Feline Stomatitis: Five Knowledge Points

Written By: 

Jeanne R. Perrone
MS, CVT, VTS (Dentistry)

Feline Stomatitis (FST) is an oral condition found in cats. The condition presents as an inflammation of the area lateral to the palatoglossal folds with or without inflammation of other oral mucosa, namely the gingiva, alveolar mucosa, labial/buccal mucosa, and sublingual/lingual mucosa. In the chronic stage, inflammation, which is often proliferative, can extend into the mucosa of the oropharynx. This condition can be challenging to diagnose and treat since no definitive cure exists. Presented are five knowledge points to remember when working with patients affected by feline stomatitis. 

Point 1: What is the Difference Between Gingivitis and Stomatitis?

Oral Anatomy

What distinguishes stomatitis from gingivitis is the location of the oral inflammation. The palatoglossal folds are at the back of the mouth, where the upper and lower jaws meet, and the throat opens. When inflammation occurs on the right and left sides, caudal mucositis indicates feline chronic stomatitis. The inflammation can extend to palatitis and glossitis. 

Periodontal Disease vs. Stomatitis

The attached gingiva and hard palate are covered by masticatory mucosa. The stages of periodontal disease, namely gingivitis and periodontitis, present inflammation focused around the tooth and does not extend beyond the mucogingival line. If the inflammation extends into the area above the mucogingival line into the submucosa, then it is considered stomatitis.

Point 2: Where to Start With Diagnostics and Treatment

The Diagnostic Pathway

Thorough diagnostics and treatment planning are crucial. The patient's medical and dental history must be reviewed to establish a timeline and assess the patient’s health status before anesthesia and treatment.

Testing may include but is not limited to:

• Serum chemistry
• CBC
• UA
• ECG 
• Full body radiographs
• FeLV, FIV, ANA, Bartonella
• CD4-CD8 ratios

Medical vs. Surgical Management 

In the past, systemic antibiotics and oral steroids were commonly given as a means of treatment. In the long run, these interventions did not provide long-term comfort to these patients causing problematic side effects and antibiotic resistance.  

While invasive and more costly, partial or full-mouth extractions in the areas of inflammation are the best outcome for feline stomatitis patients, research has shown that extractions improve the condition of 60% of these patients. Of the 60%, 55% are cured, 35% show marked improvement with medical management, and 10% show no improvement. The teeth must be extracted entirely, confirmed by dental radiographs with an alveoloplasty of the marginal bone, and sutured closed.  

Point 3: What is the Best Way to Support the Pet Parent?

Time and Patience

Many times, pet parents are not prepared to hear the news that their cat has to have most, if not all, of their teeth removed along with a high price tag. Make sure you can take the time to explain the condition and answer their questions. 

Typical questions posed by the pet parent. 

• Why does it cost so much? 
• How will they be able to eat? 
• Without their teeth, will their face look the same? 
• Will they be painful? 
• How long until they are back to normal? 
• How will I medicate them?

Detailed educational handouts on the condition allow the pet parent to review the information later with the rest of the family. Be prepared to answer any follow-up questions. When reviewing the treatment plan, each line item must be explained to provide the rationale. This step is another opportunity to provide education and answer any questions.

If the patient is referred to a dental specialist, provide the contact information so they can call and set up their appointment. Ensure you have contacted the specialty clinic beforehand to discuss the patient and the specialty clinic referral requirements. 

Involving the Pet Parent with Treatment   

Pet parents are integral to the success of treatment. Providing them with a monitoring checklist will support them as they care for their pet at home. The veterinary staff can review these checklists and journals during recheck visits to monitor patient progress. The pet parent can monitor common behaviors: eating/drinking, litterbox use, medication tolerance, and grooming.  

Recheck Visits

Recheck visits are crucial for monitoring patient progress. The rule of thumb for caudal and full mouth extractions is 14 days, one month, and three months postoperatively. If teeth are present, an additional 6-month recheck is recommended. It can take up to 2 years to see the complete response to treatment. Rigorous homecare products such as oral rinses may be added if the patient is doing well with pain management. 

Point 4: Can the Clinic Adequately Treat the Patient, or Is it Better to Refer?

Required Knowledge, Skills, and Abilities (KSA) for Surgical Intervention

When planning treatment for stomatitis patients, assessing the clinic's scope of practice is essential. Is there a staff veterinarian who is comfortable and successful performing feline extractions? The tooth must be extracted entirely and confirmed on dental radiographs. It is also essential to be prepared to treat any other dental and oral findings to ensure a successful outcome for the patient.

