Characteristics, Causes, Diagnosis
LPGS Medications and Supplements
(For FIV Meds&Supps, see Main Menu left)
1. Factors Affecting Treatment Choice
2. Some Conservative Measures
3. Primary Therapeutic Needs and Options
4. Pain Management
5. Dental Considerations
6. Laser Therapy
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The following does not attempt to be a roadmap to the treatment of LPGS. Consultation with a veterinarian is encouraged. Much remains not understood about the problem, available research does not answer all questions, vets themselves differ about when and whether to apply this or that treatment option, and experience suggests that what works on one cat doesn’t necessarily work on another. One dental vet has noted that a biopsy finding of lymphocytic-plasmacytic stomatitis "is the typical histological picture whenever cats have chronic inflammation" [Carmichael]. It does not tell you the underlying driver of a cat's disorder, nor does it dictate a single course of treatment or predict a given level of successful outcome. The best advice appears to be to educate yourself about the disease and its potential treatments, and not to put yourself uncritically into the hands of an individual vet whose decisions might make you wish, somewhere down the line, that you had looked into the matter more fully.
1. Factors Affecting Treatment Choice
Several considerations should be kept in mind when evaluating possible courses of action:
Age. Put simply, it makes a difference whether a cat is seven or fourteen years old. Few of us want to be "realistic" about the old animals that we cherish, but a fourteen year old FIV+ cat has done well for itself (or had well done by it). While an FIV+ cat can reach the late teens just as any other cat can, choosing a treatment option with the best chance of giving an optimal quality of life for a year or two might weigh more heavily than with a middle-aged cat that one hopes will arrive at the same golden years as the oldster. The younger cat, with perhaps a stronger immune-response potential, might, for instance, be a better candidate for oral interferon therapy than an older cat whose improvement might require therapy with more up-front punching power. Similarly, a younger cat cannot reasonably spend a normal lifespan on steroids; for an old cat, this caveat would not really apply.
Underlying Pathology. No, everything is not known about the underlying causes of LPGS. But what is known and what can be deduced can, and perhaps should, inform decision-making. A cat with a chronic herpes infection might be a better gamble for use of oral interferon than one without. Notwithstanding the lack of unanimity on the role of Bartonella in some feline stomatitis, it is hard to argue against knowing the Bartonella status of any given cat and weighing it in therapeutic decision-making
Reversability. Once teeth are gone, they can't be put back. Dental vets quote a success rate of 70 to 80% for full-mouth extraction. "Currently, the only treatment that will deliver consistent results of 70% cure without the use of follow up medications, are extractions of all the teeth distal to the canines" [Bellows]. "Extraction of all premolars and molar teeth is the most dependable treatment: significant, long-term improvement is reported in 70-80% of affected cats" [Harvey]. "Surgical treatment, involving extraction of all teeth caudal to the canines, has been shown to be effective in curing this disease" [Carmichael]. "Selective or whole mouth extraction of teeth may be necessary for patients with faucitis and pharyngitis. The more distal the inflammation in the oral cavity, the harder it will be to correct. Many cats with faucitis will not respond to other therapies until all teeth distal to the canines are removed. Eighty percent of cats that could not be controlled by any other means were cured by whole mouth extraction" [Rochette]. Cautionary voices seem rarer, but exist. "Full mouth extraction of all teeth as recommended by some veterinary dentists is a very traumatic procedure and rarely resolves fauces lesions" [Wolf1]. The lesson seems to be that, regardless of what is ultimately decided, this is not a decision in which blind and immediate trust in one vet's judgment needs to prevail. It requires serious thought and, perhaps, a second or third opinion.
Clinical Condition. Oral Inflammatory disease occurs at varying points of the oral cavity and with varying levels of virulence. A graduated response to varying levels of infection, applying progressively more elaborate and diverse dentistry, home care, and drug/supplement-based therapy, obviously makes sense. Mihaljevic’s programs make use of feline omega interferon at all stages, a strategy not likely to be embraced in places where access is difficult or received with great enthusiasm in all places by many people, given the expense of FeIFN. But the overall approach--the proportionality of therapy to clinical condition--is instructive.
