FELINE ORAL DISEASES: AN UPDATE

Dr. A. Caiafa BVSc BDSc MACVSc University of Melbourne Veterinary Clinic and Hospital Princes Highway, Werribee, 3030 Email toothdoc@tpg.com.au Introduction Feline oral diseases can often be a source of frustration and anxiety for the practicing veterinarian. Veterinarians are all too aware of the difficulties with the diagnosis and management of oral diseases in cats. This lecture will look at the common (and the not so common) ailments that afflict the feline mouth. More commonly seen diseases Periodontal disease Odontoclastic resorptive lesions (ORL) Trauma- MCA, high rise syndrome, cat/dog fights Less commonly seen Feline gingivitis/stomatitis syndrome (FGS) Oral neoplasia Nasopharyngeal polyps Eosinophilic granuloma complex Calici virus infection- acute and chronic Others- FB, uraemia, diabetes mellitus, malocclusions Periodontal disease (PD) PD is probably the most common chronic disease seen in the cat today. This disease is bacterial in origin, but contributing to the disease is the host response which through the release of inflammatory mediators can exacerbate the periodontal attachment loss. Compounding the complexity of this disease is the cat with a compromised immune system (i.e. FIV positive cat) which when combined with the presence of plaque bacteria leads to a more acute and severe manifestation of the disease. The primary cause of PD is gram negative anaerobic bacteria. PD is often asymptomatic in its early stages, with the cat only displaying such symptoms as pain, dysphagia and halitosis towards the later stages of the disease. PD can also be seen in combination with another common oral ailment namely odontoclastic resorptive lesions (ORL). Management of PD in cats can be complicated by the difficulty in performing homecare. Often owners resort to diet as a means of controlling or preventing PD in cats. Two common errors made by veterinarians in the management of PD are poor client education re the chronic nature of the disease and the lack of review and continuing assessment of cats with PD. Clients need to know that the disease is chronic and that their cat needs to be reviewed on a regular basis to assess disease stability or

progression. The clients ability or inability to perform adequate homecare should also be considered in the management of PD. Odontoclastic resorptive lesions (ORL) ORL is a very common disease of cats. At the present time, the aetiology of ORL is not known. Like PD, ORL may be asymptomatic, although dysphagia, ptyalism, face rubbing, jaw chattering, poor appetite and weight loss may be some of the symptoms seen with this disease. Oral examination may show abundant plaque and calculus covering the posterior teeth, while hyperplastic gingiva may sometimes be seen extending onto the eroded tooth surface. ORL can be confused with feline gingivitis/stomatitis syndrome, especially when there are retained roots in the mouth. Prevalence of ORL Prevalence rates of 28-57% have been reported in the literature and older cats are more likely to be affected, with the number of lesions increasing with age. Asian short-hair cats appear to be more susceptible, although any breed/domestic cat can be affected. Some studies show male cats to be more prone to ORL than females, and the disease often exists in conjunction with PD. Clinical appearance Posterior teeth are more commonly affected than anterior teeth, and diagnosis is often difficult when the affected teeth are covered with plaque, calculus or inflamed gingiva. In one study, the two most commonly affected teeth were the maxillary and mandibular fourth premolars. Lesions are more common on the buccal surface of the tooth, and often start in the cervical area, extending both apically and coronally. Aetiology of ORL As yet, there is no known cause, but many theories and suggestions have been put forward to explain this most perplexing disease. Gorrel (2003) concludes that ORL may be two separate disease processes, one predominantly affecting the cervical or neck area of the tooth, while the other process affects the root of the tooth and may not show any tooth loss above the alveolar bone margin. Some veterinarians felt that dietary or endogenous acids are the trigger in initiating the lesion. Others put forward the idea of occlusal stresses (so called abfraction lesions) being the cause and still others incriminated viruses as the initiator. Diagnosis Diagnosis is usually based on clinical examination with a dental explorer and the use of intra-oral radiography especially for subgingival lesions. Treatment of ORL Early lesions involving enamel- topical fluoride? and monitoring.

Lesions involving dentine+/- pulp: extraction is the current accepted treatment- can be very difficult extraction due to partial/complete root ankylosis. Most ORL extractions require a surgical technique. Restoring lost tooth structure? Today, an unacceptable method of treatment. Other treatment options Crown amputation technique described by Dupont. In the original study, DuPont treated over a hundred teeth with crown amputation. Radiographs showed continued uneventful replacement resorption of the root structure with gingival healing. Trauma The most common oral injury in cats is mandibular symphyseal separation. This is usually due to MCA or falls. Simple circumferential wiring is the most effective way of stabilising these separations. Mandibular/maxillary fractures in the cat can be more difficult to manage than in the dog, due to the smaller head size, often the comminuted nature of the fracture and the difficulty in applying tape muzzles, external or internal fixation. Inter-arcade or interdental fixation or both have offered a valuable alternative to traditional methods of fracture repair. Temporo-mandibular joint injuries do occur in cats. Ventro-rostral luxation is often treated by closing the jaws together while a wood or plastic rod separates the upper and lower carnassial teeth on the side involved, then pushing the involved mandible caudally. Fractures involving the temporo-mandibular joint area that have resulted in ankylosis or pain in the joint can be treated by mandibular condylectomy. Traumatic tooth fracture is not uncommon in cats. The canine teeth are most commonly affected and often the crown fracture is complicated and involving the pulp. Treatment of a complicated crown fracture usually requires either extraction, complete or partial pulpectomy. Feline gingivitis/stomatitis syndrome (FGS) Gingivitis/stomatitis in the cat is the cause of a lot of heartache for both the practitioner and the client. Often cats present in severe pain, with ptyalism, dysphagia and marked weight loss. Histologically, it is characterised by an infiltration of plasma cells and lymphocytes possibly in response to polyclonal B-cell activators in oral bacteria. Other co-factors such as viruses and proteins have also been incriminated. Pure breed cats (Siamese, Persians) may have more severe disease than other cats. Aetiology Aetiology unknown, multifactorial disease? Viral ?- Chronic Calici viral infection, Corona virus May be due to chronic antigenic stimulation and an inability to moderate the host response: polyclonal B-cell activation Can see hyper/hypo response of immune system to plaque bacteria, other antigens such as food additives (cinnaminase, Benzoin), viruses. Cats with FGS seem to be very plaque sensitive suggesting that periodontal disease plays a large part in the disease.