Another consideration is the available instrumentation and equipment. Instruments and equipment in good condition will move the procedure along efficiently. Are your hand instruments in good condition and sharpened? If not, it is time to purchase new instruments or refurbish them with an experienced instrument repair service. Are your dental and radiograph units running correctly? If not, consider contacting your distributor’s equipment specialist to find a repair service. 

Adequate Time

If caudal or full-mouth extractions are being performed, the veterinarian must have adequate time to complete them correctly. These procedures should not be performed over a lunch hour or between appointments. Depending on the practitioner's KSAs, this may be the only procedure planned for the day, as they can take up to 3 hours to complete. 

How to Find a Dental Specialist

If you have yet to work with a veterinary dental specialist, your first step is to find one in your area. If you go to AVDC.org and click "Find a Veterinary Dentist,” they are listed by state with their contact information. Call the specialty clinic directly to get information on the required records for referral. Once the presurgical diagnostics have been completed and the patient is cleared for anesthesia, they can be referred. In some cases, you may be able to provide the pet parent with a preliminary estimate to be completed when they reach the specialty clinic.

Point 5: What Do I Do with Refractive Cases?

Enlist Advice and Support from a Dental Specialist

Patients with little to no improvement after 60 days are classified as refractive. If teeth are still present, they might need to be extracted and medical management begun. If no teeth are present, radiographs might need to be reviewed or retaken to ensure the teeth were extracted entirely, and then medical management begins. Common medications are corticosteroids, immunosuppressants, surgical lasers, and immunomodulators. Check with your local veterinary dental specialist for advice and dosages.

References

Aruni, A., MIshra, A., Dou, Y., Chioma, O., Hamilton, B., & Fletcher, H. (2015). Filifactor alocis- a new emerging periodontal pathogen. Microbes Infect, 17(7), 517-530. doi:10.1016/j.micinf.2015.03.011.

Arzi, B., Mills-Ko, E., Verstraete, F. J., Kol, A., Walker, N., Badgley, M. R., . . . Boriesson, D. L. (2016). Therapeutic efficacy of fresh autologous mesenchymal stem cells for severe refractory gingivostomatitis in cats. Stem Cells Transitional Medicine, 5, 75-86.

Bellows, J. (2010). Oral pathology. In J. Bellows, Feline Dentistry: Oral Assessment, Treatment, and Preventative Care (pp. 101-148). Ames: Wiley-Blackwell.

Bellows, J. (2012). Caudal stomatitis. In H. Lobprise (Ed.). Ames: Wiley-Blackwell.

Brook, I., & Bronze, M. (2021, April 30). Peptostreptococcus infection. Retrieved from Medscape: emedicine.medscape.com/article/225140-print

Greenfield, B., & Niemiec, B. (2018). Oral ulcerative disease. In B. Niemiec (Ed.), Dentistry in Small Animal Practice (pp. 101-114). Orlando: NAVC Publishing.

Jennings, M. W., Lewis, J. R., Soltero-Rivera, M. M., Brown, D. C., & Reiter, A. M. (2015). Effect of tooth extraction on stomatitis in cats: 95 cases (2000-2013). Journal of the American Veterinary Medical Association, 246(6), 654-660.

Krumbeck, K., Reiter, A., JC, P., Tang, S., Kim, Y., Linde, A., . . . Melgarejo, T. (2021). Characterization of oral microbiota in cats: Novel insights on the potential role of fungi in feline chronic gingivostomatitis. Pathogens, 10(904). doi:10.3390/pathogens10070904

Lee, D., Verstraete, F., & Arzi, B. (2020). An update on feline chronic gingivostomatitis. Vet Clin Small Anim, 50, 973-982. doi:10.1016/j.cvsm.2020.04.002

Lobprise, H. (2018). Feline chronic gingivostomatitis. Clinicians Brief, 28-29.

Lommer, M. (2013). Oral inflammation in small animals. Vet Clin Small Anim, 43, 555-571. doi:10.1016/j.cvsm.2013.02.004

Mosby's Dental Dictionary (2nd ed.). (2008). St. Louis: Msoby Elsevier.

Reiter, A., Johnston, N., Anderwson, J., Soltero-Rivera, M., & Lobprise, H. (2019). Domestic feline oral and dental disease. In H. Lobprose, & J. Dodd (Eds.), Wigg's Veterinary Dentistry: Principles and Practice (2nd ed., pp. 439-461). Hoboken: Wiley-Blackwell.

Understanding the Immune System in One Video. (2018). Retrieved from https://youtu.be/_jBpv9fYSU4?si=OMuvCd1mbTwQfj-w