Slight gingivitis/stomatitis: FeIFN, aloe, vitamins, antibiotics, chlorhexadine rinse + dentistry (scaling, gingivectomy)
Moderate gingivitis/stomatitis: same + more elaborate dentistry (FORLs dictating extractions)
Severe gingivitis/stomatitis + moderate to severe oropharyngitis (w/remaining teeth): same + further
dentistry (same + poss. full-mouth extraction) + limited duration megestrol acetate
Severe gingivitis/stomatitis + moderate-to-severe oropharyngitis (w/o remaining teeth): same + further dentistry (alveolar fold drilling) + poss long-term megestrol acetate
* Stages 3 and 4 involve a more intense interferon regimen.
FIV Status. Everyone with an FIV+ cat worries about the harm that might be done by the immunosuppressive therapies often necessary for control of inflammatory diseases such as lymphocytic-plasmacytic IBD or LPGS. This is certainly a factor to take into account, and the difficulty in assessing the state of the immunity of a given cat only makes decision-making more difficult. So one might be tempted to choose the less taxing among therapeutic alternatives. However, knowing that ones LPGS cat is also an FIV+ cat with additional immune deficits could be an inducement to choose a more potent therapy from among the available alternatives in order to spare the cat the needless suffering of a failed therapy. The calculation is not a simple one.
2. Some Conservative Measures
Conservative measures may not make a decisive difference by themselves, but generally cost little in dollars and cents or in stress on the cat and owner.
Vigilance. Immune-mediated LPGS can have a very rapid onset. The classic model of feline peridontal disease--incremental worsening from a baseline of mild gingivitis--does not necessarily apply. But the owners of FIV+ should be particularly proactive in having their cats' teeth and oral cavity checked regularly for signs of problems. "There has not been a significant relationship between plaque index and gingivitis in cats; that is, there appears to be a hyperimmune response to very little plaque (and its components), so excellent oral hygiene would be needed to decrease oral inflammation" [Cebuliak]. That sounds like a very high standard of care, and there are no studies or other information available on the relative outcomes of stingent vigilence vs its absence. But some chronic oral disease can be interdicted by vigilent home and veterinary care. And since some 70% of cats are said to show signs of oral disease by age 3, it is not likely to be wasted effort. Writes one dental vet, "Early gingivitis . . . is characterized by mild plaque accumulation and mild hyperemia of the gum margins (marginal gingiva). This is the earliest detectable sign of periodontal disease. A form of juvenile-onset gingivitis is recognized in cats . . . .Treatment of "early gingivitis" is done at home. Owners should be instructed to provide regular (daily !) home care to retard the accumulation of plaque on the teeth. It is important to inform pet owners about the
proper way to care for their pets’ teeth at home, and at the same time educate them to look for signs of advanced disease that would require professional treatment. Clients who regularly brush their pets’ teeth tend to be the most responsive to recommendations for professional treatment" [Carmichael].
Home Dental Care: Obviously, providing home dental care for the cat so seriously affected by pain from oral disease that any manipulation of the mouth area is virtually impossible is a special case. For lesser situations, though, one dental vet recommends "daily tooth cleansing (brushing, swabbing), the use of a tartar-deterrent diet (Hill’s T/D, Friskies Dental Diet for Cats), chlorhexidine gels, impregnated discs (Stomadex), or rinses (Hexarinse, Nolvadent), hexametaphosphate-containing products (CET products), Maxiguard gel, Waltham's Dentabones, Tartar Chews and Nutribiscuits, etc. Home fluoride treatments are not recommended. The toxic dose for fluoride is 2 mg/kg and toxicity can be cumulative over several
treatments. Fluoride is difficult to apply properly and also inactivates chlorhexidine" [Rochette]. Healthymouth™, a water additive containing glycerin, plant extracts, vitamins and zinc, recently received the Veterinary Oral Health Council (VOHC) seal of acceptance for plaque control and has been cited favorably by at least one dental vet [Hale]. Most cases of advanced periodontal disease alone in felines can, it is said, be prevented through a program of early disease detection and appropriate treatment.
