Chronic Feline Gingivo-stomatitis (GS)

Description

Feline Lymphocytic Plasmacytic Stomatitis (FLPS) is a severe inflammation of the entire oral cavity is cats. The gingival (gums) and entire oral cavity is swollen, red and very painful. Cats may cry out suddenly when eating or opening their mouth even to yawn. We had one patient that was so painful, he hissed at himself when he opened his mouth. Often the teeth do not look diseased. They may be pearly white, but the tissues surrounding them are seriously inflamed.

We believe that FLPS is a disease of the immune system wherein the cat is intolerant to the plaque bacteria on the teeth. Normal animals are able to handle the 750,000 bacteria present in each milliliter of saliva without signs or symptoms of disease. Cats that are affected by FLPS have a much exaggerated inflammatory response to the plaque bacteria. This severe inflammation causes the gingiva to be cherry-red in appearance and to bleed easily. Cats may approach their food bowl, but not eat because they are so painful. As a result affected cats may lose weight, become dehydrated and show other systemic signs of disease.

FLPS is merely a description of the cells present on a biopsy of the inflamed tissue. We do not know what causes the disease and, because of this, we can do is treat the symptoms of the disease. There may be one or several viruses or bacteria that are causative agents. It may also be a special form of periodontitis.

Clinical Signs

Cat owners may see very red gums that bleed easily, causing the cat to avoid eating, even when he is obviously hungry, or to eat only soft food. The physical signs of inflammation are clearly visible inside a cat's mouth. What may be more noticeable to an owner, however, are behavioral changes; irritability, aggression, depression, excessive hiding, and poor grooming. Affected cats also may drool and have bad breath. A cat may cry when opening its mouth or eating.

Diagnosis

A complete diagnostic workup during the consultation and physical examination may include blood tests to help diagnose the disease. However, examination of the oral cavity can be difficult in an awake cat due to the degree of pain that the cat feels. Examination under anesthesia is the best way to diagnose GS, but we can often get an indication of the disease during the consultation appointment and evaluating blood test results. Increased levels of circulating immune cells called globulins help confirm the diagnosis. The presence of viruses and bacteria (such as FeLV and FIV, Calicivirus, Herpesvirus and Bartonella) help determine other diseases that may affect treatment success. The definitive diagnostic step is a tissue biopsy. While the cat is anesthetized, a small sample of affected gingival tissue is removed and sent to a veterinary pathologist for examination. The presence of lymphocytes (specific cells of the immune system) confirms the diagnosis. Biopsies are helpful and we use them to rule out other diseases such as oral tumors, but the clinical presentation of the cat is often enough to allow a preliminary diagnosis of GS with relative certainty. The biopsy is usually done during the anesthesia for the first treatment visit for the cat.

Treatment

The most important therapy is control of the plaque. Plaque is 80% bacteria and 20% food particles and saliva. This means that the first step in treating these cats is a thorough, professional oral hygiene procedure. Complete removal of plaque both above and below the gum line is essential. Any teeth with significant periodontal disease will be extracted, as deep pockets and the space between roots will harbor bacteria and be very difficult for the owners to keep clean. Some cats with FLPS also have Feline Odontoclastic Resorptive Lesions (FORL). Teeth affected with resorption also need extraction. Post operative dental X-rays are important to make sure that all root tissue is removed. Any root fragments remaining in a cat affected by FLPS may contribute to continuation of the symptoms.

Medical therapy consisting of antibiotics, steroids, pain medication, mouth rinses and gels help symptomatically. Steroids suppress the immune system reducing the inflammatory response. Cyclosporine is another immune suppressant that may be prescribed. Recently feline recombinant interferon omega has been successfully used to treat refractory cases. These treatments often make a cat comfortable enough to begin home-care procedures. Although FLPS is not an infection, bacteria are almost always heavily involved. An initial course of antibiotics is often prescribed to help reduce the bacterial load while the tissues heal.

