How to help a cat suffering from this painful oral condition

Analysis by Dr. Karen Shaw Becker

feline stomatitis

Story at-a-glance -

  • Feline stomatitis (FS) is a progressive, very painful mouth condition in cats; there are limited options for successfully treating the condition
  • Symptoms can include very inflamed gums, excessive drooling, bad breath and loss of appetite
  • A board-certified veterinary dentist who believes FS is a bone versus a dental disease has developed a guided bone regeneration (GBR) procedure that he says completely resolves the problem
  • Mild cases of feline stomatitis can sometimes be managed with an early and aggressive multimodal approach
  • Unless and until the GBR technique is more widely available, advanced stomatitis is often best resolved with full-mouth tooth extraction

Feline stomatitis is a chronic, serious and very painful oral condition that occurs in cats. Thankfully, there's been some recent progress in understanding more about this terrible disease and even better, there may be a way to completely resolve the pain and inflammation it causes.

The traditional treatment for feline stomatitis (FS) involves antibiotics and corticosteroids to suppress the immune system, treatment of inflamed and infected oral tissue, and extraction of some — and often all — of a kitty's teeth. Sadly, according to board-certified veterinary dentist Dr. Don DeForge, only about half the cats who lose some or all of their teeth make a full recovery.

DeForge has studied FS extensively and believes it's a disease of the bone, most likely a "polymicrobial bone pathology." (Polymicrobial diseases are caused by multiple infectious agents, e.g., viruses, bacteria, fungi and parasites.) DeForge has developed an alternative treatment for the disease — he calls it feline stomatitis guided bone regeneration — which he says, "completely and permanently reverses the oral inflammation and pain evidenced in feline stomatitis patients."

Feline stomatitis facts

"Stoma" is Latin for "mouth," and "itis" means "inflammation." There are several other names for the condition, including lymphocytic-plasmacytic stomatitis, feline chronic gingivostomatitis, immune-mediated feline refractory stomatitis and feline generalized oral inflammatory disease.

Stomatitis-related inflammation appears in the mouth as angry red swollen tissue. It can be localized, but it usually involves the whole mouth and often the back of the throat. The underlying bone in the mouth can also become inflamed or infected.

FS is thought to be an autoimmune disease in which the affected cat's immune system overreacts, triggering a massive inflammatory response in the mouth. The condition is often found in kitties with diseases of the immune system like feline leukemia virus (FeLV), and unfortunately, DeForge says cats with FeLV aren't good candidates for his procedure.

Many cats with FS also have gum disease, and there might be more of a tendency for certain breeds like the Siamese to develop the condition. There's also a juvenile onset form of the disease that occurs in kittens between 3 and 5 months of age, as their permanent teeth erupt. By 9 months, these kittens can have full-blown and very serious oral inflammation and, sometimes, infection.

Symptoms of FS

This condition starts as gum disease (gingivitis), which appears as redness at the gum line. Often the entire gum becomes red and inflamed, but it starts with a red ring around the teeth, usually at the premolars and molars. You may not see any plaque or tartar on the teeth, yet the gum is an angry red, especially at the junction of the tooth and gum.

Stomatitis causes such intense pain that it can destroy a kitty's quality of life. If your cat has the condition, you might notice behaviors such as depression, irritability, aggression or hiding. Excessive drooling is also a common symptom, along with gums that bleed easily.

Because the condition is so painful, many cats have trouble eating. Some give up after trying for several days or weeks because it's just too painful. If you have a cat who cries for her dinner and runs to her bowl, then is hesitant about putting food in her mouth, she may have stomatitis.

Dehydration, weight loss and muscle wasting are not uncommon in cats with FS because they aren't able to eat enough calories to maintain their body weight. Breath that goes from bad to unbearable is another common symptom, and so is lack of grooming because the mouth becomes too sore for any self-cleaning behaviors. Many cats with stomatitis also paw at their mouths in an attempt to relieve the pain and irritation.

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Guided bone regeneration to treat feline stomatitis

Dr. DeForge describes the procedure he developed in an article he wrote recently for the journal Innovative Veterinary Care:

"The procedure uses 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 used to cut all soft tissue and expose all the pathology identified by digital radiology. The pathologic bone is then removed, using surgical length burs and diamond instruments. This is followed by a guided tissue regeneration procedure."1

DeForge notes that when using this technique, it's not necessary to remove all abnormal (inflamed) soft tissue, because it returns to normal once the bone surgery is accomplished.

After GBR surgery, antibiotics are administered to treat infected soft tissue and bone that couldn't be removed due to its close proximity to vital anatomy. Pain management is also very important to alleviate the discomfort of the inflammation and ulcerations that were present prior to the surgery.

"Anti-inflammatory therapy is short-term and can be accomplished with traditional Western medicines or alternative Eastern medicine protocols," writes DeForge. "I do not recommend non-steroidal anti-inflammatory therapy. All medicines cease 30 days post-operatively."