Diet: "In teaching home care to clients I point out that God didn’t hand cats a box of Whiskettes as they walked out the door. (This is the equivalent of eating crackers - leaves some on the back molars for a snack for later!) He/She pointed out that birds, rabbits and mice had been created several days before. Some clients with cats in less severe stages have noticed a significant improvement on Hill’s T/D plus raw \ bone chewing, omega fatty acid nutrition, and removal of their supermarket foods. The reason this is working may relate to more than oral hygiene, as the absence of food colourings, sensitised preservatives, removal of poorer quality (phytate) proteins - which bind zinc and lack essential taurine and vitamin B - and the increase in fatty acids and vitamin E may all contribute to oral health" [Cebuliak]. Other recommendations for management include "feeding a limited antigen or hypoallergenic diet" [Wolf]. "Initiate a feeding trial with a hypoallergenic diet. Human studies have shown that food allergens can perpetuate oral inflammation. . . . Consider homemade diets" [Rochette]. Diane Addie calls food "a very important feature in this condition," but admits not knowing why. She cites sensitivity to processed food, micronutrient deficiency in certain foods, and "wrong omega 3:6 ratio causing a pro-inflammatory state in the cat being fed too much grain-based food" as possible factors. She recommends Butcher's Classic, Applaws, Wild Kitty, and MPM dry as favored brands on the basis of her own clinical experience and cites Hills A/D second hand [Addie]. It is possible (but undemonstrated) that elevating levels of omega-3 fatty acids would have a beneficial anti-inflammatory effect [Ferrucci]. Large-size, densely fibered kibble (feline dental diet) has shown favorable results as a prophylactic [Vrieling].
Nutritional Supplementation: Generally speaking, the supplements most often recommended [See Medications and Supplements] are acceptable tasting and not overly difficult to administer.
Food Dishes: . . . us[e] ceramic or metal food bowls (avoid plastic) [Wolf1]. Plastic dishes scratch easily and become havens for bacteria This, for instance, is how "chin acne" is worsened. The plastic itself can be allergenic.
Vaccinations: "Consideration should be given to decreasing the frequency and/or number of vaccinations a patient receives. Chronic immune system stimulation may aggravate a hyperresponsive animal" [Rochette]. With their primary infection in mind, many FIV+ cats are no longer vaccinated in any case, but LPGS might provide additional food for thought for those who continue to vaccinate.
3. Primary Therapeutic Needs and Options
"Nothing gold can stay" Robert Frost.
The refrain heard so often from those treating cats for LPGS: It worked for awhile; then it didn't. The
words most often encountered in researching the disease: "frustrating," "difficult."
Following are the five major categories of therapeutic agents upon which treatment of LPGS draws. An element of interpretation is obviously involved, since no single source lays out all of the major players available, evaluates their worth, and attempts to say how and when they should be used and combined. Diane Addie's therapeutic program (and website) are (probably) the closest thing to a gold standard currently available. The generalizations and specifics offered are on the basis either of what has been suggested by researched sources or a "best sense" of what feedback from people practicing therapies seems to suggest. Vitamins, minerals, antioxidants, and so forth have been left out on the grounds that in most cases they are more likely to be supporting cast than major players in various therapeutic schemes. Several proprietary supplement combinations have claimed to have significant stand-alone therapeutic impact, though validating studies are either lacking or limited in scale. Pet Plus for Cats, consisting of digestive enzymes, PUFA's, pre- and probiotics, phytonutrients, antioxidants, and various vitamin and mineral sources, is one. The so-called Dallas Stomatitis Cocktail (consitutents unknown, but speculated to include vitamins, probiotics, an H2 blocker, antibiotics, and immune modulators), previously available via The Dallas Dental Veterinary Clinic, is another. Injecting some vitamins at high dosage on a regular basis may be a dramatic step up from daily oral administration.
Unless lucky enough to inherit a situation that "resolves" and to "cure" a cat through a combination of dentistry and term-limited treatment, one is likely to need recourse to all of the following categories, in various combinations, at some point during an open-ended treatment program aimed at controlling LPGS. Adaptability and the knowledge that no one therapy or therapeutic combination may permanently or continually solve the problem are part of coping with the disease.