The most important treatment is daily plaque control (tooth brushing, dental chews, and dental diets). Since cats with FLPS can be in so much pain, they may not allow owners to provide any oral hygiene care until the periodontal therapy has been completed. We work with each patient and owner individually, to try to achieve the best treatment options. Some cats will need frequent periodontal therapy, as often as every 2-3 months for the first year.

Home Care

Once the diseased teeth have been extracted and the oral tissues have had a chance to heal, owners can try daily tooth brushing. Hopefully this can be done soon after periodontal therapy so that plaque does not collect on the teeth again. We discuss specific tooth brushing techniques with each owner.

Brushing with a pet toothpaste is important. Pet toothpastes are made to be swallowed, and the enzymatic toothpastes combine with the enzymes in the saliva to be antibacterial. Currently, I recommend the C.E.T. Enzymatic Tartar Control Toothpaste Beef and Seafood flavors, because they are more abrasive and have more enzymes than the other C.E.T. flavors. Applying 0.2 percent chlorhexidine, a mild antibacterial solution can also be helpful. Formulated especially for dental care in pets, this product is accepted by most cats and can be sprayed or swabbed onto the gum s. We may also suggest the gels and sprays manufactured by Biotene. Many companies are developing products to help us; we may have others to suggest to you as they become available.

Many cats recovering from FLPS also need to make up for months of poor nutrition. Supplemental vitamins and minerals may be recommended at this stage, and a good diet is a must. Many diets available are specifically formulated to provide nutritional support for specific medical conditions. Hills Prescription Diet T/D or Science Diet Oral Care and Friskie's Dental Diet have received the Veterinary Oral Health Council (VOHC) seal of approval and are designed to reduce the rate of plaque and tartar development. This gives owners another weapon against FLPS. The VOHC certifies products that meet the scientific claims made by the manufacturer. CET Chews, produced by Virbac, are freeze-dried treats that provide abrasive cleansing actions as well as antibacterial enzymes. These also help keep plaque from collecting on teeth.

The fight against plaque takes time and commitment from owners, but it may allow cats with FLPS to keep their teeth. Once the oral cavity is clean and the cat is being supported with the medical therapy described, these cats may allow their owners to provide the daily oral hygiene we recommend. However, in advanced cases, the cats are too painful to allow any meaningful home care and medical treatment is the only care possible.

Surgery

Surgical tooth extraction is often necessary to alleviate the pain FLPS cats experience. The rationale for this treatment is that the teeth harbor the plaque bacteria. By removing the teeth we are removing the plaque bacteria. However, even this treatment only addresses the symptoms -- not the cause. We may suggest extracting the cheek teeth (premolars and molars) first, to see how effective this is in controlling the inflammation. A cat's appearance changes very little with this procedure, because the front teeth (canines and incisors) remain in place. Eventually all teeth may need extraction. As veterinary dentists, we do not like suggesting this option, but sometimes the welfare of the patient necessitates it. Again, it is very important that all tooth substance is removed, since any fragments left behind can be a cause for treatment failure. Dental X-rays will confirm that this has been accomplished. Typically, once a cat has recovered from the surgery, he is able to eat remarkably well.

This treatment sounds drastic, but the results are often amazing. Most of the cats treated by extraction are eating hard, dry food within a week or two of surgery and sometimes even by the next day! These cats may have stopped chewing their food because of the pain. Treating the inflammation and thereby alleviating the pain allows them to eat comfortably again. Many cats gain weight, start to groom again and are much happier. Believe it or not, even with no teeth some cats will eat dry food by using the bony ridges of their palate.

However, even with all the teeth extracted, some cats will still have some inflammation that needs treatment. Continued medical therapy may help. Some cats are helped with laser therapy of the inflamed tissue; other may be helped with oral interferon, a drug used in human cancer therapy. There are many treatment protocols that have been tried and described and they all help some cats, but non have been predictably effective for all cats.

FLPS is a very frustrating disease for veterinarians, veterinary dentists, pet owners, and especially affected cats! Hopefully one day we will understand the cause of the disease and can target our treatment accordingly.