For two weeks prior to and another two weeks after surgery, kitty patients will have an esophagostomy tube (E-tube) placed in the neck through which food and medicines can be delivered. These are small rubber tubes inserted through an incision in the left side of the neck into the esophagus. The tube doesn't prevent cats from eating or drinking on their own if they want to.

DeForge: Feline stomatitis is a bone disease, not a dental disease

DeForge offers the following rationale to explain why FS is a bone rather than a dental disease:

"In all ages of FS patients, digital oral radiology shows characteristic changes in the bone. Soft tissue biopsies describe an inflammatory infiltrate, primarily of plasma cells, neutrophils and lymphocytes. The fact that all patients respond to aggressive osseous surgery sheds light on the bone origin of FS.

If FS pathology was of dental origin, all patients — rather than only 50% to 60% — would fully respond to whole mouth exodontia, with a complete and permanent resolution of inflammation."

Plain English translation: In all cats with feline stomatitis, oral x-rays show similar changes in the bone, and soft tissue biopsies also show similar characteristics. Most importantly, all the patients DeForge has treated have recovered from the disease — indicating FS is a disease of the bone — whereas, of the cats who have all their teeth removed on the premise that FS is a dental disease, only about half experience a full and permanent recovery.

Medical and lifestyle management of cats with stomatitis

While DeForge's bone regeneration procedure could at some point in the future become mainstream and more widely available, there will always be kitties who aren't good candidates for GBR, or whose owners decide against it for some reason. There are also cats who develop a mild form of FS and can enjoy a good quality of life with appropriate medical and lifestyle management.

In juvenile onset stomatitis, some kitties respond to intensive medical management. This includes excellent oral home care (brushing the teeth and gently disinfecting the mouth twice daily), regular professional cleanings and aggressive plaque and tartar control.

I've had some success treating mild to moderate feline stomatitis using a multimodal approach. First, I address the diet. Although food allergies haven't been definitively linked to this condition, I consistently see improvement in inflammation levels when I convert these cats to an anti-inflammatory diet that eliminates all potential sources of food allergens, toxic food additives, preservatives and GMOs.

I stop feeding anything with seafood or poultry in it, because they are the two most common food allergens for cats. I also discontinue all foods that are biologically unnecessary for felines. That means no potato, rice, wheat or corn. All carbohydrates need to go. Feeding an anti-inflammatory diet, which means a carb-free diet, is sometimes enough by itself to control the amount of inflammation occurring in a cat's mouth.

The next step is to begin an at-home oral disinfecting protocol. If a cat has a significant amount of plaque and tartar buildup, then we need to have a deep cleaning (performed under anesthesia) to remove all the infection along and under the gum line. Third, I prescribe natural anti-inflammatories and an esterified fatty acid complex for periodontal health. I also use plant-derived sterols and sterolins, as well as proteolytic enzymes, all of which help control the systemic mediators of inflammation.

The fourth step is to use a variety of nutraceuticals to improve gum health. These include ubiquinol, which I use both orally and topically on the gum line. I also use a product from Standard Process called VF Bio-Dent for Pets, as well as probiotics, both orally and topically.

Lastly, I recommend the cat's owner focus on removing environmental sources of toxins that can negatively impact the immune system. We stop vaccinating and start titering. If a cat goes outside, we definitely want to make sure his titers show he's protected. However, kitties with an autoimmune disorder and indoor cats with no exposure risk shouldn't receive unnecessary vaccines. We also evaluate air and water quality, as well as household chemical use.

With early intervention and an aggressive integrative protocol, cats with mild to moderate feline stomatitis have a chance to reclaim their oral health without aggressive surgery.

Full-mouth tooth extraction to treat FS

Unfortunately, most cases of feline stomatitis are diagnosed very late in the game, when kitty's breath has become unbearable or she's not eating well. By this time, the whole mouth is typically swollen. There can be ulcerations on the roof of the mouth, the tongue, the lips and throat.

The most important thing to remember about a cat with stomatitis is that she's in a tremendous amount of pain all the time. A kitty in that much pain, for that long, who isn't eating well, is in serious danger. This is the point at which full-mouth tooth extraction is usually discussed. It's an aggres­sive approach, but FS is an aggressive disease, and when things have progressed to a point where kitty is no longer eating, it's a life-threatening situation.

The good news is that many cats (between 50% and 60%, according to DeForge's estimate) who undergo full mouth extractions experience dramatic relief and have significantly improved quality of life after their teeth are removed.

To avoid chronic complications from full mouth extractions, I believe it's best to work with a board-certified veterinary dentist. Digital X-rays should be taken after extraction to make sure all of the tooth roots have been successfully removed. Pain manage­ment must be instituted and maintained until post-surgical discomfort is resolved and healing has occurred.

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