Antibiotics: Antibiotics are an inevitable part of any treatment program. Any dentistry needs to be preceded by antibiotics and followed by them in order to insure that bacteria freed by dental procedures don't travel elsewhere in the body and set up infection. Antibiotics alone or in combination with dentistry are unlikely to be sufficient to resolve or control LPGS. Anyone given to understand the reverse by the vet providing treatment should have a long discussion on the subject. Some people have expressed a desire to avoid antibiotics in long-term treatment, and this is understandable. Continuous long-term antibiotic therapy is not in the best interest of any cat because of the impact on intestinal flora and nutrient absorption, as well as the potential for generating antibiotic-resistant organisms. Depending on the particular circumstances, antibiotics may be pulse-dosed--a given period on and a given period off--or prescribed periodically for "flares" or worsening disease courses. Some people, of course, object to antibiotics--and other things as well--on broader grounds of medical philosophy, but assuming that that is not the case, deliberate avoidance of antibiotics seems difficult to justify. The perception that an antibiotic "doesn't work" has to be viewed in the context of the fact that antibiotics alone are unlikely to "work" indefinitely. Although the antibiotics usually used to treat LPGS have various extra-bacteriacidal qualities, something additional that impacts the cause or expression of aberrant immune response is almost certainly going to be required. And since "change" seems to be the law of LPGS therapy, the desirability of a change in antibiotic at some point is not necessarily a comment on the pointlessness of their use. The recent popularity of Convenia (Cefovecin sodium), the 14 day injectable antibiotic, has included use for treatment of LPGS. A recent Pfizer-sponsored trial as an adjunctive therapy to periodontal scaling or surgery for severe periodontal disease in dogs did find Convenia comparable in efficacy to clindamycin [Giboin]. Cautionary voices have pointed out that the convenience of avoidance of daily oral medication may be offset by the difficulty of coping with an adverse reaction [Pierson]. Although use of any of the recommended antibiotics for initial treatment can be justified, the documented synergy of doxycycline and niacinamide for treatment of autoimmune diseases makes this pairing particularly attractive.
Antivirals: Chronic viral infection is an important component of much feline gingivostomatitis. Feline omega interferon has direct antiviral activity against FIV, herpesvirus, and calicivirus, with an additional immune-modulating component. There seems no reason whatever at this time not to use it as a frontline therapy for LPGS--except cost. It has proven of dramatic benefit in a majority of instances when it has been used and has not shown prohibitive side effects. It can be used by subcutaneous injection, by direct injection into oral tissue, by topical application, or, as has sometimes been done, by incorporation of multiple forms of administration into the treatment regimen. The perceived monetary saving of direct injection of smaller amounts of the interferon on fewer occasions must be measured against the veterinary costs of doing so, since an owner can administer subcutaneous injections, whereas only a vet can give the oral injections and only with anaesthesia. Whether the improvements recently demonstrated with high-dose topical application for mucosal absorption are of a magnitude to justify sole use in this manner is difficult to say since the trial was head-to-head with prednisolone, not with interferon administered in more established ways. However, one field report forwarded described very good results. Feline omega is available in North America by import, but only for use in individual cats, which means that the vet cannot purchase the drug for stock; the owner must assume responsibility for purchasing the entire minimum amount that the shipper will provide. Feline omega is not a panacea. While Virbac, the manufacturer, recommends against using steroids concurrently with its product, Addie notes the need for occasional recourse to steroids in her treatment of some cats; it is unclear when or how. Mihaljevic has built feline omega into a multidrug/supplement regimen with a hormonal anti-inflammatory added for severe disease. This would suggest that the interferon may well require support with other drugs or with multiple forms of administration in some such situations.
Oral dilute human interferon has the advantage of being relatively inexpensive, available, and easy to administer. When herpesvirus is suspected or confirmed in a cat with oral disease, oral interferon and lysine may be a worthwhile response. In other situations, effectiveness is more problematical. Studies have sometimes reported benefit that fails to materialize when owners attempt to replicate it. Some hypothesize a direct antiviral action against herpes, although the general rationale for use is that it has no direct action, but instead stimulates the body's own immune response. If, as one study suggests, natural interferon alpha is a more potent product than recombinant, then, particularly in FIV+ cats, which start with immune deficits that other cats don't have, it might be a better choice.
