Oral problems - Mouth, Tooth and Dental Care

Question: My 17 year old siamese was diagnosed with chronic renal failure a year ago. Her teeth are not in good shape and I am worried that this could worsen her condition. The vet told me she has a reabsorbtion lesion that is painful. When my cat yawned today I saw a black spot on her back tooth that looks like it could be a cavity. One vet told me that putting my cat under anesthesia to pull/clean teeth would be too risky; her kidneys wouldn't be able to filter the anestethia and she could die. Another vet scolded me and said that she needed the tooth pulled b/c the lesion is painful. I am really worried that my cat is in pain but I'm afraid to put her under to get her teeth pulled. I would appreciate your advice on this matter. My cat's latest blood tests are: BUN 40.3, Creatnine 3.25

Thank you, Cathy

Answer: Cathy-

I think that dental lesions are painful enough that overall health improves when they are dealt with. So I almost always want to pursue anesthesia. However, there is some increase in risk when kidney disease is present and it is important to realize this and to compensate for it. The major risk to cats with kidney disease is low blood pressure occurring for a significant length of time during an anesthetic procedure. Giving fluids intravenously during the procedure helps to reduce this risk. In some instances a procedure may be short enough that it seems unnecessary to do this, but it is a good precaution for most anesthetic procedures in cats with kidney failure. It is also a good idea to try to rule out high blood pressure prior to the time that the anesthetic is given. Many cats with kidney failure have high blood pressure because of the effects of the kidney failure on the blood pressure regulatory system. It is good to consider this possibility when planning which anesthetics to use. With care, I think that anesthesia in patients with kidney failure is nearly as safe as in patients without this problem but it is necessary to consider it when planning the anesthetic procedure.

There is a small risk of death with anesthetic procedures but the increase in the quality of life for so many patients outweighs this risk, in my opinion. Some people view death as such a prohibitive risk that they are willing to tolerate a lot of discomfort to avoid any anesthetic risk. This is a value judgment that has to be made by each person making this decision and so both vets are entitled to their opinion. While I favor being willing to take a small risk to increase the quality of a patient's life, it is just my personal opinion. I try to present both sides and let my clients make the decision based on their view of the benefits and risks. It is just really important to remember that patients with dental disease are often in pain, so there is often a great benefit to dental care, even if it does require anesthesia. Sometimes, an increase in drinking and eating after dental care causes significant improvements in illnesses like kidney or liver failure, too.

Mike Richards, DVM 6/5/2001

Gingivitis, antibiotics

Question: Dr Mike,

I had my 9 1/2 year old cats teeth cleaned a month ago. She had severe gingivitis. She is now getting the bad breath again. She also sneezes everyday. Is she going to need her teeth cleaned every month? Could she have other problems making her prone to the gingivitis? Is it a good idea to have a blood test done on both cats?

Answer: There is pretty good evidence now that periodic use of clindamycin, an antibiotic, can slow the progression of periodontal disease in cats, making it possible to go longer between dental cleansings in patients who develop recurrent periodontal disease quickly. This may be worth considering. Giving the medication the first seven to ten days of each month is one example of a periodic schedule that seems to help. You might think about this for your older cat if your vet thinks it might help, too. There are problems that cause increases in the incidence of periodontal disease, such as kidney disease, feline immunodeficiency virus, food allergies and immune mediated disorders. Blood tests can help rule out some of these causes. It is usually possible to draw blood without sedation but there are some exceptions.

I hope that things have improved some since you wrote.

Mike Richards, DVM 2/3/2001

Oral inflammatory disorders

Question: Hi Dr Mike,, Thank you for getting back to me. My Cat Sam was having a problem with his throat and my vet said that he has stomatitis. His gums are not bad but his throat is very sore. My Vet gave him a depo medrol shot about 3-4 weeks ago and a few days after the shot his eye got really infected looking. I took Sam back to the vet and was told to put vetropolycin in his eye. After apx 5 days I took him back in and was given terramycin, I used that for 7 or 8 days and his eye still was not better. Finally my vet tested for herpes. We should have the results back tues or weds. In the mean time Sams eye looks better but his throat is hurting him again. My vet said to just try and get him to eat baby food or something that won't hurt his throat until he gets the results of the herpes test. Is there any advice that you can give my vet?? Sandy-

Answer: I think that the best help that I can give you at this time is a list of the possible oral inflammatory disorders and some of the treatments that have been advocated for individual conditions. It is important, when possible, to identify the underlying cause of problems affecting the oral cavity that appear to be chronic because they often are very difficult to resolve and may require long term maintenance therapy. It is worth having a biopsy sample taken of the sores, considering oral X-rays and a dietary trial to eliminate food allergies, as well as other diagnostic testing if there is not a good response to initial treatment attempts.

