SPONSORED BY AN EDUCATIONAL GRANT FROM IDEXX LABORATORIES, INC. CLINICAL NOTES: Feline stomatitis—the role of retroviruses KEY POINTS • Chronic stomatitis is characterized by persistent inflammation. • The etiology of chronic stomatitis is multifactorial and probably includes immune system factors and infection. • All cats with stomatitis should be tested for feline leukemia virus (FeLV) and feline immunodeficiency virus (FIV). • Chronic stomatitis is 1 of the most common problems in cats infected with FIV. • The degree of stomatitis in FIVinfected cats is often more severe when concurrent infection with calicivirus or FeLV is documented. Screening for retroviral infection, particularly feline leukemia virus (FeLV) and feline immunodeficiency virus (FIV), is important in understanding the underlying cause of stomatitis in cats, a clinical presentation that most veterinarians are very familiar with.1 Stomatitis is specifically used to describe widespread oral inflammation in order to distinguish it from other terms used to describe localized oral lesions, including gingivitis and periodontitis. Chronic stomatitis is 1 of the most common problems in cats with FIV.2 Although being classified as an outdoor cat increases the risk for infection with FeLV and FIV, even cats classified as indoor may spend time outdoors. In 1 study of lost cats, 41% were reportedly housed strictly indoors and not typically allowed outside.3 CLINICAL PRESENTATION Chronic stomatitis, which is characterized by persistent inflammation and sometimes ulceration of the oral mucosa (see Clinical Signs of Chronic Stomatitis), is typically found in adult cats. The condition can be debilitating, frustrating to treat, and in some cases may result in euthanasia. Stomatitis Case Example: 3-Year-Old Cat* Sally, a 3-year-old, spayed female, domestic shorthaired cat, was rescued as a stray and presented for examination, vaccination, and wellness testing. On physical examination, gingivitis and stomatitis were noted, as well as submandibular lymphadenopathy. Clinical Signs of Chronic Stomatitis ■ Ptyalism ■ Bleeding gingival tissue ■ Oral sensitivity ■ Halitosis ■ Partial anorexia ■ Weight loss Results of a CBC, serum biochemical profile, and urinalysis revealed mild neutrophilia and hyperglobulinemia. In addition, retrovirus serology results were positive for FIV antibody and negative for FeLV antigen.† After full dental assessment, including whole-mouth radiography, perioperative antibiotic therapy with clindamycin was administered, 2 premolars with resorptive lesions were extracted, and all teeth were scaled and polished. Sally was discharged on a 10-day course of clindamycin. At follow-up evaluation 2 weeks later, the extraction sites had healed well and the oral inflammation was markedly reduced. Home dental care was instituted and further evaluation scheduled for 3 months. *From the author’s case files † Retrovirus serology is indicated in cats that present with stomatitis; when evaluating a cat’s risk for infectious disease, consider the following risk factors: outdoor access, exposure to other cats, presence of bite wounds, multicat household, and signs of illness (eg, anemia, vomiting) AZT = azidothymidine; CBC = complete blood count; FeLV = feline leukemia virus; FIV = feline immunodeficiency virus Clinical Notes / NAVC Clinician’s Brief / February 2011.........................................................................................................................................................................53 DIAGNOSTIC DIFFERENTIALS TO CONSIDER REFERENCES The etiology of chronic stomatitis is unknown but is suspected to be multifactorial. Genetic predisposition, domestication, diet, and infection have all been proposed, while others have proposed that the disease is an immune reaction to plaque and the tooth structure itself or to Treatment Guidelines for Stomatitis in Cats the periodontal tissues. In addition, various viruses and Mild Stomatitis ■ Plaque control with professional dental bacteria have been associated assessment and treatment11 with stomatitis. ■ Diligent home care11 Several investigators have ■ Topical 0.12% chlorhexidine11 found an association between ■ Tooth extractions in cases of periodontitis, FIV infection and oral resorptive lesions, and retained roots11,12 inflammation in cats.4 The ■ Other options degree of stomatitis in FIV— Doxycycline (1 mg/kg PO Q 24 H)11 infected cats is often more — Prednisolone (2 mg/kg PO Q 24 H for 1 week, then decrease over time to maintenance severe when concurrent infecdose of 0.5–1 mg/kg PO Q 48 H)11 tion with calicivirus or FeLV is documented.4 Calicivirus Moderate-to-Severe Stomatitis has long been implicated as a ■ Cyclosporine (2.5 mg/kg PO Q 12 H) administered for at least a 6-week trial period10 causative factor in cats with ■ Carbon dioxide laser ablation of diseased tissue13 stomatitis and is more prevalent in affected cats than in unaffected controls in many studies,5 but evidence linking Bartonella infection to stomatitis in cats is contradictory and uncertain.6 Since all these infectious agents may be found in healthy as well as clinically ill cats, causal relationships are difficult to determine (see Stomatitis Case Example: 3-Year-Old Cat, page 53) and some reports have failed to document associations between various agents and stomatitis.6-8 1. Feline oropharyngeal inflammation. Bellows J. Clin Brief 8:33-37, 2010. 