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now, I know the routine quite well. Maxine, a four year old tabby owned
by Beri Goor, shows up at my practice like clockwork every four months.
I ask how Maxine has been doing. I’m told that she’s been fine, except
for the past two days she’s begun pawing at her mouth and has stopped
eating. I examine her mouth. I grimace. I administer an injection of a
long-acting steroid and I send Maxine home. Two days later, I call Ms.
Goor for an update. I’m told that Maxine is now eating and acting
completely normal.
In
four months, she’ll be back, and we’ll do it all over again.
Maxine has gingivitis – inflammation of the gums. But this is no
ordinary gingivitis. Maxine also has stomatitis – inflammation of the
entire mouth. In fact, Maxine has an extreme form of oral inflammation
that goes beyond your garden variety gingivitis. Maxine’s condition is
referred to as “lymphocytic plasmacytic gingivitis stomatitis (LPGS), a
painful inflammatory condition that causes a great deal of discomfort to
many cats.
What causes LPGS in cats?
The exact cause of LPGS is unknown, but it is most likely a combination
of various factors, and as such it should be considered a “syndrome”
rather than a specific disease entity (see sidebar). One theory is that
some cats’ gums are hypersensitive to bacterial plaque. Small amounts
of plaque will cause the immune system to overreact and mount an
exuberant inflammatory response, sending large numbers of cells, mainly
lymphocytes and plasma cells (hence the description “lymphocytic
plasmacytic”) into the gums and oral tissues. Suppression of the immune
system has also been theorized as a cause or contributing factor in LPGS.
Infection with the feline leukemia virus (FeLV) and/or the feline
immunodeficiency virus (FIV) is known to suppress the feline immune
system, although many other factors, including stress and other
environmental influences, can weaken a cat’s defenses and predispose
them to illness. Other infectious causes have been implicated, including
feline calicivirus (FCV) and a bacterium called Bartonella henselae,
although Bartonella’s role in the disorder hasn’t been clearly
defined. It has been suggested that a genetic predisposition is
likely in some breeds.
What are the signs of LPGS?
Oral pain is probably the most common sign of LPGS. This can manifest
in a variety of ways. Cats may have difficulty eating, or may stop
eating entirely. Some will drool excessively, with the drool being blood
tinged on occasion. Some cats approach the food dish as if they’re
interested in food (which they usually are), but then run from the food
dish because eating is painful. A few cats will paw at their mouths and
may develop an aversion to having their face touched. Some cats stop
eating their dry food, which can be painful to chew, and will only eat
canned food. (This is often misinterpreted as being “finicky”.) Cats
tend to be relatively secretive about their illnesses and may manifest
their oral discomfort in more subtle ways, usually as a change in
behavior, such as being reclusive, irritable, or aggressive. Grooming
may become uncomfortable and cats may develop an unkempt hair coat as a
result. Often, cats with LPGS have bad breath (halitosis).
How is LPGS diagnosed?
A
definitive diagnosis of LPGS is achieved by biopsy of the affected
tissues during a thorough oral examination. General findings include
extremely red, proliferative (swollen and overgrown), and ulcerated oral
tissue that bleeds easily when touched. The most frequently affected
tissues are the gums, although other areas of the mouth are commonly
affected, such as the roof of the mouth, the fauces (the lateral walls
at the back of the throat that surround the tonsils), the tongue, and
sometimes the lips. Various degrees of dental and periodontal disease
may be present, as this often contributes to the progression and
severity of LPGS. Oral x-rays may reveal the presence of retained tooth
roots and resorptive lesions – painful tooth erosions similar to
cavities. In most cases, the cat needs to be sedated for a proper,
thorough oral examination to be performed; general anesthesia is usually
required if dental radiographs are to be taken. If the cat is to be
anesthetized, a biopsy of the affected oral tissues should be obtained
at that time to confirm the diagnosis, as there are other disorders,
such as cancer and the eosinophilic granuloma complex (another
inflammatory condition that often affects the mouth) that may resemble
LPGS, that may have a much different treatment protocol and prognosis.