One thing in your note did stand out for me. If you really believe that there is soreness in Sam's throat, rather than around his teeth, there is a higher probability that you are dealing with plasma cell stomatitis rather than some of the other things in the list that follows.

These are the most common of the oral inflammatory conditions seen in cats:

feline herpes virus or calcivirus infection these will usually heal on their own without treatment but there can be long term problems due to calicivirus

feline leukemia virus (FeLV) it is often necessary to treat for secondary infections when FeLV is present some people feel that treatment with interferon is helpful for FeLV infections

feline immunodeficiency virus (FIV) FIV has a strong tendency to cause gingivitis and it is a good idea to test for this virus when persistent gingivitis is a problem AZT is the most commonly recommended medication for FIV infections but work is being done on developing multiple drug treatments at the current time it is somewhat controversial to use corticosteroids in FIV patients but it seems to help some of them

eosinophilic granuloma complex this is an immune mediated disorder associated with flea allergies and food allergies but it can occur for no apparent reason and may also occur with atopy (inhalant allergies corticosteroids are the most consistently successful treatment for this condition but it has also been treated with megestrol acetate (Ovaban Rx) and may respond to hypoallergenic diets, flea control or allergy injections (hyposensitization) there are lots of other treatments that have helped in some cases

lymphocytic/plasmacytic gingivitis or plasma cell stomatitis (plus other variations of these names) this condition may be related to calicivirus infection but seems to be an immune mediated disorder in most cats. High gamma globulin levels in the blood stream are supportive of a diagnosis of this condition. It is postulated that some cats are sensitized to their own teeth and removal of the teeth behind the canines (cuspids) will cure this condition in approximately 60% of cats. Oral corticosteroids, teeth cleaning on a routine basis, removal of teeth with odontoclastic lesions (holes in the enamel similar to cavities), other immunosuppressive medications (cyclosporin is currently being used) and sometimes antibiotic therapy are the standard treatments and are successful in a large percentage of cats. A small percentage (<20%) of cats seem to respond to bovine lactoferrin administration for this problem. It is pretty safe to use this so we have tried it several times and our results seem to match the 20% figure this condition tends to cause signs that clients think of as a sore throat, so I would be most concerned that this is the problem for Sam but the best way to try to get a diagnosis is by biopsy an affected area of tissue. This can be done at the time of teeth cleaning. This can be a very frustrating condition.

Ulcerative necrotizing stomatitis (this is called trench mouth in humans) Examining a smear made from the inflamed area might reveal a lot of spirochete bacteria, which are the cause of this problem. Bacterial cultures can reveal the problem and it is discernible by biopsy, or at least we have had a biopsy sample come back with this diagnosis, so we assume it is. Antibiotic therapy for at least 3 to 4 weeks is necessary to control this problem

Oral cancers are the last group of problems that is somewhat common and can lead to the signs that you are seeing. This possibility is another reason to consider biopsy of the affected area. I have seen several references that state that it is not possible to differentiate eosinophilic granuloma lesions from oral cancers, even for experienced observers.

The appearance of the eye lesion after administration of a corticosteroid is very suspicious for herpes virus infection, even if herpes virus is not found in testing. Right at this time, there isn't a completely reliable lab test for herpes virus. Herpes virus eye lesions often have infiltration of blood vessels in a pattern reminiscent of a lightening bolt, so that may help in differentiating what is going on. If there was a pre-existing eye infection or scratch on the eye at the time of the cortisone injection it could conceivably lead to a corneal ulcer, so herpes virus is not the only possibility, just the most likely one.

It can be frustrating to work through the possible problems while your cat feels bad due to the existing sores. The quickest way to an answer is probably to allow a good dental cleaning, with biopsies taken of several sites that are inflamed. Then while awaiting the pathlogist's report consider trying a hypoallergenic diet, such as Hill's z/d diet or a limited antigen diet like Hill's d/d or Innovative Diets foods (they make several). We often use antibiotics as the only medical therapy for a few days early in the effort to diagnose these conditions. If there is great improvement in a few days, we keep going with them for three to four weeks. Once in a while this resolves a problem. More often, there isn't much improvement within a week so we go ahead and go to corticosteroids to try to make our patients comfortable.

There is a tendency to use laser treatments for the plasma cell stomatitis problems at the present time. This seems to provide temporary relief but it doesn't resolve the underlying problem and my impression is that return of the problem quickly is more common than a cure with laser therapy.

