One Clinician’s Experience With A New Treatment For Feline Stomatitis

Find out why Feline stomatitis is among the least understood conditions that veterinary practices come across.

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. 

Pathology 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.

Treatments Lacking

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

Pre-Anesthetic Testing

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

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.

The Answer

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.

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16 thoughts on “One Clinician’s Experience With A New Treatment For Feline Stomatitis

  1. Where in central New York can this procedure be done? My Aunt lives in Utica and her boy Cooper has this bad. I would love to be able to give her a recommendation. She is very upset and sad over his suffering.

  2. I have a 11yr old male cat who has been diagnosed with stomatitis. All blood work shows him clear of Fiv, Leuk. bartonella, calicivirus and no cancers. I had all teeth pulled EXCEPT canines and the small teeth in between in Dec.2018.
    He has stayed on Clavamox & Prednisone since Dec. 2018.
    Two weeks ago I had remaining teeth pulled and still on Clavamox & prednisone-every other day with added Tramadol.
    He eats small amounts only twice a day due to still having pain. Im not sure whats left to do to treat him. I dont want him to suffer. I could (he also) deal with occasional flare-ups but not sure how long to wait for this -if ever- to go away. I have been to 3 different vets.
    I have been told from a friend in Mexico that they are injecting Interferon straight into the gums (NOT SUB Q )
    with great results. Any info if being done in US??

    1. Sheryl, my cat has had complete extraction including tooth roots by a leading oral surgeon. Three months later the refractory stomatitis returned. He had cryotherapy earlier this month and is on Interferon by mouth in liquid form – 1 ml daily for 50 days. I am also trying to get Gabapentin and Prednisalone into him daily. We were warned the first cryotherapy might fail, even a second or third round. He is due to go back next month. He is not cured by any means and I am thousands of dollars into this. It is painful to see him inflamed. He eats wet food multiple times daily just using his gums. He has not lost too much weight but I am at my wits end, retired & on fixed income. It’s a terrible condition. He is only 10 & a wonderful sweet cat. I don’t want to put him down.

      1. We have had 4 adult cats with feline gingivostomatitis, treated by board certified dental surgeons or else full graduates of a 2 years dentistry fellowship, all 4 cats treated at a famous research and teaching hospital in New York. The head board certified dental specialist told me last year that now they are finding that it can take 3 years for a “cure” of the stomatitis, post FME. 3 years for it to disappear post-FME. Not the year that they were assuming. 3 years! So, if it has been less than 3 years, don’t give up hope. Also, you don’t overlook Class 4 cold laser which is proven to heal wounds and inflammation, including some refractory stomatitis, at the cellular level. I did it with one cat. Class 4, not class 3. It is painless, takes 30 seconds outside of the neck and soothing.

  3. Some people recommend colloidal silver and probiotics for cats with stomatitis. Also eliminating anything from their diet that may have caused allergic reaction, especially foods they have eaten often and eliminating grains. Mine is suffering a lot, even after 17 teeth have been extracted and I am going to try this. Wishing you all the best, as I know we all love our cats and do not want them to suffer.

  4. My cat has stomatitis. I have had some help, but now have been referred to a Doctor who just removes all the teeth from the cat. It is not cheap at $4000.00.

    They have told me the cat really can get by without any teeth eating soft foods and such small dry food it can just swallow.

    I have opted for the complete surgical removal of all the teeth by a specialist.

    What do you think? The cat is in otherwise good health and 5 years old. I am on a fixed income of social security, so looks like it is Campbell’s Tomato soup for me until I can get this paid off.

    Thanks for any encouragement or suggestions.