The recent success of famciclovir in the treatment of herpes upper respiratory and ocular disease raises the distinct possibility that it will be an important new weapon in the treatment of gingivostomatitis with a herpes component. An oral drug that is well-tolerated, famciclovir can and perhaps should be tried whenever diagnostic testing or patient history suggests the presence of a chronic herpes infection. In cases of mild to moderate disease, supplements such as cranberry extract can be tried where chronic calicivirus infection is known or suspected, and lysine, lactoferrin, and/or prunella in the case of herpes.
Anti-inflammatories - Steroidal: Steroids are the 800 lb pink gorilla sitting in the room where LPGS therapy is being considered. There is no ignoring them. In a recent private contact, Richard Malik, an Australian vet notable for his work with stomatitis, called steroids "out of date" for LPGS, remarking, "most people would not recommend them anymore." The majority of vets in the U.S. would, no doubt, be interested in hearing that since steroidal anti-inflammatories not only have been but remain frontline treatment, along with dentistry and antibiotics. The down side of steroids in cats is well known: they can lead to diabetes, they cause weight gain, and in FIV+ cats there is always the worry of adding to the immunosuppressive effects of the viral disease, since they are immunosuppressive. In the last regard, while there are no trials as such of steroids vs control in assessing the impact on life-expectancy, anecdotal accounts suggest that this worry may be somewhat exaggerated. At low dosage, particularly, the so-called "Plechner" protocol [http://www.drplechner.com] appears to be beneficial for FIV+ cats, at least those not too immune suppressed at the time therapy is begun. Dosage is a crucial factor in the management of steroidal therapy. "With the exception of substitution therapy, the use of corticosteroids . . . in disease is empirical . . . the appropriate dose to achieve a therapeutic effect must be determined by trial and error" [Brunton]. The common procedure seems to be "hit them hard to begin with then back off on medications as they respond" [Sheilah Robertson DVM, private communication]. That means begin with a therapeutically
standardized, efficacious dose, then gradually retreat to a level where the steroid begins showing signs of unacceptably reduced activity. This authority arrives at the same point by a somewhat different route: "Translated into terms of clinical practice . . . When corticosteroids are to be administered over long periods, the dose must be the smallest one that will achieve a desired effect. This dose must be found by trial and error. Where the goal of therapy is relief of painful or distressing symptoms not associated with an immediately life-threatening disease . . . the initial dose should be gradually increased until pain or distress has been reduced to tolerable levels. Complete relief is not sought. At frequent intervals the dose should be gradually reduced until the development of more severe symptoms signals that the minimal acceptable dose has been found" [Brunton]. Some clinician's have reported success piggybacking steroids with a so-called "triple steroid injection": several very high doses of short-acting dexamethasone and triamcinolone in conjunction with a high dose of an antibiotic, given once a week for three weeks. "The idea behind this is to suppress your cat's immune system so far down, that it will take a long time to come back up enough for the stomatitis to return. We have had several cats get relief up to a year with this combination" [All Feline]. This practice would not be advisable, however, with an immune-suppressed cat.
All of this having been said, the fact remains that finding a way not to use steroids,or to use them as little as possible, has been something like the Holy Grail of stomatitis therapy. For one thing, side effects aside, they aren't effective indefinitely. Diane Addie's opposition to reliance on steroids is based partly on the "rebound" effect: "whilst they appear to help the cat initially, there is a bounce-back effect - with the cat
re-presenting with worse clinical signs than initially and requiring higher and higher doses just to maintain." In one study, methylprednisolone and sodium aurothiomalate were compared clinically and by measuring immunoglobulin (antibody) levels during the course of therapy. "After three months of treatment, the cats receiving methylprednisolone had a significant reduction in serum IgG levels compared to the cats treated with sodium aurothiomalate or metronidazole and spiramycin, but after six months of treatment there were no significant differences between the groups" [Harley]. Nothing gold can stay. Steroids can provide immediate and dramatic relief, but not forever. Switching among steroids may buy additional time. One source recommends that dexamethasone be used after prednisolone is no longer effective [Dentalsvets].