How is LPGS treated?
The goal of treatment is to decrease the inflammatory response. If a
hypersensitivity to dental plaque is believed to be the major factor in
an individual cat’s LPGS, a thorough dental scaling and polishing should
be performed. “Plaque control is the cornerstone of therapy” says Dr.
Bonnie Shope, a veterinarian at the Tufts Cummings School of Veterinary
Medicine whose practice is limited to veterinary dentistry. “In some
instances, these cats may need a professional dental prophylaxis three
or four times a year”. Ideally, cats’ teeth should be brushed regularly
after the dental scaling, however, cats with LPGS have mouths that are
too painful to tolerate brushing. Oral rinses or gels may be of benefit,
but again, many cats find any manipulation of their mouths intolerable.
“Home care is an essential part of therapy, if the cat will tolerate
it”, says Dr. Shope. Unfortunately, even with thorough dental
scaling and subsequent home care, the condition often progresses.
Antibiotics and anti-inflammatory steroids are of some benefit in many
cats, however, the use of these drugs usually offers only a short-term
“fix”. Eventually, most cats become non-responsive to medical treatment
and will require extraction of all of the teeth. “Extracting the teeth
tends to be the most successful treatment”, says Dr. Shope. In some
individual cases, the canine teeth (the “fangs”) may be salvaged,
however, they may need to be extracted at a later date if the condition
doesn’t improve, or if it worsens over time. In some cases, extraction
alone successfully reduces the inflammation and allows the cat to eat
and live normally. Clients often worry that their cat won’t be able to
eat after full-mouth extraction, however, most cats tolerate extractions
very well and can eat moist food readily, with many cats able to crunch
on dry food after the extraction sites have fully healed.
Many cats need an occasional short course of anti-inflammatory drugs
during flare-ups. Ideally, the anti-inflammatory medication is given
orally at initially high doses to control the inflammation, and then the
dosage is tapered to the lowest dose that keeps the condition under
control. However, as stated above, most cats won’t allow oral
administration of medication. In these cases, an injection of a
long-acting steroid is often the only alternative. A few cats require
continuous administration of anti-inflammatory medications even after
all the teeth have been extracted. Such is the case with Maxine, who
had most of her teeth extracted when this problem first became
apparent. Before her extractions, medical therapy was largely
unsuccessful at keeping Maxine comfortable, and she was truly
miserable. Although she improved markedly after her extractions, she
still requires regular doses of anti-inflammatory medication to keep her
mouth relatively pain-free. Other drugs, such as lactoferrin and
interferon, have been tried, however, results have been inconsistent.
Dr. Shope has had moderate success using cyclosporine, a potent
immunosuppressive drug, in some cases. “For cats with LPGS that have
improved after extraction but still need other medications to control
the condition, I’ve seen some positive results using cyclosporine”, she
says.
Management of LPGS can be challenging. Clients need to be aware that
the long-term prognosis for a cure is guarded, and that the cat is
likely facing a lifetime of frequent veterinary visits and treatments.
With vigilant monitoring and conscientious veterinary care, cats with
LPGS can live comfortable happy lives.
Sidebar: Possible causes of lymphocytic plasmacytic gingivitis and
stomatitis
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Hyper-responsiveness – some cats are “plaque
intolerant” and develop an exuberant inflammatory response to very
small amounts of plaque
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Immunosuppression – a weakened immune system, due to
viral infections, stress, certain drugs, and environmental factors,
may promote development of LPGS
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Viral and/or bacterial infection – the feline
leukemia virus, feline immunodeficiency virus, feline calicivirus,
and bacterial organisms are suspected to play a role in promoting
development of LPGS
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Genetic predisposition – some breeds are believed to
be more susceptible to gingivitis and LPGS than others.
Updated 2/9/06
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