29 Feb Feline Juvenile Gingivitis/Periodontitis
Felines with oral inflammatory diseases are commonly presented to the small animal veterinarian. Many factors may contribute to the development of oral inflammation in the cat, including diet, oral conformation, immune-mediated diseases, infectious diseases, and specific breed characteristics. Oral inflammatory conditions have been described in the immature feline, including feline juvenile gingivitis, juvenile-onset periodontitis, stomatitis, tooth resorption, or a combination.
This article describes feline juvenile gingivitis/periodontitis, an under-recognized condition in young cats. Sometimes classified as two separate conditions, the two states are actually the same syndrome at different points of severity on a spectrum.
Feline Juvenile Gingivitis
Feline juvenile gingivitis (aka juvenile hyperplastic gingivitis) is a pronounced generalized inflammation of the gingival tissues in the young cat. Gingivitis means inflammation of the gingival tissues, or gums. In this syndrome, the gingival tissues show pronounced generalized inflammation which is disproportionate to the amount of dental plaque and tartar.
Certain breeds are over-represented, including Maine Coons, Ragdolls, and Siamese; yet any cat breed may develop this condition. It is typically diagnosed between 7-10 months of age. However, because this is a poorly recognized condition in the veterinary field, its presence is sometimes not realized until 12-24 months of age.
Causes
This juvenile form of gingivitis may be due to exaggerated tooth eruption inflammation, viral exposure (e.g. FeLV, FIV, Calicivirus), immune-mediated disorders, or a multifactorial response. Some have speculated about a “temporal trigger” (e.g. persistent deciduous teeth) for the development of this early gingivitis.
Symptoms
This syndrome is distinguished from other oral inflammatory disorders (like stomatitis) in that the generalized gingivitis has not radiated to the adjacent alveolar mucosa or to the caudal oral structures. In the early stages of this syndrome, periodontitis changes have not yet developed, e.g. alveolar bone loss, gingival resorption, pocket formation, and/or root exposure. In many such cases, if the oral inflammation can be controlled and kept controlled for the first 2 years of life, recurrence may be decreased or prevented altogether.
By the time of adulthood around 2 years of age, these patients often mature into a more normal state. On the other hand, juvenile cats with this form of oral inflammation who are not controlled aggressively at a young age can suffer permanent anatomical changes and frequently progress to severe periodontitis or even stomatitis.
How Is Feline Juvenile Gingivitis Treated?
Patients with these symptoms require detailed oral and dental assessment under anesthesia with dental radiography (either dental X-rays, cone beam CT imaging, or both). Meticulous dental cleaning should be performed even though minimal plaque is usually present. In applicable cases, extraction of persistent deciduous teeth may be necessary.
Young cats with a hyperplastic response require gingivectomy to remove pseudopockets and create an environment more amenable to plaque control. When performed, the veterinary clinician is cautioned to be conservative and not excessively remove gingiva.
A biopsy of excised tissue may be considered if the presentation is unusual. The histopathology will reveal a typical lymphocytic-plasmacytic inflammatory cell pattern. Some advocate PCR testing for Calicivirus, performed from a piece of gingiva or from a cytobrush swab.
Plaque Management
Diligent home plaque control will greatly influence the outcome. The home care must be tailored to the individual patient based on the influences of the owner, animal, and environment. Tooth brushing is considered the gold standard of care, but often is too uncomfortable for many of these patients – at least until early control is achieved.
Other options include dental formulated diets (e.g. Prescription diet t/d, Royal Canin Veterinary Diet Adult Dental Food), chlorhexidine rinses and gels, topical enzymatic gels (e.g. Oratene), OraVet barrier gel, feline dental treats, Healthymouth water additive, PlaqueOff food additive, or anti-plaque food toppers.
It is essential that immunomodulation is introduced simultaneously with plaque management (see below). The individual’s response to initial professional treatment is a good prognostic indicator. If a cat shows significant reduction in gingival inflammation, the chances of eventual full recovery are improved.
Many patients enter remission by the second dental cleaning visit. Repeated professional dental cleaning visits may be required every 3 months until adulthood is reached (18-24 mos). If cat owners cannot provide dental home care, maintenance cleaning visits may be required as frequently as every 4 weeks until remission is achieved.
Once the individual reaches maturity, a more normal state may be achieved and less frequent professional dental visits are required. If aggressive attempts to control gingivitis are unsuccessful, long-term prognosis is guarded and extraction of teeth may need to be considered.