2. Feline immunodeficiency. ABCD guidelines on prevention and management. Hosie MJ, Addie D, Belák S, et al. J Feline Med Surg 11:575-584, 2009. 3. Search and identification methods that owners use to find a lost cat. Lord LK, Wittum TE, Ferketich AK, et al. JAVMA 230:217-220, 2007. 4. Chronic oral infections of cats and their relationship to persistent oral carriage of feline calici-, immunodeficiency, or leukemia viruses. Tenorio AP, Franti CE, Madewell BR, et al. Vet Immunol Immunopathol 29:1-14, 1991. 5. Concurrent oral shedding of feline calicivirus and feline herpesvirus 1 in cats with chronic gingivostomatitis. Lommer MJ, Verstraete FJ. Oral Microbiol Immunol 18:131-134, 2003. 6. Association of Bartonella species, feline calicivirus, and feline herpesvirus 1 infection with gingivostomatitis in cats. Dowers KL, Hawley JR, Brewer MM, et al. J Feline Med Surg 12:314-321, 2010. 7. Evaluation of the association of Bartonella species, feline herpesvirus 1, feline calicivirus, feline leukemia virus and feline immunodeficiency virus with chronic feline gingivostomatitis. Quimby JM, Elston T, Hawley J, et al. J Feline Med Surg 10:66-72, 2008. 8. Immunohistological evaluation of feline herpesvirus-1 infection in feline eosinophilicdermatoses or stomatitis. Lee M, Bosward KL, Norris JM. J Feline Med Surg 12:72-79, 2010. 9. 2008 American Association of Feline Practitioners' feline retrovirus management guidelines. Levy J, Crawford C, Hartmann K, et al. J Feline Med Surg 10:300-316, 2008. 10. The use of oral cyclosporin to treat feline dermatoses: A retrospective analysis of 23 cases. Vercelli A, Raviri G, Cornegliani L. Vet Dermatol 17:201-206, 2006. 11. Gingivostomatitis. Lyon KF. Vet Clin North Am Small Anim Pract 35:891-911, 2005. 12. Chronic gingivo-stomatitis in cats: Longterm follow-up of 30 cases treated by dental extractions. Hennet P. J Vet Dent 14:15-21, 1997. 13. Use of CO2 laser as an adjunctive treatment for caudal stomatitis in a cat. Lewis JR, Tsugawa AJ, Reiter AM. J Vet Dent 24:240-249, 2007. TESTING PROTOCOLS When oral disease is found in cats, testing should be done to determine their infectious disease status. Regardless of their age and despite previous negative test results or vaccination, cats with evidence of oral disease should be tested for retroviruses. Testing should also include a minimum database consisting of a complete blood count (CBC), serum biochemical profile, and urinalysis.9 Common findings include leukocytosis and elevated total protein from increased gamma globulins. TREATMENT INDICATIONS Chronic stomatitis is often refractory to treatment, although some strategies may be beneficial, depending on the severity of the case. Mild-to-moderate cases may benefit from professional dental assessment and treatment, home care, and antiinflammatory therapy with corticosteroids or cyclosporine (see Treatment Guidelines for Stomatitis in Cats).10-13 Any teeth with periodontitis or resorptive lesions should be extracted. More severe cases, as well as FIV-infected cats, will not always achieve long-term control with conservative treatment. The only treatment shown to provide long-term relief in a majority of these cats is caudal (all teeth behind the canines) or whole-mouth dental extractions.11,12 FIV-infected cats with stomatitis may benefit from treatment with the nucleoside analog azidothymidine (AZT),9 which is given at a dose of 5 to 10 mg/kg PO or SC Q 12 H with careful monitoring of the CBC, as nonregenerative anemia is an important adverse event. Cats with bone marrow suppression should not receive treatment with AZT. However, FIV-infected cats often suffer stomatitis refractory to conservative treatment and may benefit from whole-mouth extractions, as for uninfected cats.11 Susan Little, DVM, DABVP (Feline Practice), Bytown Cat Hospital Ottawa, Ontario, Canada and Past President, The Winn Feline Foundation; winnfelinehealth.org The opinions expressed herein do not necessarily reflect the point of view of the publisher or sponsor. Gathering pretreatment information from the minimum database, including testing for retroviruses, will help in the long-term care of these feline patients. AZT = azidothymidine; CBC = complete blood count; FeLV = feline leukemia virus; FIV = feline immunodeficiency virus © 2011 Educational Concepts LLC 09-80257-00 54 .......................................................................................................................................................NAVC Clinician’s Brief / February 2011 / Clinical Notes