Anti-inflammatories - Nonsteroidal: Use of NSAIDS requires careful monitoring, but offers an alternative to steroids that is not immunosuppressive and will not lead to diabetes or weight gain. NSAIDs are unlikely, however, to offer the same level of anti-inflammatory and overall relief from symptoms as steroids. Many people have been scared off the use of aspirin in cats by widely-deseminated warnings
about the inappropriateness of casual use. Carefully controlled doses can be helpful, particularly with mild to moderate symptoms. Topical salicylates such as Bonjela offer an alternative to oral aspirin. Meloxicam [Metacam] has more potency than aspirin and is very easy to administer. The general experience has been to start with the largest dose and rachet down. Anecdotally, one person has attributed anemia to use of meloxicam, and another ascribed her cat’s renal failure to its use; most users do not seem to note side effects, although they worry about them. Being dosage-shy out of fear of side effects may be counterproductive. However, use of metacam entails risk and should be carefully considered. Addie finds it generally complementary to therapy with Feline Omega Interferon. A blanket recommendation is difficult, though, because of the many people who are so passionately against its use.
Immune-Modulators, -Potentiators, -Suppressors. Effective treatment of LPGS without steroids will require the use of an agent capable of making a significant impact on immune response, since LPGS is an immune-mediated disease. Immune modulators such as curcumin can be tried in food. Bovine lactoferrin is a good first choice for mild or moderate disease, and the idea of combining it with a pasty base such as aloe or slippery elm (or interferon) is attractive since it is believed to work better when applied directly to affected tissue than when given with food. Lactoferrin by itself will not often make a decisive difference, but there is reason to be impressed by the regimens (Addie, Mihaljevic) it has been incorporated into. And it has so many other potential benefits for an FIV+ cat that it should probably be part of almost any multi-agent regimen. Testimony is generally lacking on the use of gold
salts (Sodium Aurothiomalate; Aurothioglucose, Auranofin) and levamisole, so it is hard to recommend either. Just how immunosuppressive gold salts are and whether they are a safe option for an FIV+ cat is worth some consideration. Some people have had success with pentoxifylline, which seems an underutilized resource and worth a try at some point when other things are not working. It is more widely used in HIV-related therapy than in FIV-related therapy, but is recognized in veterinary medicine as a treatment for some autoimmune diseases. Interferons have significant immune-modulating action (see "Antivirals" above).
Thalidomide has unique immune-suppressive and anti-inflammatory properties that may make it a route worth going in cats with severe LPGS. Research has drawn contradictory conclusions whether it might
favor, hinder, or be neutral to long-term HIV disease advancement. The long term prospects for FIV+ cats can only be established by long-term studies or clinical experience. Unfortunately, thalidomide's very
limited availability in most parts of the world is likely to limit not only its use, but the kind of study that might help to establish how best to use it. Cyclosporin may well be a wave of the future for FIV- cats with severe LPGS. At the moment, however, no one is on record as having used it safely in FIV+ cats. Megestrol acetate is immunosuppressive and so belongs with this grouping. Its use as LPGS therapy seems to be
more common in continental Europe than in the U.S. and elsewhere. While there is some reluctance to use it long term, it appears to be an effective steroid substitute, at least for a time, and, for that reason, worth looking further into. The broad spectrum of possible side effects do not, however, make it seem like a major therapeutic advance. There is no clear reason to prefer parapox preparations such as Baypamun or Zylexis for injection into the oral cavity when omega interferon is available, and testimony is lacking on direct oral application of unreconsitituted powder.
Cimetidine ought, it would seem, to be attempted as part of a nonsteroidal treatment program. It is safe for use in cats and has a known dosage, though not an LPGS-specific dosage. There are a lot of desperate people out there and not much to lose. The chief drawback is its numerous drug interactions, which must be carefully checked out and planned around.
4. Pain Management
It is a persistent finding in human medicine that clinical physicians pay too little attention to pain and, when they do, provide inadequate treatment. So if the same proved true with veterinary care, this should not be surprising. A graduated response to pain would involve choice of analgesia sufficient to provide comfort and a maximum level of functioning for a cat with a minimum of side effects or potential for side effects. A pet owner is in a much better position than a vet to observe closely the extent to which effective pain relief is being provided. If eating behavior, recoil-reflex, and general demeanor indicate that pain relief is inadequate, the owner needs to prod the vet to examine the current pain-management program for possible improvement.
