Feline stomatitis, the most painful oral disease in the feline, has many faces and names. It is the most misunderstood, frustrating and refractive of all feline oral conditions seen by the general practitioner as well as the oral specialist. It has been studied in detail by many researchers over the last 20 years and its etiology is still unknown.
FS has been called lymphocytic plasmacytic stomatitis, gingivostomatitis, immune mediated feline refractory stomatitis and feline generalized oral inflammatory disease. The histopathology of oral biopsies in these cats evidences a predominance of plasma cells, lymphocytes and neutrophils. A polyclonal gammo-pathy is commonly noted.
The name is not as significant as the pain this disease causes. FS produces a chronic non-responsive generalized oral pain affecting the gingiva, mucosa, palate, lingual and sublingual area, the glosso-pharyngeal arches, the commissures and entire pharynx. Depending on the feline, all mentioned or site-specific pathology centers can be identified.
The inflammation is progressive. There is no successful medical treatment. The inflammation can be hidden with glucocorticoids, immunosuppressants, herbs, gold salts, antibiotics, analgesics, vitamins, probiotics, local topical anesthetics, salicylate therapy, and multiple anti-inflammatory protocols. None is effective in the long term. Most often the pain relief is short-lived and discomfort quickly returns when they are discontinued.
Laser therapy is controversial in feline stomatitis and I do not recommend it. Airway blockage caused by laser usage in the distal pharynx can lead to respiratory embarrassment or patient loss. In the December 2007 issue of the Journal of Veterinary Dentistry, J. Lewis, A. Tsugawa, and A. Reiter include a case report [“Use of C02 Laser as an Adjunctive Treatment for Caudal Stomatitis in a Cat”] in which the laser was utilized. They state: “It is difficult to determine what role the laser treatment played in resolution of the inflammation, especially after extraction of the remaining canine teeth performed at the fourth and last ablative laser treatment.”
Sub-Groups of FS
Three subgroups of FS have been identified by this author: juvenile (4 months to 18 months); adult onset (1.5 years to 10 years); and geriatric or late onset (10+ to 20+ years)
A monomicrobial form of oral inflammatory disease in very young felines, affecting the gingiva and moving into the alveolar mucosa at the mucogingival junction, has been identified. It is seen in Bartonella-positive felines.
Many young Bartonella-positive felines, less than a year old, with a specific subtype of feline oral inflammatory disease, most often will respond to Azithro-mycin therapy as described by William D. Hardy Jr., VMD, at the National Veterinary Labs. He states, “Veterinarians should consider Bartonella in their differential diagnosis as the etiologic agent for a subset of cats with oral inflammatory disease.”
Dr. Hardy has investigated Bartonella in cats and the multiple pathologies that they can cause. He is to be applauded for the information he has brought to feline medicine through the feline Bartonella test he has innovated. If a patient less than 1 year old is Bartonella positive and does not respond to Azithromycin therapy, it is most likely juvenile FS and should be referred to an oral specialist/ dentist/surgeon for diagnosis and treatment.
I do not feel that Bartonella is the etiologic agent for FS. Azithromycin does reverse some oral inflammatory disease in patients under 12 months of age that are Bartonella positive. In older Bartonella-positive felines with FS, treatment with Azithro-mycin does not help reverse the pathology.
Signs of FS
The main characteristics of all age groups are advanced oral inflammation and severe pain. No veterinarian should rely on corticosteroids and antibiotics as the treatment protocol for these felines.
It is non-productive, does not help the patient in the long term and, most importantly, can predispose the patient to systemic pathology.
I see many FS cases that have been treated for years with corticosteroid therapy with adrenal disease, liver disease, kidney disease and transient diabetes. Others present with septic oral pathology that has been influenced by the immune system being suppressed by glucocorticoids.
Some patients with long-term FS are very aggressive because of the pain. Owners comment that not only mouth-pain aggression is present but say they can be attacked by their cat at home at any moment. Many of these cats have been gentle and well socialized before developing FS. It is not uncommon to also see in advanced FS patients dehydration, cachexia and anorexia.
Diagnosis of FS
Diagnosis is accomplished using biopsy and histopathology. The practitioner must never confuse FS with squamous cell carcinoma or any other oral neoplasia. Biopsy must be deep and representative of the pathology. I recommend both soft tissue and bone biopsy specimens be sent to an oral histopathologist.
These areas are not easy to biopsy, and significant bleeding can occur. I recommend performing all soft-tissue biopsies using radiowave radiosurgery with an understanding of indirect radiowave radiosurgery coagulation. See The Journal of Veterinary Oral Radiowave Radiosurgery at their website.
Whether for biopsy or for surgical treatment, all FS felines should be scrutinized for other non-related medical problems. The young feline should have a comprehensive chemistry profile, CBC, and U/A along with a current leukemia and immunodeficiency virus test. If respiratory or GI problems are present, chest and abdominal radiology and an ultrasound of the abdomen are recommended to rule out other problems that can coexist with oral inflammatory disease.
All middle-aged cats with murmurs should have chest X-rays and electrocardiograms before any anesthesia is contemplated. The geriatric feline should have a full cardiopulmonary workup, including an echocardiogram.
Feline leukemia testing should be repeated if not performed within the last year in all age groups. Feline immunodeficiency virus testing should be ordered but I do not consider a positive test contraindication for anesthesia.
