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Oral problems - Stomatitis
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Stomatitis - new treatment medications
Stomatitis - is it contagious?
Chronic stomatitis/chronic inflammatory gingivitis
Plasmacytic stomatitis
Plasmacytic stomatitis continuedalso see Dental problems
also see Feline Leukemia
also see FIV
Stomatitis - new treatment medicationsQuestion: Dear Dr. Mike,
I read an interesting article the other day (Mayo Clinic, I believe)
about the success they seem to be having with treating stomatitis in AIDS
victims with thalidomide. I understand that there have been no official
studies done, but wondered if this has been tried on FIV+ cats.
Since I have 3 cats afflicted with the dental problems of FIV, I'm
always looking for ways to manage it. I checked into bovine lactoferrin, and
it sounds promising, but the source I found would cost me about $150/month-
something my husband probably wouldn't tolerate. I will continue to search
for other sources.
We have had the most success treating them with clindamycin and oral
prednisone. My most severely afflicted cat was nearly cleared up 2 weeks
ago, when the vet gave her an injection of Depo Medrol, and discontinued the
prednisone. Now she is getting worse again, so I will take her in again
tomorrow to see what's going on. It does get discouraging, so I'm always
looking for new treatments that just might work.Sincerely, Jennifer
Answer: Jennifer-
There are several studies that suggest that thalidomide may be useful for HIV syndromes,
including gastrointestinal disease and Kaposi's sarcoma. I can not find any research studies that
involved the use of thalidomide for cats with FIV. There is interest in thalidomide in veterinary
medicine, primarily for treatment of metastatic cancers, but if that works well it will be tried for
other things. At the present time I think that thalidomide is not available to veterinarians in the
United States, though.There is evidence to support the use of AZT (ziduvudine, Retrovir, Rx) in cats for severe
stomatitis associated with FIV. The dosage that was used in one study was 5mg/kg given by
subcutaneous injection twice daily (Hartman 1992) and cats treated with the medication
improved compared to the control group. I think that the current thinking is that AZT is safe to
use for about 3 weeks but that liver toxicity starts to become a problem with longer term use.
This may be long enough to get control of the stomatitis, though.The only source of lactoferrin that I know of is Emerson Ecologics: 800-654-4432. Your
veterinarian should be able to get this from them. I can't remember the cost but it wouldn't
surprise me if it would be in the $150/mo range if you are going to have to treat three cats with
it. Our success rate has only been about 20 to 25% with this product but it seems really safe to
use, so we do try it in most cats that do not respond quickly and for long periods, to the use of
methylprednisolone (DepoMedrol Rx) injections.Anecdotally, there is support of the use of amitriptyline (Elavil Rx), as well. This may be given
orally, or if cats are not able to tolerate oral medications it may be made into a transdermal
preparation by a compounding pharmacist familiar with this sort of preparation. The dosage for
oral amitryptiline is 5mg per cat, once or twice a day. I do not know how transdermal
preparations are made to approximate this dosage, unfortunately. I think that the amitriptyline
primarily supplies pain relief, which improves the quality of life for affected cats, but it does have
some anti-histamine effects so maybe that helps, too.We have had good luck with clindamyin and with methylprednisolone, too. In addition, some
cats do much better if the majority of the teeth are removed. This can cut the inflammation down
in the mouth considerably. Cats seem to do well but this is an expensive procedure because
removal of healthy teeth amidst all the gum inflammation is fairly difficult and it must be done
really well -- no little root fragments left behind.I hope that this helps some. If I hear any more about thalidomide I am sure it will make it into
one of the issues of the VetInfo Digest.Mike Richards, DVM
8/27/2001
Stomatitis - is it contagious?
Question: Dear Dr Mike:
Is Stomatitis contagious? Can you have a cat suffering from
this condition living with other cats?
Answer: Suzanne-
There are infectious causes of stomatitis, including feline leukemia virus
and feline immunodeficiency virus. It is a good idea to check cats for
these viruses when a cat has chronic stomatitis. If they are not present,
then it is unlikely that there would be a contagious cause of the
stomatitis and I don't think there would be a problem with keeping an
affected cat with unaffected cats.
