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Feline Lymphocytic Plasmacytic Stomatitis
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Feline lymphocytic plasmacytic stomatitis is often a painful condition for the pet as well as a frustrating disease to treat for the practicing veterinarian. This case report will describe a satisfactory treatment option of total mouth extraction for this condition. A brief discussion of the etiological factors, the need of supportive treatment care and possible complications to the extraction technique will be included. Feline lymphocytic plasmocytic stomatitis (LPS) is a chronic, rapidly progressive, periodontal disease that often becomes nonresponsive to conventional treatment such as good oral hygiene, antibiotics, anti-inflammatory drugs and immunoregulators.(1) The exact etiology of this disease complex is still unknown, however, the interactions of infectious and immunological factors of the host play a significant role in at least the expression is this condition. In general LPS does not appear to be a distinct disease entity but rather an excessive immune inflammatory response.(2) While there is no complete agreement, some authors suggest a possible genetic tendency of LPS in the pure breeds (such as the Siamese, Persian, and Himalayan), based on observation of the severity of the disease.(3) Refractory cases often require extraction of at least the caudal teeth (premolars and molars) , and possibly the entire dentition. While a biopsy may be indicated to rule out neoplasia and eosinophilic granulomas, a tentative diagnosis can be made on the basis of a classic clinical picture of hyperemic, proliferative, ulcerative mucosa with a cobblestone appearance.(4) With few exceptions routine laboratory work, including culture and sensitivity, is of little help in controlling the progression of this condition. Treatment planning of LPS usually begins with frequent professional prophylaxis and energetic home care. Antibiotics such as Clindamycin at a dose of 5mg/lb every 24hrs.P.O. and metronidazole at a dose of 30-60mg/kg every 24hrs. P.O. are frequently given as an adjunct to improve the initial response to treatment.(5) In the FeLV/FIV negative cat, immumosuppressive doses of Prednisone (2mg/kg) are frequently needed initially to reduce the pain associated with the inflammation of the disease.(6) Despite these and other anecdotal remedies that have been tried in most cases there is a failure to establish acceptable long term success. Due to the significant painful expressions of behavior that many of these patients appear to demonstrate partial or full mouth extraction is a viable course of treatment.(7) Case report: A 14 month old, male, domestic short hair cat owned by Mrs. Chapman and answering to the name of "Chester" was presented to the Norwalk Animal Hospital and Dental Clinic on 7/11/93 for its first year booster vaccinations. On physical exam the cat appeared in good health except for a mild gingivitis adjacent to the posterior teeth (#107,108,207,208 using the modified Triadan system). A brief discussion to educate the owner in the benefits to the patient of proper oral hygiene was made. The owner returned with "Chester" on 7/30/94 for the annual vaccinations. At this time it was again noted that although the cat was in otherwise good health the gingivitis was considerably more severe. The gingival tissues appeared hyperemic and edematous and the pathology extended past the muco-gingival line. It was readily apparent on examination that the gingiva adjacent to all the premolars and molars were inflamed as well as sensitive to the touch on oral examination. The owner commented that "Chester" was not eating as much as usual and their was a bad odor coming from the mouth. A single 2mg injection of Vetalog I.M. to reduce the gingival inflammation was given and Flagyl 125mg P.O. once daily for two weeks was dispensed to reduce the anaerobic bacterial population. A follow-up phone call on 8/11/94 revealed that the cat had responded well to the medication and was much improved behaviorally and the odor from the mouth was gone according to the owner. A complete prophylaxsis cleaning was recommended at this time. On 11/11/94 "Chester" was admitted for a complete dental prophylaxsis. After passing a physical exam "Chester" was anesthetized with Telazol at 0.1ml I.V. and his vital signs were monitored. Both Penicillin G and Dexamethasone were given (1/2cc I.M. each) before any scaling was done. The mouth was completely flushed with a 0.2% solution of chlorhexadine to reduce the level of bacterial contaminants. Ultrasonic scaling using a TFI-1000 Cavitron tip supragingivally and mini after 5 Hu-Friedy gracey hand curettes subgingivally was performed. A fluoride polishing paste was applied supragingivally, following subgingival irrigation with a 