Feline leukemia-positive cats should be evaluated by an internal medicine specialist. Surgery is not recommended in these felines. If there is a question of any complicating health issue, contact an IM specialist before proceeding.
I recommend testing FS cats for feline Bartonella and treating the Bartonella positives with Azithromycin, because of the public health significance of a positive feline in the home with oozing oral sores.
Mixed pathology is found in the FS patient. Feline eosinophilic granuloma complex, external and internal root resorption, root ankylosis, and bone changes can all be present. The soft tissue changes are the most extreme with ulcerated sites that bleed readily when examined. In many FS patients the attached gingiva, under general inhalation anesthesia, can be peeled back from the tooth and bone as easily as peeling a banana.
A Disease of Bone
My study at The Connecticut and New York Specialty Centers for Oral Care has confirmed that FS is not a disease of the dentition but is a disease of bone. I hypothesize a polymicrobial bone pathology.
Characteristic changes are noted in the bone, utilizing digital oral radiology, in all age groups of patients. The pathologist in FS soft tissue biopsies will describe an inflammatory infiltrate composed primarily of plasma cells, neutrophils and lymphocytes. At the centers, bone is also sent for histopathology examination.
The histopathologist consistently reports that osteomyelitis is present. This has been ignored in the past as consequential to dental pathology.
Tissue culture and bone culture are needed to confirm a polymicrobial hypothesis.
Any university clinical research team that wishes to participate in such a study can contact me at DonDeForge@aol.com.
The fact that all my patients respond to aggressive osseous surgery sheds new light on a bone origin of FS. If FS pathology were of a dental origin, all patients would fully respond to whole-mouth exodontia. This is not the case. Only
50 percent to 60 percent of patients respond fully to exodontia with a complete permanent resolution of the inflammation.
Feline stomatitis radiowave radiosurgery, or FSRWRS, can successfully treat any feline with FS and reverse the pathology so that the patient has a pain-free quality of life. The procedure is a surgery of bone using oral digital radiology to identify areas of sclerosing osteomyelitis, condensing osteitis, sclerotic alveolar crestal bone loss and hypertrophic bone reaction with resorption.
Once the pathology is identified, radiowave radiosurgery is utilized to cut all soft tissue and expose all of the pathology identified with digital radiology.
Using the fully filtered rectified waveform, radiowave radiosurgery, or RWRS, produces a blood-free atraumatic surgical field that allows visualization of the bone pathology to be treated. Pencil point electrodes [113F] in a partially rectified waveform are used to establish hemostasis. (See the Journal of Veterinary Oral Radiosurgery online at their website.)
Osseous surgery and guided tissue regeneration are the important keys to the completion of FSRWRS. Radiowave radiosurgery is not being used to obliterate or excise abnormal soft tissues. It is for cutting and coagulation in this operation ONLY to allow exposure to the pathology. The pathologic bone is then removed using surgical length burs and diamond instruments. This is followed by a guided tissue regeneration procedure.
An antibiotic protocol after surgery eliminates the osteomyelitis that cannot be surgically treated because of proximity to vital anatomy.
FSRWRS operatory time, under Sevoflurane and/or Isoflurane inhalation anesthesia, is three to four hours with patient monitoring by an anesthesia technician.
Pain control is paramount intraoperatory and post-operatory. The pain present is not primarily from the surgery itself but is from the oral inflammation and ulcerations present before surgery.
Contrary to past belief, the procedure has proved that the abnormal soft tissue does not need to be removed at the time of surgery. The inflammation in soft tissue quickly resolves once the osseous surgery is completed.
Any FS edentulous feline who has experienced complete exodontia by a qualified surgeon or veterinary dentist with return of the oral inflammatory disease can be successfully treated. This proves that FS is not a dental disease but a bone disease. What remains to be shown is the identity of the proposed polymicrobial system in the bone, initiating the immune-related oral inflammation.
Whenever a new surgical protocol is discovered or initiated, there is doubt and disbelief in the surgical community. This is common in human as well as veterinary surgical communities and cannot be changed.
This author’s contributions to bone augmentation were challenged for years, and now bone alloplast is widely used by veterinary dentists, veterinary oral surgeons and veterinary orthopedic surgeons.
FSRWRS can permanently remove this pathology from any FS patient. Whole mouth extraction or extraction distal to the canine teeth resolves only 50 percent to 60 percent of the patients treated. The rest will return to some form of oral inflammatory pathology within the first year post-exodontia.
This statistic has been validated with data collected from veterinary dentists by the Connecticut and New York Specialty Centers for Oral Care. Excluded from FSRWRS are patients with feline oral cancer and/or feline leukemia.
It has been a privilege to see quality of life and pain-free existence return to these patients.
This column is intended only to give general information concerning a new surgery that has been tested and proved effective in the treatment of FS.
The aggression noted in FS patients pre-FSRWRS is invariably reduced or removed post-FSRWRS as the tissues heal and the pain resolves. The letters, e-mails, cards, and phone calls from the pet owners of patients are heartrending.
Dr. DeForge is director of The Silver Sands Primary and Urgent Care Center in Milford, Conn., and an adjunct at Northwestern Connecticut College and at Mercy College in New York in oral radiology and periodontology.