Mar Vista Animal Medical Center

3850 Grand View Blvd.
Los Angeles, CA 90066

(310)391-6741

marvistavet.com

PLASMA CELL STOMATITUS (FELINE)

(also called “lymphoplasmacytic stomatitis” or
“LPS” or more correctly "Feline Caudal Stomatitis")

A general physical examination involves an inspection of the teeth and mouth, provided that the patient is of a cooperative nature. We see plaque build-up, tartar, missing teeth and all sorts of dental conditions that result from a lifetime of basically no toothbrush use (sadly, the norm for cats) but sometimes we see a very special type of gingivitis. 

The picture on the left shows a cat’s teeth and gums that are affected with only minor periodontal disease.
The cat on the right has Plasma Cell Stomatitis. Note the red, irritated gums. 

 

The teeth usually do not look too bad but the gums are an angry red. They bleed at the slightest touch and sometimes there seem to be irritated proliferations growing from them. The breath stinks, the cat drools, and often the cat will hardly eat or will only lick the juices off canned foods. The irritation is most obvious in an area called the “fauce” which is the area in the back of the mouth where the upper and lower jaws come together. (Technically speaking this area is not the "fauce" but is actually the "palatoglossal fold" but the term "fauce" is still in common use).

A biopsy is needed to confirm the diagnosis but this is the characteristic appearance of “plasma cell stomatitis.” It is an extremely painful condition.

 

HOW DO CATS GET THIS DISEASE? 


Cat with Caudal Stomatitis.
The palatoglossal arches are angry and red.

Unaffected Cat. This cat has some dental tartar
but notice the normal color of the palatoglossal arches.
(Photocredit: P. Fernandes via Wikimedia Commons)

Sadly, we do not know how cats get this condition and until we do it will be hard to effect prevention. The condition does seem to result from an excessive immune reaction against the plaque that forms on the teeth or against the dentin making up the tooth itself. 

There is an association with this condition and the Feline Immunodeficiency Virus (abbreviated "FIV") as well as with Calicivirus infection. Further, there are metabolic causes of oral ulceration that can mimic plasma cell stomatitis. Cats suspected of having this condition require some metabolic screening (i.e. blood testing) including viral testing for FIV. A biopsy of the mouth is needed to confirm that the problem is actually plasma cell stomatitis and not something of similar appearance but requiring different treatment.

Electron micrograph of the feline calicivirus
(Photocredit: CDC Public Health Image Library)

Sadly, we do not know how cats get this condition and until we do it will be hard to effect prevention. The condition does seem to result from an excessive immune reaction against the plaque that forms on the teeth or against the dentin making up the tooth itself. 

There is an association with this condition and the Feline Immunodeficiency Virus (abbreviated "FIV") as well as with Calicivirus infection. Further, there are metabolic causes of oral ulceration that can mimic plasma cell stomatitis. Cats suspected of having this condition require some metabolic screening (i.e. blood testing) including viral testing for FIV. A biopsy of the mouth is needed to confirm that the problem is actually plasma cell stomatitis and not something of similar appearance but requiring different treatment.

 

HOW DO WE TREAT IT?

No single treatment seems to be appropriate for every patient but the basic principles in treating feline caudal stomatitis involve: plaque control, inflammation control, pain control, and nutritional support.

PLAQUE CONTROL/EXTRACTION

Stringent control of plaque is crucial to the management of these cats. Plaque is a mixture of food particles, bacteria and salivary proteins coating the teeth. Though it may seem dramatic, the best way to control plaque in this situation is to extract the teeth and generally all the molars and premolars (all the teeth from the fangs back to the throat) must be removed including any root tips. Some cats must have the fangs and the tiny incisors between the fangs removed as well but most cats are controlled with just back teeth extractions.

This may seem extreme but this approach yields the best long term results in most patients. In one study of cats with caudal stomatitis, 60% were cured by extraction and another 20% had enough improvement that medication was able to control the pain and inflammation. The cats that did not do well with extraction were those that had a prior long course (months to years) of medications, cats where inflammation was limited to the palatoglossal arches and did not extend forward of this area, and cats from whom calicivirus could be isolated from the mouth. Full mouth extraction is not inexpensive and often referral to a veterinary dentist is needed for proper radiography of the mouth to insure all the tiny tooth roots have been retrieved. Pain medications is typically prescribed after extractions of this extent but it is common for owners to report that cats appear less painful than prior to the extractions right away and accept food hungrily for the first time in months. Lack of teeth does not hamper a cat's ability to eat in any way as food is commonly swallowed whole.