0.2% chlorhexadine solution, by a Lynx slow speed contra-angle latch type handpiece. Maxigard's Oral Cleansing Gel was dispensed along with Flagyl at 125mg and Prednisone at 5mg P.O. once daily for all medications. A tentative diagnosis of Lymphocytic/Plasmocytic Stomatitis was made based on the clinical signs and the response to treatment The treatment plan was to continue medication for as long as there was a favorable response. When medical management fails to yield a comfortable mouth, as is often the case, then partial or full mouth extraction should be considered. At the next visit for the annual vaccinations on 8/8/95 it was obvious from the resistance toward examination of the mouth that the cat was in discomfort. The owner indicated that it was increasingly more difficult to medicate the cat with the Oral Cleansing Gel as well. More frequent dental prophylaxis was advised as well as diligent home care would be needed to maintain an acceptable quality of life. The owner expressed concern for the long term effort and expense of maintaining a "healthy" mouth for "Chester". On 3/19/96 "Chester" was presented for a full mouth extraction of the dentition. The physical exam was normal in all respects except for a classic appearance of LPS. Pre-surgical blood work showed a BUN of 20, ALT of 46, PCV of 37, and T.P. of 6.5. Penicillin G 1/2cc S.Q. and 200cc L.R.S. was given S.Q. approximately one hour before surgery. "Chester" was anesthetized with 0.1ml of Telazol I.V., maintained on Isoflurane gas anesthesia and monitored. The entire mouth was initially flushed with a 0.2% solution of CHX. Using a #15 scalpel blade the lingual and buccal mucosa was incised just below the muco-gingival line completely along the dental arch and reflected away from the alveolar bone with a P-20 Hu-Fiedy periosteal elevator. An alveoloplasty with a #1 round bur in a high speed hand piece was used to remove a portion of the alveolar bone and expose the tooth roots. All multirooted teeth were sectioned into single roots with a #701 taper crosscut bur. A # EX-15 Cislak elevator was used to luxate each tooth root in the socket and then removed with small Miltex-H extraction forceps. Each alveolus was curretted and flushed with water before the alveolar crest was reduced with a #702 crosscut bur. The gingiva was then placed over the extraction site and sutured with 4-0 Vicryl making sure there was no tension at the suture line. This technique was repeated on each of the four arches. The only variation in extraction technique occurred over the canine teeth where a reverse bevel flap through the gingival sulcus and subsequent periosteal reflection was performed. The remaining steps for extraction stayed the same. Post operative care included Torbugesic at 0.1ml S.Q. for control of pain. Amoxi drops at 1 and 1/2ml once daily were dispensed and a soft diet was recommended for the next three weeks until there was complete healing of the soft tissues. On 3/26/96 "Chester" returned to board with us and continue medication while the owners were away on vacation for a week. During this time the cat ate well and seemed to be comfortable. (Comments on follow-up to this case will be noted when the owner comes in on the week of Feb.10th.) Discussion: No biopsy was submitted for confirmation of the LPS condition in this case due to the classic appearance of the gingiva and the typical response seen in the initial treatment. No immediate post operative dental radiographs were taken due to the excellent visualization of all the sockets during the procedure and inspection of each of the complete tooth roots once they were removed. While not every cat will have a 100% recovery from the LPS condition using the partial or total mouth extraction procedure, it is often the best that we can offer for long term relief from suffering. While extraction may substantially reduce the opportunity for infectious agents to be cultivated in the gingival sulcus, thus initiating a cascading immuniologic event resulting in excessive inflammation, it does not completely eliminate all infectious agents Thus in some cases, antibiotic and/or anti-inflammatory treatment must be continued even after total mouth extraction has been performed.. In this case, the owner and I agreed that total mouth extraction was the best alternative course of action to resolve the inflammation and discomfort on a long term basis. The rapid adjustment to eating without any dentition and the lack of any negative personality effects were proof that we made the correct decision in this case. 1. Harvey, Shofer, Venner, Haskins.
Results following conservative treatment of gingivitis/stomatitis
in cats. Philadelphia: Department of Clinical Studies, School of
Veterinary Medicine, University of Pennsylvania; 1988. |
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Faulkner
and Associates