I hope this helps to start out. If this raises additional questions please feel free to send them.

Mike Richards, DVM 1/17/2001

Lymphocytic/plasmocytic gingivitis

Question: My five-year-old Cornish Rex has had mouth problems. Last week I finally bit the bullet and had him sedated (he has a heart murmur) and a biopsy done; the diagnosis was what the vet expected, which is chronic plasmocytic gingivitis. Right now we're trying 1 cc daily of oral prednisone until he gets better, then it will be 1 cc every other day. After a week he still seems to have pain when he eats. (It's not the teeth, which, the dentist said, "looked pretty good.") He tested negative for FIV and FeLV last March but does go outside on a "Saturday afternoon in good weather" kind of basis. However, the problem was beginning to show up as early as last January so I doubt it's FIV related. But it COULD be.

Are there any other treatments that might be effective? What CAUSES this, anyway?

Answer: Stephanie-

If corticosteroids don't work alone for lymphocytic/plasmocytic gingivitis problems in cats, sometimes adding azathioprine (Imuran Rx) or another immunosuppressive agent works. I haven't tried any other ones and have had some cats that the combination didn't work in.

Removal of all of the teeth except the four big canines and the incisors is an effective treatment for this condition in many cats. It has to be done correctly, though. Leaving any root fragments can leave problem areas. This sounds like a radical option but it works pretty well.

There was an article in the AVMA research journal in 1996 on something called bovine lactoferrin that suggested it worked well for this problem. It was in the October issue and was written by Sato et al. I think I can find a dosage if necessary. It has to be applied topically, which seems like it could be a problem in some cats. In addition, there is a CO2 laser treatment for this condition that is reported to work in some cats, too. I don't know much about this, either -- but it is still an option to look into if cortisones don't work.

So there are options. We have only used the corticosteroids, corticosteroid/azathioprine combination and extraction and so far have been able to resolve most cases of this problem. I don't think I'd hesitate to try the other options if they are more attractive to you than tooth extraction, though.

Hope you have success with cortisones alone.

Mike Richards, DVM 10/1/99

Tiny black spots on teeth

Question: Dear Dr. Richards,

I am a subscriber and have another question about Shadow (my Snowshoe kitty with the quivering eyes)...his gingivitis continues to be a problem that's still being worked on but very recently he's gotten very tiny (like a pin prick) black spots on some of his teeth and not near the gums. He's scheduled for a teeth cleaning very soon. Do you have any ideas? Thanks very much, Leslie & Shadow P.S. He eats Waltham's pHformula dry food and a tiny bit of canned food.

Answer: Leslie-

I can't help with this question. Your vet will hopefully be able to give you information after examining and cleaning the teeth. There is some chance that these are odontoclastic resorption lesions but they usually occur near the gumline. Not always, though. Some sort of staining of the enamel seems possible, too. I don't know what would stain the enamel in small spots like you describe, though. I wish I could help some with this but you're going to have to rely on your vet for this one.

Mike Richards, DVM 1/31/2000

Severe gingivitis in kitten

Q: I have read alot of stuff on the internet, but I just would like to hear what you have to say on this as well. I got my kitten in April, she was 4 months old at that time. Her breath seemed a little weird but it would come and go. She eats Iams Eukabana Chicken and Rice (dry). The other day she was biting at my fingers and I noticed that her gums were swollen and red so we went to the Vet today. The vet said it is not due to tartar buildup so she would have to do a biopsy next week and put her under to do it to find out the cause. What is the usual course on these things and is there anything I should be worried about. She is a Birman, are they prone to such an illness. Anyway I am worried alot and thought maybe you could help. Thanks. Susan

A: Susan- There are several possible problems when young cats have severe gingivitis. One of these, often referred to as "juvenile gingivitis" has not been well characterized. Presently I think the major theory is that it is the result of chronic calicivirus infection but am not absolutely certain that a definitive cause has not been found. This type of gingivitis seems to respond to persistent teeth cleaning (often takes several closely spaced cleanings) and treatment with fluoride or chlorhexidine (or both) may also be helpful. Plasmacytic/lymphocytic gingivitis can be diagnosed by biopsy. This sometimes responds to anti-inflammatory medications. It is more common in more mature cats and sometimes requires removal of the teeth where the gums are inflamed. Feline immunodeficiency virus is often associated with gingivitis. Feline leukemia may occasionally play a role in it. Kidney disease may be present but usually there are a lot of other problems in this case (poor growth, drinking and urinating a lot).

