Feline and Canine Stomatitis
One of the most painful and frustrating conditions
cats can develop is feline stomatitis. The cause is unknown, but appears to be
a severe reaction to plaque and the tooth structure itself, or the basement membrane
of the periodontal tissues. Clinical signs include severe chronic gingivitis,
with or without the following: faucitis, pharyngitis, or palatitis (inflammation
of the throat or roof of the mouth). Other signs include excessive salivation,
reluctance to eat, bleeding gum tissue, extreme oral sensitivity, and weight
loss or anorexia. Diagnosis is based on clinical signs and biopsy of the affected
gingival tissue. The histopathology usually finds abundant lymphocytes, plasmacytes
and occasional neutrophils. Although many organisms have been cultured or found
in affected cat’s mouths, none has been proven to be the cause. As such,
oral culture and sensitivity or viral isolation has been of little benefit. One
recent interesting relationship is that of Bartonella sp. with chronic feline
diseases such as gingivitis, stomatitis, and conjunctivitis. The test for Bartonella
is available and if positive, the recommended treatment is Azithromycin, an antibiotic
given once daily for 21 days. Bartonella sp. have zoonotic potential and thus
are important from a public health standpoint.
management of a cat with stomatitis should include CBC, full chemistry profile,
urinalysis, T4 and free T4, FeLV and FIV testing, gingival biopsy, and Bartonella
serology. Cleaning the teeth, homecare/brushing, oral antibiotics and corticosteroids
are helpful initially, but their effectiveness for treatment usually wanes within
3-6 months. The only treatment thus far shown to have long-term results without
the need further medication is either caudal or full mouth dental extraction.
In the only study to report long term results of caudal or full mouth extractions,
60% had significant improvement, another 20% had some improvement, and a final
20% had little to no clinical improvement in the gingivitis, but we have seen
that most seem to be more comfortable. Dental radiographs are essential when
performing these extractions to ensure the entire root of every extracted tooth
is removed. Post-operatively, antibiotics are given for 14-28 days. Pain management
is paramount in these patients and is accomplished with pre-anesthetic opioid
administration, intraoperative local anesthetics
(Bupivacaine), and postoperative NSAID and opioid given orally for at least 5-7 days.
For those patients with anorexia prior to presentation, nutritional support via
esophagostomy or gastrostomy tube may be warranted either pre or post-operatively
until eating well again. Re-evaluation at one month should show some improvement,
and further follow-up at three months should be indicative of success of treatment.
If there is little to no response, the remainder of the teeth may need to be
extracted or dental radiographs taken to ensure all tooth/root remnants have
been removed and that there are no areas of reactive alveolar bone borders.
question that consistently arises is “How can these patients
eat without their teeth?” The fact of the matter is that the one’s
who respond favorably do tremendously better without the oral pain and chronic
infection eating soft food than they ever did before, and those who still have
inflammation seem to be more comfortable. Many continue to eat dry kibble even
The severe gingivitis shown here is typical of feline gingivostomatitis.
The severe gingivitis creates thick saliva and is very painful.
This is the same patient as in the above two photos, 3 months following full
mouth dental extractions.
There is significantly less gingivitis, he is eating
much better, and his owner reports that he seems to feel much better.
Canine Stomatitis: (Chronic Ulcerative Paradental Stomatitis)
Similar to cats, dogs too can have stomatitis. In dogs, the underlying etiology seems to be related to a severe reaction to plaque on the teeth surfaces. The hallmark clinical sign in these cases is “kissing” ulcers of the cheek and lip mucosa over the teeth covered with a soft creamy plaque. There is usually severe halitosis, ulcerations on the lateral margins of the tongue, and extreme sensitivity within the oral cavity. Some dogs will stop eating, but most continue reluctantly. Histopathology (biopsy) of the oral ulcerations usually results in chronic active inflammation with mucosal ulceration.
Early in the course of disease, cleaning the teeth can be beneficial if the
owners can brush the teeth. This is usually difficult because the pets are sensitive
around their mouths and as plaque accumulates, the ulcers tend to return within
4-6 weeks. Adjunctive modalities include adding antiseptics to the drinking water,
pulse antibiotic therapy, oral chlorhexidine rinses, or barrier sealants to
help slow/reduce plaque accumulation. Over time, the effectiveness of these efforts
tend to diminish and more aggressive therapy is needed. In advancing cases, removal
of the source of plaque accumulation, i.e. the teeth, usually results in resolution
of the oral ulcerations. Although there are no studies to show response to extraction
therapy, my experience has been that these are more responsive than cats and
significant relief can be obtained from partial or full mouth dental extractions.
“Kissing ulcers” where the oral mucosa touches a plaque laden tooth is typically of a case of canine ulcerative stomatitis.