Effect of tooth extraction on stomatitis in cats: 95 cases (2000–2013)

Michael W. Jennings Department of Clinical Studies-Philadelphia, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA 19104.

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John R. Lewis Department of Clinical Studies-Philadelphia, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA 19104.

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Maria M. Soltero-Rivera Department of Clinical Studies-Philadelphia, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA 19104.

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Dorothy C. Brown Department of Clinical Studies-Philadelphia, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA 19104.

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Alexander M. Reiter Department of Clinical Studies-Philadelphia, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA 19104.

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Abstract

Objective—To evaluate long-term response of cats with stomatitis to tooth extraction.

Design—Retrospective case series.

Animals—95 cats with stomatitis.

Procedures—Medical records of cats with stomatitis that was treated with tooth extraction during a 14-year period were reviewed. Demographic information and diagnostic results were recorded as well as surgical procedure, including full-mouth extraction (FME) versus partial-mouth extraction (PME), and specifics of medical management. Patients were categorized according to response to treatment.

Results—Median postoperative follow-up time was 231 days (range, 33 to 2,655 days). Of 95 cats, 6 (6.3%) had no improvement and 25 (26.3%) had little improvement in stomatitis following tooth extraction and extended medical management (EMM). Following tooth extraction, 37 (39.0%) cats had substantial clinical improvement and 27 (28.4%) cats had complete resolution of stomatitis; of these 64 cats, 44 (68.8%) required EMM for a finite period to achieve positive outcomes. Extent of tooth extraction (PME vs FME) was not associated with overall response to treatment. At initial recheck examination, a better long-term response to tooth extraction was observed in patients with resolution of abnormal behavior (OR, 7.2), decrease in oral inflammation (OR, 3.5), and lack of need for follow-up medical management with antimicrobials (OR, 3.7).

Conclusions and Clinical Relevance—Extraction of teeth in areas of oral inflammation provided substantial improvement or complete resolution of stomatitis in more than two-thirds of affected cats. Full-mouth extraction did not appear to provide additional benefit over PME. Most cats with stomatitis may require EMM to achieve substantial clinical improvement or complete resolution. (J Am Vet Med Assoc 2015;246:654–660)

Abstract

Objective—To evaluate long-term response of cats with stomatitis to tooth extraction.

Design—Retrospective case series.

Animals—95 cats with stomatitis.

Procedures—Medical records of cats with stomatitis that was treated with tooth extraction during a 14-year period were reviewed. Demographic information and diagnostic results were recorded as well as surgical procedure, including full-mouth extraction (FME) versus partial-mouth extraction (PME), and specifics of medical management. Patients were categorized according to response to treatment.

Results—Median postoperative follow-up time was 231 days (range, 33 to 2,655 days). Of 95 cats, 6 (6.3%) had no improvement and 25 (26.3%) had little improvement in stomatitis following tooth extraction and extended medical management (EMM). Following tooth extraction, 37 (39.0%) cats had substantial clinical improvement and 27 (28.4%) cats had complete resolution of stomatitis; of these 64 cats, 44 (68.8%) required EMM for a finite period to achieve positive outcomes. Extent of tooth extraction (PME vs FME) was not associated with overall response to treatment. At initial recheck examination, a better long-term response to tooth extraction was observed in patients with resolution of abnormal behavior (OR, 7.2), decrease in oral inflammation (OR, 3.5), and lack of need for follow-up medical management with antimicrobials (OR, 3.7).

Conclusions and Clinical Relevance—Extraction of teeth in areas of oral inflammation provided substantial improvement or complete resolution of stomatitis in more than two-thirds of affected cats. Full-mouth extraction did not appear to provide additional benefit over PME. Most cats with stomatitis may require EMM to achieve substantial clinical improvement or complete resolution. (J Am Vet Med Assoc 2015;246:654–660)

Stomatitis in cats is a severe chronic inflammatory disease of the oral cavity. Affected cats may have an abnormal immune response to dental plaque, often resulting in widespread inflammation of oral mucosa. Clinically, it is differentiated from gingivitis and periodontitis by extension of the oral inflammation into the nongingival mucosal tissues, and this marked mucositis is also often present in the caudal portion of the oral cavity.1–3 The prevalence of stomatitis in cats ranges from 0.7% to 12% of the general population,4–6 with 72% of veterinary dental specialists reportedly seeing more than 1 case/wk.7 Affected cats will often have signs related to oral inflammation, including oral discomfort, decreased appetite or anorexia, ptyalism, weight loss, an unkempt coat, and halitosis.8–11

