Feline Gingivostomatitis/other painful oral conditions

Question 1

Discuss FCGS?

Answer 1

Caudal Mucositis or Gingivostomatitis - FCGS
This persistent inflammatory disease affects cats of any age sex or breed but
often affects cats less than eight years old. The gingiva, alveolar, labial and buccal mucosa is always involved while the lingual and sublingual mucosal is infrequently affected. The pharyngeal and palatal mucosa is rarely involved.

Caudal stomatitis (inflammation of the caudal oral mucosal lateral to the glossopalatal folds) is always a feature of refractory cases.

Question 2

What are the symptoms of Caudal Mucositis or Gingivostomatitis - FCGS?

Answer 2

Common clinical signs of affected cats include severe oral pain, depression, aggressiveness, dysphagia and anorexia, halitosis, weight loss, lack of grooming, restricted opening of the mouth (yawning is very painful), oral bleeding, drooling
thick malodorous saliva.
Conscious clinical examination should be performed with great care because of
hyperalgesia of the orofacial tissue. The upper lip could be gently elevated with
moist cotton buds. Sedation or anaesthesia is always necessary for complete
examination.
In affected patients, gingivitis is usually diffuse. Mucositis is usually associated
with areas of mucosa in close contact with larger plaque laden crown surfaces,
creating so-called contact (or interface) ulceration. The lack of involvement of
the vestibular mucosa lateral to the glosso-palatine folds generally indicates a
better prognosis.
Various degrees of periodontitis and tooth resorption effects teeth associated
with these lesions. Periodontitis is usually exaggerated by undisturbed accumulation of plaque as very little mastication occurs because of pain associated with
this action

Question 3

What are Aetiologic factors?

Answer 3

The aetiology of chronic stomatitis is unclear, but it is accepted that it’s multifactorial. Affected individuals may have an exaggerated immune response to infectious and non-infectious antigens. An immunological basis for this disease is
strongly suspected.

Question 4

Discuss viruses that may be implicated?

Answer 4

The immunodeficiency viruses (FeLV, FIV) could play a role, but are not specifically identified as a cause. Feline Calici virus (FCV) is assumed to play a significant role but it is not clear whether this virus is an opportunist or directly indicated as a direct cause. Some studies indicate that the presence of FCV increases the severity of the lesions.

Question 5

Discuss bacteria which may be implicated?

Answer 5

Bacteria in the dental plaque biofilms plays an important role and explains the
significant benefits of extraction (removal of plaque retentive surfaces) as part
of the treatment.

Question 6

Discuss the Excessive Immune Response implicated in this disease?

Answer 6

It is generally accepted that an aberrant immune response is the underlying core
problem of these patients. The exaggerated response to normal plaque levels
supports this theory. The response to immunomodulating drugs as well as
promising results to initial stem cell therapy, supports this suggestion. This is
obviously a multifactorial cause, and the importance of different components
might differ between individuals. A theory that seems to be gaining more support is the possibility that this condition represents a lack of immune suppression.

Question 7

What clinical database should be obtained for these patients?

Answer 7

Complete biochemistry and haematology profiles are important to rule out any
underlying systemic problem. These cases often display hyperproteinaemia
mostly associated with hyperimmunoglobulinaemia.
Viral screening to at least rule out immune suppressive viruses are important.
In especially asymmetrical presentations, biopsy and histopathology is important
to rule out neoplastic disease.

Question 8

How should expectations be set for clients with animals with this disease?

Answer 8

Preoperative discussion with owners is crucially important to manage expectations. Even though studies indicate that 60 to 80% of affected patients will be
cured or significantly improved by either partial or full mouth extraction, the remaining about 20% of cases are considered refractory and requires some form
of medical treatment either occasionally, or ongoing for the rest of their lives, in
attempts to manage the condition.

Question 9

What pain relief should be considered for this condition?

Answer 9

This condition is considered to be extremely painful, and analgesia should be
prioritised before any investigation is considered. Long-term non-steroidal antiinflammatory drugs is always indicated (except if steroids are being used). The
oral administration of buprenorphine is extremely helpful because of the fact
that this drug is so effectively absorbed via this transmucosal route.