X-rays to look for bone resorbption can help sort through the problems affecting the teeth (bone loss occurs in juvenile gingivitis). Teeth cleaning can help determine what is going on. Since this usually takes anesthetic doing a biopsy at the same time seems reasonable to me.

Good luck with this.

Mike Richards, DVM

Lost canine tooth

Q: I panicked this morning when I saw my 12-year old cat, Muffy, meow and noticed that her upper left canine tooth was missing!! I tried to look in her mouth and saw that where the tooth had been didn't look red or infected. How could a cat lose a tooth like that without showing signs of distress. She had an upper respiratory infection in February and refused to eat for about 4 days. On the advice of my vet I kept her hydrated with chicken broth and tried everything to get her to eat. Then I took her to the vet for a vitamin injection. It worked and within 12 hours she was eating everything she get a hold of. Her weight did drop some during the illness but her appetite continued to be strong and the vet suggested putting her on the Hill's Health Blend Geriatric formula. (she was on c/d but never would eat it again). She didn't like the canned version of the Geriatric but liked the dry. It is lower in fat and never thought too much about her weight not coming back up. She has had a continuously watering eye and had been checked twice but the vet said it might be a clogged tear duct or a result of the herpes virus that sweep throug the house in February. She was treated with an eye ointment but it never stayed cleared up. The only time that she didn't have the watering eye was when she had the respiratory infection which seems strange. Could this watering eye have been a signal that a tooth was infected? I can't believe that we all missed it. She seemed very healthy. Very energetic and affectionate. Her urine and stool is normal and her fur is shiny and free from dandruff. I have been giving her a natural canned food for the last month (Pet Guard brand) and she loves it. After the respiratory infection, the only food she would eat was Friskies Senior. (I never felt comfortable giving her a supermarket brand food) Since she refused all the canned food from Hill's, I tried the Pet Guard. I don't know when the tooth came out but it seemed to have healed. She is still able to eat dry food but should I continue to let her eat the dry with this tooth missing? I feel so bad that she lost a major tooth and no one could see the problem ahead of time. Do these things happen? Any information you can provide would be appreciated. Thank You. Lou.

A: Lou- The canine teeth have extensive roots and this is where damage to these teeth often occurs. There may be little to no sign of problem above the gum line. Periodontal disease is one cause of losing canine teeth but it usually advanced when they finally come out on their own. Her other teeth should show signs of this condition if it is present. Odontoclastic lesions (cervical neck lesions) are a condition that is seen in cats in which cavities form just at or just below the gumline. These will eventually weaken the tooth to the point that it comes out. This would have to have been going on a while too, but these are harder to see. It is uncommon for this to happen in just one tooth so it may be a good idea to check for these lesions in her other teeth. Often a small reddened area (like a flap) is visible at the base of the tooth where it meets the gumline when one of these lesions is present. It seems inconceivable that these cavities wouldn't hurt but many cats do not show any obvious signs of distress.

Odontoclastic resorptive lesions sometimes respond to "filling" using glass isomers or other methods but many of them continue developing despite this sort of treatment. If this is an option you would like to pursue it would be important to find a vet with at least an interest in dentistry or preferably a board certified veterinary dental specialist. Since the success rate of treatment long term is reported to be about 33% many vets just recommend removal of affected teeth, especially if visible discomfort is present.

Mike Richards, DVM

Teeth, gums and FIV

Q: Hi, Dr. Mike. About a week ago I took my one year old male oriental/tabby to my vet to get his booster ect. in preparation for "tutoring". Dewberry is the offspring of my girlfriends female oriental tabby and my 2yr old male tabby. The litter was quite large, she had nine kittens, seven of which survived, which we thought was quite remarkable for a cat that weighs less than ten pounds having her first litter. Dewberry was the runt of the litter, he had to be fed at times with a dropper. When he was about 2 months old he developed an infection in his back legs (about two days apart) we immediately took him to the emergency, and as it was only one leg, the emergency attentant thought it may have been a strain from aggressive kitten play. They recommended keeping him in the carrier for a couple of days to slow him down to allow it to heal. When we noticed his other leg was swelling we brought him back and they gave him an antibiotic (milky texture). The swelling went down in a couple of days. He has gone on to be the largest of all the kittens (much longer and taller). He is a very well mannered, happy little boy, who has no lack of energy and likes to get into everything. His appitite is good, his eyes are clear and bright, his coat is shiney, (although he gets the occasional zit like both his parents) and his stool is solid. On his last visit to the doctor, while getting his booster, the vet noticed some reddness in his gums around his K9s. (I have a 4 year old DSH who has bad tarter on his back teeth so I've recently changed thier food from Whiskas to Standard Choice, quite noticably crunchier). When the vet noticed the gums he suggested the possibility of FIV, even though he thought he was healthy in every other way (we are in touch with the owners of his brothers and sisters, and they are all healthy). He has never been out side as all our cats are indoor cats.He still has to wait at least another week or two before he can get neutered. The health of our cats is very important to us and I'm wondering if I'm just overreacting, or if our concern is justified and we should get him to the vet immediately. Thank you for your attention to this matter (sorry for the length of this letter).

