B.A. Niemiec, DVM, DAVDC, DEVDC, FAVD
Veterinary Dental Specialties and Oral Surgery, Dentistry, San Diego, CA, USA
The history will generally include anorexia, drooling, gagging, and pain during mastication. Physical exam will typically include a thin pet with unkempt fur. The oral exam will reveal severe stomatitis, usually over all teeth. The inflammation will most commonly be worse on cheek teeth than canines and incisors. However, faucitis is the key clinical finding. Severe hyperplastic inflammation to the gingiva can result from periodontal disease; however, faucitis will not be present.
A preoperative blood panel will generally show a marked elevation in globulins (polyclonal gammopathy) and total protein.
Most medical therapies will work for a while; however, in general, resistance will start within a year or less. In addition, most therapies have side effects worse than the disease process in and of itself. In general, medical therapy is very frustrating to the practitioner and client.
Corticosteroids are the mainstay of most medical therapies today. They are generally very effective at first and relatively inexpensive for the client. In my experience, injectable (Depo-Medrol 10 mg IM) is much more effective than oral preparations. However, they will typically lose effectiveness after a year or so, requiring higher and higher doses at shorter increments. This generally results in significant deleterious effects. About 10% of stomatitis cases we treat are already diabetic!
Antibiotics are safer than steroids, but much less effective, especially in long-term therapy. They are generally disappointing in their success. Metronidazole and clindamycin are the mainstays of therapy; however, Clavamox and amoxicillin can be used as well. Metronidazole may be the antibiotic of choice due to its anti-inflammatory effect.
Other immune-suppressives such as Imuran, Cytoxan, gold salts, and cyclosporine have been used. However, they are all very expensive with numerous adverse side effects (myelosuppression). Cyclosporine is currently the most commonly prescribed immune-modulatory drug (other than steroids) for this disease process. However, its chronic use is somewhat expensive and has been implicated in severe fungal and protozoal infections.
Starting dose is 5–10 mg/kg. Look for a trough level of about 500 ng/ml on a regular basis. In most dentists’ opinions, it is only really effective after teeth are removed. However, it has shown promise in resistant cases.
Laser therapy is not proven at all; most clients and RDVMs are very unhappy with the long-term results. It is very expensive and provides short-term relief only.
Extraction is currently the only effective long-term treatment for this disease process in cats. In our experience, the sooner this is done, the better cats do both postoperatively as well as long term.
For extractions to be successful, the teeth must be completely removed. Therefore, postoperative radiographic confirmation of complete extraction of the tooth roots is recommended. Following the insurance of complete removal of the teeth, perform alveoloplasty to remove the periodontal ligament and smooth rough bony edges. This is typically performed with a rough diamond bur.
Studies report a 60% success rate when all teeth caudal to the canines are extracted; however, our experience has not been as good. However, whole-mouth extractions have a success rate of approximately 90–95% for clinical remission. Slight faucitis may remain, but pets are comfortable. In addition, the rare cases that don’t completely respond are generally much more responsive to medical therapy.
If there is no inflammation to the canines or incisors (which is rare), then the owner is given the option of leaving the canines. However, if these are inflamed, all teeth should be extracted.
In the rare cases where the teeth have been fully extracted but inflammation and pain continues, other therapies are needed. The current treatment of choice in the USA is cyclosporine. Another option, which appears to work better in Europe, is feline interferon. Finally, UC-Davis has had some success with stem cell therapy.