Diagnosis of FGS A complete oral examination is normally performed under general anaesthesia due to the painful nature of the disease. A hematological workup including viral assays is necessary to rule out FIV, FeLV and other possible causes. Biopsies may be required especially where lesions are asymmetrical and viral culture of lesions may be of benefit to rule out calicivirus infection. Bacterial culture and sensitivity testing may also be required if there is a poor response to empirically chosen antibiotics. Management of FGS No one treatment is successful. Owner education: prepare the owner for a long battle. Professional scaling/cleaning with extraction of teeth with poor prognosis should be your starting point. However, often this is unsuccessful long term. Any root fragments need to be removed. Never leave fractured root tips behind in these cases when extraction is necessary. Intra-oral dental radiographs are essential when evaluating for retained roots. Often lack of permanent response to meticulous oral hygiene, professional scaling, antibiotics, anti-inflammatories and immunosuppressant drugs (better to use liquid or parenteral administration if considering drug therapy). Other drugs including: Aurothioglucose- gold compounds, oral cyclosporin 10mg/kg SID Hypoallergenic diets where food allergy suspected. Refractory cases often require caudal (premolar/molar) extractions; if not the entire dentition- currently this treatment shows the highest success rates in resolving the inflammation. However, in a study of 30 cats, 7% showed no improvement after multiple extractions (Hennet,1994)

Oral neoplasia The most common oral neoplasia in the cat is Squamous cell Carcinoma (SCC). A common site for feline SCC in the mouth is the ventral tongue. The cancer is often detected too late for local control and cats do not respond well to partial glossectomy. Early detection may offer a better prognosis. Feline oral fibrosarcoma is the second most common oral tumour in the cat. It also is very difficult to manage, but early diagnosis and surgery offer the best chance for cure. Intralesional anti-cancer drugs have also been tried with varying success. Nasopharyngeal polyps This inflammatory disease tends to occur in young cats. Clinical signs include sneezing, swallowing and breathing difficulties. Firm fleshy masses may be palpated in the caudal pharynx or above the soft palate. Occasionally masses may be visualized in the external ear canal. Most polyps originate in the tympanic bullae or Eustachian tube and grow towards the pharynx. Treatment through the oral cavity involves traction and ligation to try to remove as much of the stalk as possible, but recurrence is common. If a polyp occurs in the bulla, a bulla osteotomy may be required to remove the polyp.

Eosinophilic granuloma complex (EGC) EGC classically has three forms, namely eosinophilic ulcer (rodent ulcer), eosinophilic plaque and linear granuloma (collagenolytic granuloma). Rodent ulcers occur on the upper lip and hard palate. Females may be more predisposed. The lesions are often associated with excessive licking. Eosinophilic plaques are raised ulcerated, erythematous and hairless lesions occurring on the skin of the lower abdomen, groin, neck and between the toes. These lesions may be very pruritic. Linear granuloma occurs mainly in young animals and can present in the oral cavity and pharynx as raised, linear yellowish plaques especially on the tongue. Possible aetiologies for eosinophilic granuloma complex include: Allergies: Atopy, flea bite dermatitis, mosquito bites, food allergy Chemical: contact irritants, insect parts- FB reaction Genetic: colony of cats specifically bred at Davis University

Treatment involves identifying and removing the underlying cause. This may involve fastidious flea control of all in-contact animals, a strict elimination diet and avoidance of environmental allergens (difficult). Drug therapy often involves high doses of corticosteroids especially injectable methylprednisolone acetate (4mg/Kg every 3 weeks for 3 doses) or oral prednisolone (1-3 mg/kg SID until resolution then alternate days). Initially antibiotics may be required to treat the secondary skin infection associated with the pruritus. Doxycycline (10mg/kg SID) is a good antibiotic choice because of its anti-collagenase activity as well as its antimicrobial action. Other immunosuppressive drugs (chlorambucil- 0.1-0.2 mg/kg on alternate days) may be used in combination with corticosteroids in refractory cases. Other oral diseases Foreign bodies- needles under tongue Renal disease and oral uraemic ulcers Diabetes mellitus- dehydration, neutrophil dysfunction leading to periodontitis. Malocclusion- Persian cats with rostrally tipped maxillary canines. In general malocclusions are rare in cats.

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Scarlett JM et al. Risk factors for odontoclastic resorptive lesions in cats. J Am Anim Hosp Assoc 1999; 35:188-192 Wiggs RB, Lobprise HB. Veterinary Dentistry: principles and practice. Philadelphia; lippincott-Raven, 1997: 487-90 Zetner K, Steurer I. The influence of dry food on the development of feline neck lesions J Vet Dent 1992:9: 4-6