A: . Feline immunodeficiency virus (FIV) infection is associated with gum disease and calcivirus infection can also cause redness of the gums around the teeth. Sometimes this seems to be just from teething (especially if it occurs when they are teething and goes away when the permanent teeth are in). You might want to consider testing for FIV at the time of surgery or prior to surgery. Your cat probably doesn't have it but it might be reassuring to be sure.

Mike Richards, DVM

Gingivitis plus

Q: Dear Dr Mike, As a cat breeder of many years, I have in the past three years come across at least three of the kittens I have bred suffering from Gingivitis, and some times ulcers on the tonge and in the mouth, accompanied by 'smelly breath'. I realise that this may be genetic in 'one' of my breeding lines, but do you know of an effective treatment that would lead to a cure, rather than courses of antibiotics when the ailment occurs? My cats have a good balanced diet, and do chew on bones as well as 'some' dry foods. However this problem still comes back, particuarly in the kitten stages, and up to one or two years old. I would be grateful for your advice.

A: You didn't mention the breed of your cats. There is a congenital problem with gingivitis in Abyssinians and Persians in which there is significant overgrowth of the gingiva, resulting in gingivitis. This condition is reported to resolve spontaneously as the cats mature. We have found it necessary to treat the affected cats, using repeated dental cleanings and sometimes removal of the excessive gingival tissue prior to the time that the condition resolved. I think that this is commonly the case. Siamese cats are reported to be prone to "trench mouth" or ulceromembranous stomatitis. Same basic treatment plan except that antibiotics are necessary to control this and it may clear up and stay away. (from the Clinics of North America, Feline Infectious Diseases, May 1993, Hoskins and Loar).

There are a number of causes of gingivitis in these and other cat breeds. The causes get a lot more difficult to evaluate and the treatments a lot less likely to work consistently with these other conditions, though.

Viral diseases play a major role in many cases of gingivitis in cats. At least two viruses, feline immunodeficiency virus (FIV) and feline calicivirus are capable of inciting or exacerbating gingivitis in cats. It is possible that feline leukemia virus (FeLV) may also be involved in some cases of gingivitis. Both of these viruses are common in cats. It is unclear whether or not calicivirus is a primary cause of gingivitis or whether it just causes problems in cats that are already immune compromised for some reason, including FIV infection. In any case, these are difficult problems to control since anti-viral medications tend to be only partially effective, at best. Good control of all other factors contributing to the problem seems to work best -- so again, dental prophylaxis, antibiotics to control secondary infections if necessary and good nutrition and husbandry are all necessary.

There is a condition known as plasmacytic-lymphocytic gingivitis (sometimes with stomatitis appended, too). It is an inflammatory condition affecting the gingival tissues. This is an abnormal immune response that some people feel is a form of allergy response in cats and others feel is another immune system disorder. As far as I know, the exact cause of this problem has not been worked out. It is diagnosed with biopsy specimens from the affected gum tissue, usually after FIV and FeLV testing have been done to rule out those problems. If there is no viral illness, treatment is usually attempted using corticosteroids to suppress the immune system. They are probably the most consistently effective medications. Other medications, including gold salts and megestrol acetate have been used to treat this problem, as well. A fairly common recommendation is to remove all of the teeth except the four big canine teeth and the incisor teeth between them. This works pretty well and most cats do fine without the teeth, even eating dry foods readily. Alternatively, aggressive prophylaxis to prevent any dental disease, treatment with immunosuppressive medications and quick treatment of any secondary problems may provide good control of this problem.

There are several other possible causes of gingivitis in cats. The best bet, if possible, is to have a biopsy done of the affected gingival tissue and try to get to a diagnosis. It may be a good idea to screen for FIV and FeLV virus in your cattery if you have not done that. Your vet can help you figure out what is going on, perhaps with a little persistence on everyone's part, since it can take a couple of tries at biopsies to get a good answer.

Mike Richards, DVM

Last edited 09/23/02