Oral problems - Stomatitis

Stomatitis - new treatment medications

Question: 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

Plasmacytic stomatitis

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