Judy Rochette, DVM, FAVD, DAVDC

H o w I Tr e a t 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.

T
he incidence of stomatitis within the general
population of cats, while variable, is generally
considered 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.

✔ 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
thyroid dysfunction
How I Treat Feline Stomatitis
➤ Immunosuppressed animals should not receive ❏ Perform preanesthetic diagnostics & provide supportive care
antiinflammatory medications, as they can further ❏ Perform diagnostics, assessment, & treatment while patient
suppress the ability to control oral infection is anesthetized
➤ Serum biochemistry panels can assess ability to ❏ If inflammation persists after healing period, extract
tolerate anesthetics and may exclude specific remaining teeth
therapies
❏ Reassess the patient
➤ Testing for calicivirus or presence of Bartonella spp
has limited value ❏ If extractions were insufficient, administer medications
➤ A positive response should not influence treatment ❏ Follow up
of the oral cavity
➤ Treat comorbidity if patient shows signs of active
bartonellosis, especially given its zoonotic potential2
➢ Because azithromycin and doxycycline have

CONTINUES

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H o w I Tr e a t CONTINUED

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 therapy3,4
➤ Nutritional support can be crucial to preoper- For Adult Patients
Diagnostics, ative stabilization ➤ Begin multimodal analgesia as soon as possible
➤ Place esophageal feeding tube to provide ➤ Options include presurgery gabapentin, pre-
assessment,
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 ✔ Perform diagnostics, assessment,
❏ ➤ Place esophageal feeding tube (if not done
patient is & treatment while patient is earlier) if patient is debilitated
anesthetized ➤ Stomatitis is rarely unilateral or focal
anesthetized. ➤ 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 ✔ 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 life6,7 ➢ If blood value is too low, adjust dose to
as much as 5 mg/kg q12h
✔ 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
➤ Request in-office reassessment 7–14 days levels
reassessment
postsurgery 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 inflammation9
healing and
✔ If extractions were insufficient,
❏ ✔ 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 events8 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
ω-interferon cannot be acquired
algorithm on oral inflammation in cats.

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