tissues. plans and help with home-care. A and feline herpesvirus from domestic cats equivocal about the benefits and a Commonly described clinical highly-motivated owner is a strong ally from 1980 to 1989. Vet Rec 128: 77-80. placebo-controlled trial in a small findings include elevated serum in the provision of successful Harley, R., Helps, C. R., Harbour, D. A. et number of cats did not show a globulins and a sub-mucosal infiltrate treatment. al. (1999) Intra-lesional cytokine mRNA significant difference from placebo only. of plasma cells, lymphocytes, expression in chronic gingivostomatitis in Some suggestions for use have been neutrophils, and macrophages. Selected references and cats. Clin Diag Lab Immunol 6: 471-478. provided but monitoring of blood Potentially various viral agents and further reading Harley, R., Gruffydd-Jones, T. J. and Day, levels to avoid toxicity is deemed bacterial species are involved. Bellei, E., Dalla, F., Masetti, L., Pisoni, L. M. J. (2003) Salivary and serum essential due to erratic absorption It is considered that atypical and Joechler, M. (2008) Surgical therapy in immunoglobulin levels in cats with chronic differences. In general, the currently hyperimmune responses are the basis chronic feline gingivostomatitis (FCGS). gingivostomatitis. Vet Rec 152: 125-129. available data are not sufficient to of the syndrome. Multiple mechanisms Vet Res Commun 32 (Suppl 1): S231-S234. Healey, K. A., Dawson, S., Burrow, R. et al. support a recommendation to use this appear to be acting concurrently. Camy, G. (2010) Results of a pilot study (2007) Prevalence of feline chronic drug, according to the consensus study Successful management of this exploring the use of peri-lesional gingivo-stomatitis in first opinion group. complex requires a logical diagnostic infiltration of recombinant feline veterinary practice. J Feline Med Surg 9 (5): approach. The need for first-line interferon omega in refractory cases of 373-81. Azathioprine/chlorambucil/low information gathered before treatment feline gingivostomatitis. Proceedings 19th Hennet, P., Camy, G., Privat, V. and dose doxycycline/gold salts alters the host response cannot be European Congress of Veterinary McGahie, D. (2011) Comparative efficacy There are insufficient data to over-stated. Dentistry, pp187-191. of a feline recombinant interferon omega 38 DENTISTRY VP JULY 2012

lesions to be a chronic, active stomatitis. Case study Initial treatment consisted of Signalment: “Jambo”, Main Coon, scaling and polishing all teeth followed six years, male neuter, 6.65kg by full-mouth dental radiographs Initially referred following 30 months (Figures 7 and 8) and elective surgical of a number of unsuccessful extraction of the right side cheek teeth treatments. He presented bright and ( and molars) via wide based responsive, eating soft foods well but mucogingival flaps for access. reluctant to eat hard foods. Halitosis In those cases where extraction was marked. The submandibular lymph proves difficult, time-consuming and glands were markedly swollen and a traumatic, it is often sensible to delay Figure 9. Note palatoglossal folds caudal mucositis plus maxillary surgery to the other side for a short Figure 10. Two weeks post- bordering tongue laterally caudal to gingivitis and alveolar mucositis was period. extraction RHS cheek teeth only; lower molars. For many FCGS cases note no improvement to tissues also present (Figures 5 and 6). Treatment to the left side cheek the most severely inflamed tissues either side despite elective Pre-op testing for viruses was teeth followed four weeks later. Oral are located lateral to these folds extraction cheek teeth. negative for FIV, FeLV and FHV. Feline inflammation levels tend not to where antigen laden pools. calicivirus was isolated on an improve markedly until all cheek teeth This is termed caudal mucositis. oropharyngeal swab. Routine are removed (Figures 9 and 10). His The loss of the cheek teeth reduces haematology and biochemistry was SDAI score for this second visit was moderate inflammation of the tissues the antigen burden (mainly plaque) unremarkable. Bacteriology showed a 14/30. lateral to the palatoglossal folds. considerably but does not eliminate it. moderate mixed culture with Pasteurella Daily interferon treatment was Feline calicivirus testing proved Disclosing solution can be used to species dominant. initiated following the second visit in negative at the three-month recheck inform and motivate the owner to Initial Stomatitis Disease Activity addition to analgesics and twice daily and interferon therapy ceased at this continue chlorhexidine use long term Index (SDAI) score was 15 out of 30. chlorhexidine application. time. Daily chlorhexidine treatment (Figures 13 and 14). Dental charting showed high levels of At his three-month recheck, his continued as reduction of dental plaque Further reviews have not shown any dental calculus and gingivitis for the SDAI score had improved to 3/30 is still a mainstay of the regime. deterioration in his condition. caudal maxillary cheek teeth. (Figures 11 and 12). This score Histopathology confirmed the comprised mild maxillary gingivitis and

