14 Idiopathic chronic gingivostomatitis with extraction leading to cure
There was no history of any oral disease until 1 year ago, when the cat presented with inappetance and drooling. The owner reported that he would start to eat and then back off his food as if he was in pain. The oral mucous membranes were intensely inflamed. He had been treated with antibiotics and corticosteroids intermittently (six treatments in total) during the last year. Initially, the combination of a short course of antibiotics and long-acting steroid had resulted in clinical improvement in that the cat had resumed eating. The effect had only lasted for 4–6 weeks and become shorter for each course. The last course of antibiotics and long-acting steroid had been ineffective. There was no history of oral/dental examination under general anaesthesia or periodontal therapy. The referring veterinarian reported that the cat was FeLV and FIV negative. The only blood abnormality was elevated plasma globulins and a left shift in the neutrogram.
The cat was referred to us for management of the chronic gingivostomatitis.
ORAL EXAMINATION – CONSCIOUS
The cat would not allow conscious examination of the face or oral cavity.
ORAL EXAMINATION – UNDER GENERAL ANAESTHETIC
A thorough oral examination, including investigating periodontal parameters, was performed and all findings were noted on the dental record.
In summary, examination under general anaesthesia identified a severe generalized oral inflammation. The gingivae as well as the buccal mucosa and the glossopalatine folds were intensely inflamed (Fig. 14.1a–c). Moderate amounts of plaque and calculus were present on the buccal aspects of the upper premolars. All teeth were present and showed no evidence of periodontitis.
Figure 14.1 Right lateral (a), left lateral (b) and rostrocaudal (c) photographs of the oral cavity.
A series of full-mouth radiographs (10 views) was taken.
An oropharyngeal swab from the glossopalatine mucosa was taken and submitted for feline calici virus (FCV) isolation.
No obvious pathology (Fig. 14.2a, b) could be identified on any of the 10 views.
Chronic gingivostomatitis (CGS) describes a clinical syndrome characterized by focal or diffuse inflammation of the gingivae and oral mucosa. It occurs in dogs but is predominantly seen in cats. It is thought to be an inappropriate response to oral antigens, namely bacterial plaque present on the tooth surfaces.
It is useful to view CGS as being subdivided into three different types, which may overlap. In one type, an underlying cause that explains the inflammatory response (albeit not the intensity) can be identified. Common causes are retained root remnants from previous extraction, periodontitis or other dental pathology. In the second type, concurrent disease that alters the animal’s ability to mount an appropriate inflammatory response can be identified. Systemic diseases, e.g. chronic renal failure and diabetes mellitus, will alter the immune response and may predispose to the development of severe gingival inflammation in the presence of plaque. Cats infected with FeLV and/or FIV are also unable to mount an appropriate immune response to the presence of plaque on the tooth surfaces. Cats infected with FCV are also likely to have an altered immune response. In the third type, no obvious dental pathology or underlying immune incompetence can be identified, i.e. idiopathic.
Cats with CGS require a thorough work-up prior to any treatment. The purpose of the work-up is not to reach a diagnosis per se, but rather an attempt to identify possible underlying causes. Such a work-up includes: testing for FIV and FeLV infection; sometimes testing for FCV infection; routine haematology and blood biochemistry; and sometimes biopsy and microscopic examination of the affected tissues. A meticulous oral and dental examination, including full-mouth radiographs to identify the presence of periodontitis, resorptive lesions, retained root remnants or other lesions, is mandatory. Systemic diseases, e.g. chronic renal failure and diabetes mellitus, which may predispose to the development of severe gingival inflammation in the presence of plaque, must also be excluded before any treatment is initiated.
In this case, no underlying cause for the inflammatory reaction in the oral mucous membranes was identified. The cat appeared otherwise healthy based on clinical examination and blood results. It tested negative to FeLV and FIV, and FCV could not be cultured from oral swabs. All teeth were present, with no evidence of periodontitis or resorptive lesions.