    1. Richard-
      While you have probably had the surgery for your cat by now.. If you do happen by here again, I would like to respond. I have a cat named Salem. He is now 3 1/2 years old. Adopted him in Sept., 2018 at 1 year and 4 months old., When I got him home he turned up his nose at the kibble he was on, and he would go to hide in my closet (it was the pain). He could be very affectionate, but when he came up for attention, he might suddenly jerk/turn his head away because of the pain episodes he would have ( not sure if t was pain from his mouth at first).. Pain came on like lightening for him, and he did not know what to do with himself. He might be walking accross the living room floor and then would get a hit of pain; this causing him to turn his head and start to run, and eventually hide. When I took him into the Vet his mouth did not look bad at all. He did have a line along the gums but it was not bad.. But, not all can be visible to the naked eye in the begining. Anyway, I went out and got soft pate to try and feed him. He was eating less and less.. He was hungry, but could not eat.. He was famished when I put the soft food in front of him at first -and went for it (started to hop all over me when he saw it coming)-and inhaled it at first.. But, even when eating it , he started to have more and more trouble. He was young and friendly, but was hiding more and more. I was not sure if there was an element or neurological problem at first or not; and the vet sent me to a specialist who actually diagnosed him with a seizure disorder because of his intense reactions.. (I was awaiting approval for an MRI for him).. Forgive the length of this. In the end , I went back to my regular vet and requested an appt. with a dental specialist-I was unconvinced of the neurological component the more I saw how he reacted to food or trying to give him a treat… The specialist diagnosed him right away with Stomatitis. To get to your quesiton. The specialist told me that the cat needed a full mouth extraction, and we did all the tests to check for pre existing calcivirus, FELV and FIV- for which he was negative. Many cats carrying these retro virus’s tend to develop stomatitis. Anyway, after my reading and speaking with the specialist.. I was convinced a full mouth extraction was the way to go. Some cats can develop refractory cases of stomatitis or gingivostomatitis, but in a good percentage of cases, the full mouth extraction (making sure all roots are carefully removed) can provide an actual cure; and It did for my boy. There was a Vet who tried to convince me to leave just a few teeth (eye teeth) for the cat, but the specialist had warned me against this, and said that in the end, with this disease, if they leave any teeth the cats may go into a temporary remission, but one is asking for trouble because problems again arise since the nature of the disease itself with stomatitis is that your cat is reacting negatively to his/her teeth and plaque.. It is auto immune in nature.. From what the specialist said , a complete extraction saves alot of trouble in the long run for most cats… If not handled properly, ongoing expenses can easily be incurred -and the use of other meds employed while trying to save teeth can be hard on their systems.. My boy Salem was totally cured.. Recovery is a challenge, and you need to care for them with pain meds and antibiotics, but after a couple of months the change that can occur is tremendous! I thought he was having a relapse at one point during the post op period and they put him on clindamyicin a few weeks post op.. Well, it helped at first , but then he got loose stools and was sick to his stomach and stopped eating.. So, after talking it over with my regular vet , and the concern for antibiotic related C. difficille , I certainly did not want to see him suffer with abdominal probs too, so I decided to stop the clindamyicin. Good decision. My Salem totally recovered, mouth cleared, no more stomach probs.. Anyway .. spent so many days feeding him half hiding under a lounge chair in the living room he picked to stick his head out of.. I would get down and feed him by hand with soft food during his recovery period too. And, for the pain I had him on gabapentin and since he was refusing food at diff intervels, I had to get pain med down him too. Turned out he loved lactose free milk, so in a small 1./4 measuring cup with milk in it I put his gabapentin (liquid).. He had this during the day between meals (bid) to enable him to eat and help with pain. Post op he had stronger meds also.. He now just loves to eat and I feed him both wet and dry.. He enjoys the wet more as it is easiest for him, but he adapts to many types of dry food…Just loves food now -Tis a new world for him.. He is so well now! I hope you had the surgery!!

  5. I am in Southern California and the surgery will be performed this next Tuesday the 9th at 1:30 PM in Ontario, California. My regular Vet is in Riverside, California and referred me to the Specialist who works to my knowledge only in California. I just hope and PRAY it works.

    Right now I have given her a food stimulant and also another medication to help with her appetite until the surgery can be performed. I have 3 more days. I have been trying hard with a syringe and blended food and water trying to keep her hydrated and at least some food in her until the surgery can be performed.

    1. Are you saying there is a Specialist vet in California that uses feline stomatitis radiowave radiosurgery? Did you have it done, and how did it work out. What was the cost? I rescue cats and currently have 11. I’m seeing stomatitis being inherited in families. I have a mother and her two babies (now grown) have it. I feed her and she eats, but is very timid and I can’t touch her to see if she has it. The babies eat soft canned food (mostly lick the gravy.
      Thanks for your reply.
      Louise Jones

      1. No he was talkiing about total mouth extraction of all the teeth. I had my boy done and he is fine! It has been just about 2 years now.. A total mouth extraction of all teeth is expensive, but worth it.. Please read my post right below Richards..

  6. I have read with interest,this article on new treatment for this terrible ailment.Of 12 stray cats I look after,one has stomatitis and I have been treating him for about 2 years with daily doses of Predesolone and have lately added silver.Now and then he has a shot of a stronger steroid.He eats well and seems happy except for minor drooling now and then.I can only imagine what the cost of this new treatment is as the ongoing, relatively simple treatments at the vet cost about $300 a time

    1. Anthony,
      It can be very expensive to care for a cat with Stomatitis. But, when my cat had total Mouth Extraction surgery.. (All the teeth removed and carefully removing the roots) It was healing for him.. No more problems with pain or eating. No drooling. He feels great and eats like a pig.. LOL.. Please see a specialist who will discuss removing all your cats teeth. Trying to save the teeth using medicatons like prednisolone etc. can have overall negative long term affects on your cat.. and his organs. If you read carefully and do your research you will see that removing all the teeth can provide a cure for a majority of cats.. It is extremely expensive to struggle to keep teeth here and there trying to prevent surgery.. Just have them all removed .. The cats do fine with no teeth. The surgery can be expensive, but in the long run one saves money.. See a dental specialist.. My Salem is healed.. He was operated on at 1 1/2 years old. Do not look for complicated answers.. Best of luck!

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