Figures 11 and 12. Three months post-op. Note the marked improvement in all soft tissues.

Figures 5 and 6. Severe ulceration and inflammation of tissues lateral to palatoglossal folds plus maxillary gingivitis and alveolar mucositis both sides.

Figure 13 (left). Note improvement in tissues lateral to palatoglossal folds following elective extraction of cheek teeth and interferon therapy. Figure 14 Figures 7 and 8. Many cases of FCGS exhibit normal periodontal attachment (right). Same image after application of plaque disclosing solution. Elective levels. However, radiographs of all teeth perioperatively will provide advance extraction reduces the level of dental plaque in the mouth but does not warning of feline tooth resorption lesions, root ankylosis or periodontal disease. eliminate it. in refractory cases of calici positive cats calicivirus, feline leukaemia virus and with chronic gingivostomatitis. Oral W. T. and Jansen, K. L. (1984) with caudal stomatitis: a randomised, antibodies to FIV in cats with chronic Microbiology and Immunology 18: 131-134. Association of calicivirus infection with multicentric controlled double blind study stomatitis. Vet Rec 124: 336-338. Lyon, K. F. (2005) Gingivostomatitis in chronic gingivitis and pharyngitis in cats. of 39 cats. J Feline Med Surg 13 (8): 577-87. Knowles, J. O., McArdle, F., Dawson, S. et 2005. Jul 35 (4): 891-911, vii. J Small Anim Pract 25: 201-210. Hennet, P. (1997) Chronic al. (1991) Studies on the role of feline Sparkes, A. H., Heiene, R., Lascelles, B. Thyse, L. F. H., Logan, E. I. and Picavet, gingivostomatitis in cats: Long-term calicivirus in chronic stomatitis in cats. Vet D. et al. (2010) ISFM and AAFP P. (2003) Partial extraction in cats with follow-up of 30 cases treated by dental Microbiol 27: 205-219. consensus guidelines: long-term use of gingivitis-stomatitis-pharyngitis complex extractions. J Vet Dent 14: 15-21. Lewis, J. R., Tsugawa, A. J. and Reiter NSAIDs in cats. J Feline Med Surg 12 (7): – beneficial effects of a recovery diet.

Hennet, P. and Boucrault-Baralon, C. A.M. (2007) Use of CO2 Laser as an 521-538. Proceedings Hill’s European Symposium (2005) Relationship between oral calici Adjunctive Treatment for Caudal Southerden, P. and Gorrel. C. (2006) on Oral Care Amsterdam, pp64-65. virus and herpes virus carriage and Stomatitis in a Cat. J Vet Dent 24 (4); 240- Treatment of a case of refractory feline Zicola, A. et al. (2009) Feline herpes virus palatoglossitis lesions. Proceedings 19th 249. chronic gingivostomatitis with feline 1 and feline calici virus infections in a Veterinary Dental Forum, p443. Lommer, M. J. and Verstraete, F. J. M. recombinant interferon omega. J Small heterogeneous cat population of a rescue Knowles, J. O., Gaskell, R. M., Gaskell, C. (2003) Concurrent oral shedding of feline Anim Pract 47: 1-3. shelter. Journal of Feline Medicine & Surgery J. et al. (1989) Prevalence of feline calicivirus and feline herpesvirus-1 in cats Thompson, R. R., Wilcox, G. E., Clark, 11: 1,023-1,027.

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