Mike Richards, DVM
12/28/2000
Chronic stomatitis/Chronic inflammatory gingivitis
Question: Dr. Richards,
I need help for my 4 year old black & white neutered male tuxedo cat
named Sammy. Two years ago he developed chronic stomatitis. Sammy has
had depo shots which seem to alleviate the pain and redness temporarily,
and is currently taking lactoferin (a nutritional supplement). I am
curious to know if there are any treatments whether conventional or not
available for Sammy. I would even try interferon if plausible. Please
help me to help Sammy. Cats have very short lives compared to us and
deserve the best care and treatment possible.Thank you,
JoDell
Answer: JoDell-
This is information from the last issue of the VetInfo Digest:
Chronic Inflammatory Gingivitis (Gingivostomatitis) in Cats
Chronic inflammatory gingivitis that is not directly related to the usual
progression of dental plaque, dental calculus, gingivitis and then
periodontal disease, in cats, has been referred to as
gingivitis/stomatitis, plasmacytic/lymphocytic gingivitis, plasma cell
gingivitis, plasmacytic stomatitis and probably a number of other names, as
well. There are some variations in these conditions but they are similar
enough to consider together as a disease syndrome.Cats can develop very severe gingival inflammation without having dental
calculus formation. This condition can lead to obvious oral pain, severe
inflammation of the oral tissues, bad oral odor, loss of appetite and
lethargy. This condition can occur early in life (less than a year of age)
in some cats, but usually shows up in young adult cats. The presence of
dental calculus seems to accelerate the onset of this problem and can
independently cause gingivitis, so it is important to clean the teeth and
keep them clean while attempting to treat chronic gingival inflammation in
cats. This is the basic step in treatment and it is sufficient in many
cases to control gingivitis without further treatment.When keeping the teeth clean on a regular basis doesn't work, treatment for
gingivostomatitis in cats can be frustrating. There are several medications
that are used for this condition and none of them works effectively in all
cases. In some cats, the use of antibiotic therapy, usually using
clindamycin (Antirobe Rx) for 5 days of each month will control the
gingivitis. This can be supplemented with chlorhexidine rinse or gel
products such as CHX (tm) if necessary. Omega 3 fatty acids are also
helpful in combating the inflammation associated with chronic gingivitis in
cats. There are a number of omega-3 fatty acid sources available. These are
safe products to use, so they should be considered for all cats with this
condition.Corticosteroids, such as prednisone or methylprednisilone injections, work
well to control plasmacytic/lymphocytic gingivitis in most cats. For this
reason, they are the mainstay of treatment for this condition. In some cats
topical corticosteroids, such as Lidex (Rx) gel will work but most cats
require oral or injectable corticosteroids.Bovine lactoferrin will help to control gingivitis in some cats. When this
product works it is considered to be safe to use long term and it works
very well. Unfortunately it appears that only about twenty percent of cats
respond to lactoferrin use based on initial case reports. The usual dosage
of lactoferrin for cats is 175mg/day. It is either mixed in milk and
swabbed on the gums or given orally mixed with food. I do not know which
application method works better.Surgical treatment of the inflamed gums with a CO2 laser has been reported
to control gingivitis well in many cats. Lasers are becoming more common in
veterinary practices and many of the veterinary referral practices have
this capability now.Removal of the teeth in the affected area usually will help a great deal to
control gingival inflammation. This sounds like a really bad idea but most
cats feel so much better without the gingival inflammation constantly
bothering them that they do not appear to miss their teeth much. It is very
important that the entire tooth be removed, so careful extraction is
necessary. If a portion of the root is left behind in cats with chronic
gingivostomatitis, there is often a continued reaction at the site that the
root is retained.As we have pointed out before, when there are a large number of treatments
for a condition it usually means that none of them work all the time. This
is certainly the case for chronic gingival inflammatory conditions in cats
but usually it is possible to find a therapy that will work, if you and
your vet are persistent enough.If there is a veterinary dentist in your area, it may help to ask for a
referral if your usual veterinarian isn't having good success treating
Sammy. Your vet is trying the approaches to this problem that work best
and working towards trying medications with less side effects so there is
nothing wrong with his or her approach. Pretty much everything I have seen
regarding interferon use, for this particular problem, suggests that it is
not very effective.Good luck with this.
Mike Richards, DVM
2/23/2000
Question: Thanks for all your previous indulgence of my obsession with plasmacytic
stomatitis. Here's one more question and possibly the last though don't
bet on it:Ranger the Expensive Rex had a shot of prednisone five weeks ago -- how
long should I wait before giving him another one? He still seems fine,
though his gums are starting to get red again. But I don't want to
over-medicate. How harmful is it to give him shots too often vs. too
seldom?
Thanks! S.-Answer: Unfortunately the situation you are in requires that you "walk the razor's
edge". Yes, overadministration of corticosteroids can definitely be
harmful. But not administering them often enough can make Ranger's life
pretty miserable. I really don't believe in waiting until a cat is hurting
before using corticosteroids when they work well for conditions like this.
My thinking is that quality of life is worth taking some risks for. The
risks in this case are increased susceptibility to other infections,
increased susceptibility to diabetes, possibly increased susceptibility to
pancreatitis (more likely in a dog), weight gain, behavioral changes and
some less common side effects. These are significant risks but most
patients do not experience these side effects. Because they exist, though,
every vet picks out a "comfort zone" in which they will risk the side
effects to benefit the patient.For this disease my comfort zone is to keep methylprednisilone (DepoMedrol
Rx) injections at 4 to 6 week intervals or longer, when possible. There are
vets who won't use injectable corticosteroids at all, favoring every other
day administration of prednisone. There isn't much question that this
approach is better if it works but our experience has been that it doesn't
work as well as injections. I can't explain why.We usually end up giving three or four injections at fairly close intervals
and then often there is a time of remission in which we can let the
interval get longer. But we recommend looking at the gums daily and
starting up again when they show signs of problems, rather than waiting
until the cat shows obvious signs of problems without having to look at its
gums.The shortest intervals we have had to use for injections are two week
intervals. We have seen problems with secondary infections (stuff like
abscesses in cats that don't go outside) when using DepoMedrol this
frequently but in some instances even that much risk is worthwhile. You
have to see how bad some of these cat's mouths can get to appreciate that,
but I believe it.We try very hard to get our clients to consider removal of the teeth when
we have to give injections closer than 4 weeks apart for more than two or
three injections. This really does work well in most instances and is a
good course of action if the problem becomes very persistent.If this just made things more confusing, write again!
Mike Richards, DVM
11/20/99
Plasmacytic stomatitis continued
Question: Thanks. My vet says "Wait until he's suffering," which I plan not to do.
(Solution: Lie.) I figure every 5-6 weeks at a minimum, given your
schedule.My question now: Is over-administration harmful?
Thanks again!
Answer: S.-
I am pretty happy in cases of plasmacytic/lymphocytic stomatitis if I can
keep corticosteroid (I use methylprednisilone) injections four weeks apart.
Longer is better when it is possible to get longer intervals. But keeping
this condition under control is important. Since it has been longer than
four weeks since the last injection I'd lean towards controlling the
inflammation now. Ranger would feel better. Ask your vet, though. He or
she can see the amount of inflammation and assess the need a little better
than I can, obviously.Mike Richards, DVM
11/20/99
Last edited 09/23/02
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