Severe Gingivitis/Stomatitis

By 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). 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 analogous to cavities to humans. 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?

Severe Gingavitis / Stomatitis

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. 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.
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. Although it sounds drastic, extracting the teeth tends to be the most successful treatment. 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.

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.

Updated 4/1/16