The first level of relief for mild to moderate pain is herbal preparations such as aloe or chamomile or commercial products that contain them. Little is required in the way of monitoring and little potential exists for side effects.
Any anti-inflammatory agent will provide some level of pain relief simply be virtue of reducing inflammation. NSAIDs (aspirin, meloxicam, ketoprofen), which may be given for inflammation in any case if steroids are not currently being used, have both anti-inflammatory and analgesic properties Because of potential adverse effects with long-term administration, their use needs to be monitored ongoingly. If steroids are being given, the anti-inflammatory effect will provide some level of pain relief.
Tramadol is a good second or third-line analgesic. It is non-opioid, but works partially in an opioid-like manner ("mu-agonism") and has anti-anxiety properties. It can also be combined with NSAIDs or with
opioids in the event that a single analgesic is unable to provide sufficient relief.
Pain relievers that target opioid receptors are the last line of defense. All carry with them some level of opioid-like side effects, though when they are effectively employed these effects should be tolerable. Butorphanol is of limited usefulness. Its kappa-agonist activity (i.e., stimulation of the kappa opioid receptor) provides only a short duration of relief. For chronic discomfort, butorphanol, used by itself, is not likely to be adequate. Buprenorphine is the agent of choice among partial or mixed mu-agonist or -antagonist opiods. At optimal dosage it may produce up to 12 hours of pain control, and has useful characteristics with regard to administration.
Amantadine has no downside as an add-on second analgesic. It works in an entirely different manner from the previously described analgesics. The recommendation is not to use it by itself, but to use it along with another analgesic to provide synergy. Side effects are generally not an issue. There is no reason not to use amantadine as an adjunct therapy.
Fentanyl is a pure (not mixed or partial) mu-agonist. It is therefore potentially strongest among the products usually used. However, because the analgesic effects of pure mu agonists wane over time, requiring increased dosage, fentanyl patches, like codeine, are an option best reserved for temporary use during periods when pain is at its worst.
5. Dental Considerations
Detailed description of dental procedures are beyond the purview of this document and beyond the interest of most nonprofessionals and probably their capacity to evaluate meaningfully. It is universally accepted that therapy aimed at LPGS that does not include appropriate dentistry will be unsuccessful. Dentistry generally means the following: "Perform full scale . . . to eliminate all calculus and necrotic cementum from supra and subgingival areas. Special attention must be paid to pockets with the use of a small subgingival curettage. Extract teeth not viable. Polish as normal with a prophy cup" [Dentalvets].
Candidate teeth for extraction are described as having the following features:
● Severe periodontitis (grades III and IV)
● FORLs (except stage I, shallow lesions confined to the enamel)
● Teeth surrounded by severe buccostomatitis (spontaneous
or induced bleeding on palpation)
● Mandibular molar teeth, maxillary fourth premolar
teeth, and first molar teeth in cats with faucitis [Klein]
Although removal of all teeth, all teeth caudal to the canines, entire quadrants of teeth, and so forth has often been described as necessary and highly successful in many cases, it is a major step. "Elective extraction of whole cheek teeth quadrants should not be undertaken lightly as there are several problems associated with it" [Dentalvets]. A high level of veterinary dental competence is required to insure that no fragments have been left behind and that potential complications have been properly assessed and treated. Statistically, full mouth extraction (FME), including canines and incisors, offers the greatest likelihood of successful resolution of oral inflammation. Complete resolution of inflammation occurs in 50-60% of cases, with another 20-30% showing significant improvement. Some dental vets argue for removal of periodontal ligaments, as well. Although FIV does not disqualify a cat from major surgery, post-anaesthesia immune suppression is an additional consideration in such cases. One fatality owing to probable sepsis has been reported to this writer. In cases unresolved by full-mouth extraction, "debulking and scorching" the ulcered tissues at the back of the mouth and into the pharynx using laser or radiosurgery are sometimes done in order to sterilize the tissue, reduce pockets that might trap antigen, and form scar tissue more resistant to inflammation than normal epithelium [Hale]. One dental vet has claimed considerable success for proprietary osseous surgery using radiowave radiosurgery (RWRS) to cut soft tissue and expose underlying bone pathology identified with digital radiology [DeForge]. This treatment is controversial, with some veterinary dentists objecting to the lack of peer-reviewed publication and objective data supporting effectiveness.