Question 10

What should stage 1 of treatment be?

Answer 10

During this first procedure complete examination of the oral cavity and all its
teeth, charting and full mouth radiography is indicated. All compromised teeth
and retained roots should be extracted. This includes all teeth affected by tooth
resorption. All identified teeth should be completely extracted and crown amputation should not be considered.
Biopsy of areas of concern is important. Treatment after this first procedure
should include non-steroidal anti-inflammatory drugs with or without transmucosal buprenorphine. Attention to meticulous oral home care in these patients
are even more important.
Some benefits of barrier products like SANOS and lactoferrins are suggested primarily based on manufacturers’ information

Question 11

What is stage 2 of treatment?

Answer 11

With the poor response to stage one treatment, complete extraction of all remaining premolar and molar teeth should be performed. If the Incisors are affected by gingivitis, these should be extracted too, but generally the canine
teeth are not extracted except if a specific indication (e.g.tooth resorption, periodontitis) is identified

Question 12

What is stage 3 treatment?

Answer 12

Stage 3
Persistent caudal stomatitis, with only the canine teeth remaining, should be a
strong indication of a refractory case. Many clinicians would suggest extraction
of the canine teeth at this stage. Recent publication confirmed that there are no
significant difference in response to extraction between cats that had all their
teeth extracted and those that have just had the premolar and molar teeth extracted. NSAIDs and alternative analgesics remain indicated

Question 13

What is stage 4 treatment?

Answer 13

Very few cases in which this stage is reached but these should be considered as truly refractory cases. Various combinations of medical treatment
options should be considered. If the pain associated with this condition
cannot be effectively controlled, euthanasia should be considered.

Question 14

What antibacterials can be used and when can they be helpful?

Answer 14

The use of antibiotics should be considered during the initial stages of treatment.
The use of topical oral disinfectants (chlorhexidine containing mouthwash or oral gel) is important at all stages of the treatment.

Question 15

What about steroids?

Answer 15

Glucocorticoids should always be used at anti-inflammatory doses rather than
immunosuppressive doses. Some publications indicate that patients that have
not had steroid treatment before extractions have a better prognosis of a good
response to extractions as well as subsequent medical treatment.

Question 16

Discuss Cyclosporines?

Answer 16

Cyclosporine is a powerful immunomodulating drug and has been used
with some success

Question 17

Discuss Mesenchymal stem cells?

Answer 17

Mesenchymal stem cells represent a new promising treatment option that
is currently in the development phase.

Question 18

Discuss Interferons Recombinant feline interferon omega?

Answer 18

Trans oral administration of this antiviral drug can be considered in refractory
cases.
10 MU vial of injectable drug is mixed into hundred millilitre bag of saline.
After thorough mixing divide this into fractions of 10 ml each. Freeze nine of the
10 units (shelf life when frozen, of one year is suggested)
After defrosting each 10 ml unit has a shelf life of three weeks. A dose of 1 ml
per day is administered on alternating sides of the mouth, for 90 days.

Question 19

Discuss Canine Chronic Ulcerative Stomatitis (CCUS)?

Answer 19

This condition has previously been known as Canine Ulcerative Paradontal Stomatitis (CUPS). This extremely painful condition affects all dog breeds, but
spaniels and terriers appear to be overrepresented. An allergic hypersensitivity
reaction to normal plaque levels appears to be a significant contributing factor.
This could therefore be a similar condition to chronic stomatitis in cats.
In general, the ulceration affecting these dogs usually occurs at sites in close
contact with large plaque retentive surfaces, especially at the maxillary canine
and maxillary fourth premolar teeth.
Like in cats with ulcerative mucositis, affected dogs display severe oral pain with
presenting clinical signs of depression, anorexia, restricted yawning, drooling and
severe halitosis.
Teeth affected by moderate to severe periodontitis are usually present in close
association with these lesions. Because of the severe pain, mastication is reduced, and this again leads to further plaque accumulation, which again exacerbates the ulceration.
The diagnosis relies on elimination of all other causes. Biopsy of especially
asymmetrical lesions is important.
Treatment relies on extraction of any teeth with signs of periodontitis and meticulous dental homecare of the remaining teeth. Antibiotic and anti-inflammatory treatment with additional analgesia form important parts of the treatment
plan.