Immunomodulation
Feline juvenile gingivitis patients also require concurrent incorporation of immunomodulation as the recommended professional and home plaque control measures are introduced. Depending on the severity, the author has experienced success using doxycycline or topical application of 1-TetraDecanol Complex (1-TDC). 1-TDC is an esterified fatty acid which is applied directly to inflamed tissues to achieve transmucosal absorption. For milder cases, this may be all that is needed to decrease the production of local inflammatory cytokines.
When a stronger immunomodulatory effect is needed, doxycycline may be prescribed. The author usually starts at the normal antimicrobial dose (5 mg/kg twice daily) for the first 2-4 weeks. Then after achieving initial response, the doxycycline is reduced to a sub-antimicrobial dose (2 mg/kg once daily) long-term. The low dose of daily doxycycline inhibits matrix metalloprotease and reduces inflammation. Neither 1-TDC nor doxycycline should be administered as mono-therapy, i.e. plaque management must be provided concurrently.
Pain Medication
In early treatment stages, the incorporation of pain medication may be necessary. Gabapentin or opioids like buprenorphine are frequently prescribed. To help with inflammation, at least early on, a non-steroidal anti-inflammatory medication may be considered, e.g. meloxicam or robenacoxib (Onsior). In very severe cases, the incorporation of an appetite stimulant like Mirataz, a transdermal mirtazapine gel, may be needed.
Anecdotally, there have been reports of administering Solensia (frunevetmab), a feline anti-nerve growth factor monoclonal antibody, for help in controlling inflammation associated with stomatitis in cats. At the time of this writing, and to the author’s knowledge, there is currently no established evidence to support this medication for the treatment of feline juvenile gingivitis.
Feline Juvenile Periodontitis
Feline juvenile periodontitis is differentiated from feline juvenile gingivitis by the presence of periodontal attachment loss. In actuality, this is the same syndrome, but at a more advanced stage of severity.
Symptoms
Dental radiography will demonstrate alveolar bone loss. Other anatomic changes are common, and include gingival recession or dehiscence, periodontal pocketing, and root/furcation exposure. Gingival hyperplasia (red swollen gums) is also common. This form of the syndrome is similarly diagnosed in young cats less than 9 months of age, but it may not be recognized until the signs have become severe.
The breed representation is the same (Maine Coon, Siamese, and other Asian breeds), but any cat could be affected. Unlike the juvenile gingivitis stage, this more severe form is often associated with abundant dental plaque and tartar.
Extractions and Cleanings
Feline juvenile periodontitis is approached in a similar fashion as feline juvenile gingivitis, with the exception that extractions are frequently necessary. Teeth with periodontal attachment loss (bone loss, root exposure, furcation exposure, etc) are unlikely to be salvageable, and extractions are needed. Extracting the periodontally unsound teeth creates a healthier oral environment and improves the prognosis for the salvage of the remaining teeth.
Like cats affected with juvenile gingivitis, many of these cats may enter remission fairly quickly, but require more frequent professional cleaning visits than the average cat. The response to initial professional care can help determine long-term prognosis. Uncontrolled juvenile periodontitis will likely progress to adult periodontitis or stomatitis, requiring full-mouth or near full-mouth extractions. When extractions are performed, the prognosis is excellent.
Treatment
The elected treatment approach depends on many factors including the severity of inflammation, the commitment of the pet owner to oral care, the pet owner’s expectations (do they want the quickest resolution; are they more inclined to “be done with it” or do they want to save teeth?).
The cost will depend on the approach taken: Will it be diagnostics and cleaning with strategic extractions? Or will it be full mouth extractions right from the onset? At the author’s practice, oral surgery cost is time-based just like other surgeries.
Ideally affected patients receive professional dental care +/- surgery before they are critical, and most will eat readily after surgery if appropriate pain management is provided (e.g. combination of longer-acting local nerve blocks, gabapentin, NSAIDs, +/- opioids).
For a more critical patient or one experiencing a hunger strike, the addition of an appetite stimulant or pre-placement of a feeding tube prior to oral surgery should be considered. A feeding tube ensures better caloric intake prior to the big surgery day and the mouth seems to “calm down” when it is bypassed.
For some patients, administration of transdermal mirtazapine is all that is needed to kick start the appetite. In some instances, antibiotics may be started a week prior to surgery in order to achieve healthier gingival tissues, which makes for easier flap creation and closure.
Cat Dentist in Denver, Colorado
For feline juvenile gingivitis and feline juvenile periodontitis patients, post-professional treatment care should include home plaque control, repeated professional visits, immunomodulation, +/- antibiotics, and pain medication as needed. Prognosis is variable and highly dependent on the individual’s inherent healing ability. If you suspect your cat is having dental problems, don’t hesitate to contact Apex Veterinary Specialists.
Donald Beebe, DVM, Dipl AVDC
© Donald Beebe, DVM