6. Laser Therapy
In recent years, the use of a CO2 laser has been advocated in LPGS therapy. "Although this therapy is still in its infancy, proponents suggest that resolution of bacterial ‘tracts’ is responsible for its success and may preclude full-mouth or selective extraction" [Dentalvets]. Numerous sources cite "reported," success, but no good first hand accounts have been uncovered for inspection, and anecdotal instances of laser ablation not being helpful have been reported. One dental specialist says, “I do not recommend it. Airway blockage caused by laser usage in the distal pharynx can lead to respiratory embarrassment or patient loss. In the December 2007 issue of the Journal of Veterinary Dentistry, J. Lewis, A. Tsugawa, and A. Reiter include a case report ['Use of C02 Laser as an Adjunctive Treatment for Caudal Stomatitis in a Cat'] in which the laser was utilized. They state: 'It is difficult to determine what role the laser treatment played in resolution of the inflammation, especially after extraction of the remaining canine teeth performed at the fourth and last ablative laser treatment'” [DeForge].
Cold Laser (also called Low-Level Laser, or LLLT).
Cold Laser has for some time been an accepted modality in Asia and Europe for clinical purposes. It has generally not been accepted in the United States, although some practitioners use it "off label." In dentistry, it has been used as "a treatment for soft oral tissue lesions, and positive results have been seen in the healing of diseases such as exudative erythema multiforme, gingivitis, periodontitis, and different forms of oral ulcers. In gingival tissues, LLLT applications can stimulate DNA synthesis of myofibroblasts without any degenerative changes and transform fibroblasts into myofibroblasts, which may promote wound healing. Concerning pain relief, one proposed mechanism is modulation of nociception by modification of nerve conduction by way of the release of endorphins and enkephalin" [Kahraman]. There are claims that cold laser is antimicrobial, including antiviral. In human dentistry it has been used to treat herpetic gingivostomatitis. One person has reported dramatic improvement of oral inflammation following her cat’s repeated sessions of cold-laser therapy: "After the first treatment, he seemed better...not as red in his throat. 2nd treatment we noticed his eating more like when we give him a depo shot and he starts to feel better. Vet examined him before 3rd treatment, and even I could see that the bright red was all gone except right over his teeth in a few spots on his gums. 3rd treatment . . . she concentrated on the lesions on the gums as well as the rest of the mouth. The treatment is totally painless. The vet decides how long to do it, and there are guidelines. For us it is 30 seconds. She moves the laser continuously around his mouth, throat and now the gums." How long benefits lasted is unclear.
Because it may be more convenient for the patient than being punctured, Chinese medicine has for some time used HeNe lasers for replacement of needles in acupuncture, a use that has spread to some places in Europe, Australia, and the United States [Kahraman]. One person who had laser acupuncture performed on her cat for pain relief reports as follows:
“--Re acupuncture: We did this, using a laser. Points stimulated weren't stomatitis-specific, but FIV-related. They were sourced from Cebuliak, [who says, “. . . it has been suggested that tonifying and regulating the immune system with 4 leading points (St 36, LI 11, LI 4, Sp 6) and considering others (GV 14, Bl 40, GV 20, Bl 2) . . . may be useful (Schoen, A pers com May1999).] Background info about the points is from Schwartz, Cheryl (DVM), Four Paws Five Directions - A Guide to Chinese Medicine for Cats and Dogs, 1996, Celestial Arts, California.
--Considered to be the four most important:
Stomach (St) 36 - Boosts general qi of the body;Large Intestine (LI) 11 - Clears heat from the upper body and regulates immune system. Used in all excess heat and wind invasions; Large Intestine (LI) 4 - Master point for the head; Spleen (Sp) 6 - Moistens and tonifies blood and fluid.
--Also: Governing Meridian (GV) 14 - Used to dispel wind invasion; Bladder (Bl) 40 - Used to clear heat and regulate water in lower part of body. Useful in irregular cycling, groin pain, lower back, hip and knee pain, stiffness and constipation;Governing Vessel. (GV) 20 - Calms and balances yang. Useful in tremors and seizures; Bladder (Bl) 2.”
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