Question 20

What is Feline Orofacial Pain Syndrome?

Answer 20

This complicated and frustrating condition causes severe self-mutilation affecting especially, but not exclusively, Burmese cats. (One study showed 88% of
cases to be Burmese)
All indications are that FOPS is the result of development of disturbances in the
sensory nervous system and dysfunction causing neuropathic pain affecting the
trigeminal nerve.
Allodynia appears to be a central component.

Question 21

When does Feline Orofacial Pain Syndrome generally appear?

Answer 21

There appears to be a bimodal age distribution, with the syndrome either presenting in cats less than a year of age (7-9 months), or those older than seven
years. In the younger age group this coincides with the eruption of permanent
teeth.

Question 22

When do flareups of Feline Orofacial Pain seem to happen?

Answer 22

Flareups appear to be associated with oral associated functions like eating,
drinking or grooming and usually appear to present unilaterally.

Question 23

What drugs have been used to try and treat feline orofacial pain syndrome?

Answer 23

A variety of analgesic and anti-epileptic drugs can be used to attempt to control
the pain. In about 10% of cases this is not possible, and euthanasia is the only
option.
On initial presentation, non-steroidal anti-inflammatory drugs and opioids
should be used and as a second step, attempts to reduce neural excitation.
Drugs to consider:
* Glutamate (Gabapentin, at 3 to 10 mg/kg BID,
* preGabalin, 1 t- 5 mg/kg SID,
* phenobarbital, 1 to 3 mg/kg BID
* Amitriptyline, 0.5 to 2.0 mg/kg SID,
* Carbamazine , 25 mg/kg SID alternatively decrease inhibition with opioids use:
* Buprenorphine, 0.02 mg/kg per kilogram transmucosal BID to QID.
* diazepam, 0.1 to 0.5 mg/kg SID/BID.

Question 24

What is Xerostomia?

Answer 24

Dry mouth syndrome could be a consequence of surgical removal of the saliva
glands, but this is a very rare complication. This condition may be the result of
systemic disease like diabetes mellitus or prolonged drug use, especially antihistamines.
The protective action of saliva in the oral cavity is lost to these patients and
their often affected by increased periodontal disease.

Question 25

What is Sialadenitis?

Answer 25

Painful inflammation of the salivary glands could be a consequence of trauma,
infection, infarction or immune-mediated disease.
This inflammation is more common in medium to large dog breeds and sialocoeles a possible consequence. Many of these cases do respond to anti-inflammatory and antibiotic treatment but surgical treatment might be considered.

Question 26

Discuss Sialocoele/Salivary Mucocoele?

Answer 26

The cause of saliva leaking into the surrounding tissue is not always clear. Saliva
accumulates in the tissue and even with large accumulations of fluid, there is
never “cyst” lining associated with this structure.
The sublingual and mandibular saliva glands are usually involved and placement
of a patient in dorsal recumbency usually indicates which side is involved.
In general, surgical removal of the mandibular and sublingual salivary glands or
others as indicated, is required to prevent recurrence.

Question 27

What is Canine Masticatory Muscle Myositis?

Answer 27

This is an immune-mediated disease that affects the masticatory muscles in
dogs. During the acute phase, pronounced painful swelling of these muscles occurs, but in the chronic phase, muscle atrophy is evident.
During the initial acute phase, there is painful opening of the mouth, which
could result in restricted opening in chronic stages.
Diagnosis is usually based on clinical presentation. Immunohistochemistry on biopsies of especially the temporal muscle can be attempted in the acute phase.
In the chronic phase histopathology usually indicates fibrosis or atrophy of the
muscles.
Treatment with non-immunosuppressive doses of corticosteroids is usually effective.

Question 28

Discuss Trigeminal Neuropathy?

Answer 28

These patients present with slack apparently paralysed lower jaws. The flaccid
paralysis could be linked to dogs carrying heavy objects for long periods of time.
Supportive therapy usually leads to a complete recovery in 2 to 4 weeks time.