scott@vtx-cpd.com

Hi,

It seems you’re handling a challenging case of feline chronic gingivostomatitis (FCGS), a complex immune-mediated disease involving chronic oral inflammation. Here’s a detailed breakdown of the current best practices in managing FCGS, along with options beyond full-mouth extraction (FME).

Clinical Management of FCGS
The goal in FCGS is to reduce antigenic stimulation and modulate the abnormal immune response. Nearly all affected cats have moderate to severe periodontitis and tooth resorption, so surgical extraction is often essential to reduce the inflammatory burden.

Surgical Extractions:

Full-mouth extractions (FME) or partial mouth extractions (PME) are considered the gold-standard treatment. About 60-80% of cats show significant clinical improvement post-extractions. Even though full-mouth extractions may seem extreme, they have been shown to significantly reduce inflammation, allowing the immune system to focus on any viral contributors, such as feline calicivirus (FCV) or feline leukemia virus (FeLV) .
Periodontitis creates a heavy inflammatory burden, and removing the teeth, particularly those with resorptive lesions or subgingival disease, alleviates part of that burden .
In one large study, up to 28% of cats achieved complete resolution, and an additional 39% showed significant improvement after extractions .
Importantly, the extent of extractions (PME vs. FME) does not seem to significantly affect the success rates . So, if inflammation is limited to the molar and premolar regions, PME might be a valid alternative to FME.
Preoperative Evaluation:

A comprehensive workup is crucial, including:
CBC, serum biochemistry, and viral testing (FeLV, FIV, FCV, PFFV).
Viral co-infections like FeLV, FIV, or FCV negatively impact the prognosis, with FeLV-positive cats being 7.5 times more likely to fail surgical management .
Use of the Stomatitis Disease Activity Index (SDAI) to track inflammation and quality of life, which can help gauge treatment response .
Medical Management
For cats that either can’t undergo extractions or for cases refractory to surgery, medical management becomes essential. Here are the options:

Glucocorticoids:

Prednisolone and Depo-Medrone are often used to manage inflammation pre- and post-surgery. However, long-term steroid use carries risks, including diabetes mellitus and immunosuppression . You could continue using prednisolone as it has a shorter half-life, making it easier to control side effects compared to long-acting steroids like Depo-Medrone.
Ciclosporin:

Ciclosporin has been successful in reducing oral inflammation in many cases, with a study showing 77.8% improvement in cats receiving oral ciclosporin after extractions . It’s worth considering as an alternative to glucocorticoids, especially in long-term management.
Analgesics:

Gabapentin or Amantadine are useful for managing neuropathic and chronic pain associated with FCGS. Gabapentin is commonly used for musculoskeletal and neuropathic pain in cats .
Bovine Lactoferrin:

Bovine lactoferrin is emerging as a promising adjunct therapy for FCGS. A randomized, double-blind clinical trial evaluated the combination of bovine lactoferrin oral spray (6 mg/cat, q12h) and piroxicam (0.3 mg/kg PO q48h). The study found that 77% of cats showed significant improvement in oral lesions and overall clinical signs over a 12-week period .
Lactoferrin alone has been shown to improve clinical signs and enhance neutrophil phagocytic activity, providing an immune boost for cats with stomatitis, even those with concurrent viral infections like FIV .
Reference: Arzi B, et al. “A randomized, double-blind, placebo-controlled clinical trial of piroxicam and bovine lactoferrin for the treatment of FCGS.” Journal of Feline Medicine and Surgery, 2021 .

Recombinant feline interferon-omega (rFeIFN-ω):

This therapy has shown moderate to marked improvement in 55% of treated cats. Subcutaneous administration may be particularly beneficial in cats with FCV .
Mesenchymal Stem Cell Therapy:

In refractory cases, stem cell therapy has shown up to 71% improvement or remission in cats with severe stomatitis after extraction therapy .
Surgical Considerations
While surgery is the best long-term solution for most cats with FCGS, a more conservative approach like PME might be acceptable for cases where inflammation is localized.

However, if medical management is only offering temporary relief, FME should be considered sooner rather than later. Cats with viral co-infections or severe oral inflammation tend to do worse with medical management alone.

Conclusion
In summary:

FME or PME remains the gold standard for FCGS, though adjunct therapies like bovine lactoferrin and ciclosporin may offer additional relief.
Prednisolone can be continued if the cat is responding well, but long-term management should focus on reducing steroid dependence.
Bovine lactoferrin, especially in combination with NSAIDs like piroxicam, could be worth trialing before committing to FME.
Postoperative medical management, including pain control and possibly immunosuppressive or immunomodulatory therapies like rFeIFN-ω or stem cells, is essential for refractory cases.
I hope this provides a clearer picture of your options. If you’d like to discuss further or explore any other treatment pathways, feel free to reach out.

Best regards,

Scott

Replying to Karin V. 16/09/2024 - 18:53

Really sorry to hear this.

Will look at this now.

Scott 🙂