If extractions are not going to be possible, then at least a full teeth cleaning under general anesthesia should be performed every 6 months and home care of the teeth should be performed to minimize plaque build up. The painful nature of this condition will make brushing problematic but mouth washes will help.

(Photocredit: Morguefile.com)

INFLAMMATION AND PAIN CONTROL

Caudal stomatitis is an immune mediated disease so medical management is centered on suppressing and controlling the excessive activity of the immune system.
Cortisone derivative medicines such as prednisone are often helpful in relieving the inflammation. Again, because of the pain, oral medication may be difficult to administer. A compounding pharmacy can be used to convert the tablet into a palatable liquid but often a long acting injection is needed to initiate treatment. Frequently, long-acting injectable steroids such as methylprednisolone acetate (Depomedrol®) are used with favorable responses generally observed within 1-2 days. This may be very helpful particularly when the cat is so painful that he cannot accept food; within days of treatment the swelling and pain is alleviated greatly. Steroids such as these, however, are problematic with long term use. Methylprednisolone acetate injections are associated with the development of diabetes mellitus plus their immune-suppressive nature may empower an underlying calicivirus infection and/or periodontal bacterial infections.


(original graphic by marvistavet.com)

Cyclosporine, another immune modulating medication, is gaining popularity for the treatment of caudal stomatitis inflammation. This product is available as an oral liquid and has fewer associated side effects compared to the steroids. Rapid results are not seen as with the steroids but sometimes they are given together so that the cyclosporine has had time to reach its peak effect just as the steroid injection is waning.

Bacterial infection complicates plasma cell stomatitis so antibiotics such as clavamox or clindamycin are often prescribed, sometimes for long term use (at least 4 weeks). These antibiotics are especially good for oral infections as they especially target anaerobic bacteria that live in the mineralized plaque covering the teeth. Other antibiotics that might be recommended include:  metronidazole, doxycycline, and azithromycin. A long-acting injectable antibiotic called "cefovecin" (Convenia®) is often used since no oral manipulation is needed and one injection lasts two weeks precluding manipulation of a very painful mouth.

During a particularly painful flare up sometimes a fentanyl patch is helpful for pain control. This is a small plastic patch that is generally applied to the back of a foot. It releases a continuous supply of pain relief for 5-7 days. Buprenorphine is another popular pain reliever for caudal stomatitis patients as it requires less oral manipulation; the liquid is simply squirted into the mouth and is absorbed directly with actual swallowing being unnecessary.

MISC MEDICATIONS

Pentoxifylline is a medication which helps red blood cells become more flexible thus allowing oxygen to be carried deeper into damaged tissues to facilitate healing. It is emerging as an adjunctive treatment for caudal stomatitis.

Maropitant citrate (Cerenia®) was developed as a strong anti-nauseal but its unique mechanism of regulating the interaction of Substance P and the N-K Receptor has led to the discovery of numerous uses for this medication. It appears to have pain relieving properties and anti-inflammatory properties beyond its stomach settling ones.

Other therapies to try might include the use of interferon omega, an immune modulator that theoretically helps normalize immune reactions. This treatment has been effective for cats needing adjunctive therapy after extractions yield only partial improvement but it is not available in North America.

Bovine Lactoferrin is a natural compound that is similarly immunomodulating and antibacterial. It can be formulated by a compounding pharmacy into a palatable liquid. Bovine Lactoferrin is used to bathe the tissues of the mouth. Initial studies showed a large percentage of affected cats responded at least partially.

Coenzyme Q is presently being investigated for medical management in cats for whom extraction yielded only partial results. Coenzyme Q is a supplement available in  most vitamin stores and pharmacies.

It is important to remember that medical management is not the first choice approach for most patients and that medications tend to get less and less effective over time. Extractions are best done early. Medication is helpful to get long-standing pain controlled quickly and as a supplement to patients who do not respond completely to extraction.

SUMMARY

  • Caudal Stomatitis is a painful, chronic condition.
  • Proper diagnostics including an oral biopsy are needed to confirm the diagnosis and get the correct treatment.
  • Extraction of the molars and premolars early in the course of disease yields the best long term results in most patients. Medical management is for special situations (flare ups, patients who need more than extractions, patients with no tooth associated lesions)
  • This can be a very frustrating disease to treat.

 

Page last updated: 7/22/2016