Various potential viral, bacterial, immunologic, genetic, and environmental etiologies of stomatitis in cats have been investigated.8,9,12–20 Although a possible relationship with feline calicivirus seems most likely,21–23 no direct causal relationship has been established with any factor, and the underlying cause of stomatitis may be multifactorial.4,24 Medical management with antimicrobial, anti-inflammatory, or analgesic medications is often empirically tried, but long-term resolution of signs associated with stomatitis in cats is rare.16 Reduction of dental plaque by professional dental cleaning and home oral hygiene may help but is difficult to maintain,1,25,26 and chronic inflammation often persists.24 Currently, removal of plaque-retentive surfaces by extraction of teeth is considered to be the most effective method of reducing or eliminating oral inflammation.1,26 Authors of 2 previous studies11,27 have concluded that approximately 60% of cats treated with tooth extraction in areas of the mouth affected by inflammation had complete resolution of their disease and were free of clinical signs by removal of teeth alone. Approximately 20% of the cats had some remaining oral inflammation, but signs previously associated with stomatitis had resolved or improved. Another approximately 20% of the cats required ongoing medical management.11,27 In both studies,11,27 most cats had only PME, indicating most or all premolar and molar teeth were removed, with the canine and incisor teeth remaining.

Questions remain as to whether PME or FME is the better treatment option, given that remaining teeth have plaque-retaining surfaces, potentially resulting in persistent oral inflammation. The extent of tooth extraction impacts veterinarians, patients, and clients on multiple levels, including difficulty and length of surgery, recovery and postoperative function, and financial and emotional effects, respectively. The purpose of the study reported here was to reevaluate reported response rates to tooth extraction and medical management in a larger number of cats with stomatitis and to determine whether there is a difference in outcome when PME or FME is performed.

Materials and Methods

Case selection—Medical records of patients treated at the Matthew J. Ryan Veterinary Hospital of the University of Pennsylvania from 2000 through 2013 were searched for the following keywords: feline and stomatitis. Cats with stomatitis were included in the study if their oral cavities were evaluated under anesthesia, they had full-mouth intraoral dental radiographs taken, they were treated with PME or FME as previously described,28,29 and their medical records contained documented historical and physical examination findings for both the initial and recheck examinations. Patients treated with PME had stomatitic lesions that were not associated with all teeth. Only teeth with associated stomatitic lesions, severe periodontitis, or tooth resorption were extracted; any remaining teeth were scaled and polished. Cats treated with FME had stomatitic lesions associated with all teeth. Cats were considered to have stomatitis if they had clinical signs consistent with stomatitis and nongingival mucositis was present in the caudal portion of the oral cavity. Histologic confirmation of stomatitis was not required as an inclusion criterion. Cats with stomatitis were excluded from the study if they underwent additional surgical treatments beyond PME or FME that could have affected outcome of treatment (eg, CO2 laser treatment). Cats for which complete data were unavailable were also excluded from the study.

Medical records review—Age, sex, neuter status, breed, presence of and relationship to other cats in the household with or without stomatitis, diagnostic test results, signs associated with stomatitis and their duration, and medical or surgical management prior to tooth extraction were recorded for each cat. Additionally, physical examination findings, radiographic oral examination findings, histopathologic diagnoses, extent of tooth extraction, immediate postoperative medical treatments, EMM, and time from initial treatment to the last reexamination were also collected. For the purpose of this study, EMM was defined as warranted treatment with analgesic, antimicrobial, or anti-inflammatory medications beyond the 14-day immediate postoperative period because of ongoing clinical signs consistent with unresolved stomatitis. Treatment with analgesic, antimicrobial, or anti-inflammatory medications following PME or FME in the 14-day immediate postoperative period was not considered EMM.

Duration of clinical signs of stomatitis was categorized as < 366 days, 366 to 730 days, and > 730 days, and time elapsed from the date of initial treatment to the last reexamination was defined as < 366 days, 366 to 730 days, and > 730 days. Effectiveness of treatment was evaluated on the basis of history and physical examination findings and any subsequent medical treatment. Documented clinical signs and examination findings at reexaminations were compared with those at the initial treatment. For each cat, a numeric EOT score was assigned on the basis of outcome category following tooth extraction (PME or FME) and any required EMM. Categorization was modeled after that used in prior studies11,27 to allow further comparison: 0, unchanged or worsening clinical signs and examination findings following FME or PME with EMM continuing at final recheck examination; 1, little improvement, with some ongoing clinical signs and examination findings following FME or PME with EMM continuing at final recheck examination; 2, substantial improvement (2a, resolution of clinical signs and some ongoing but improved clinical examination findings following FME or PME; 2b, EMM for some finite period, discontinued prior to final recheck examination in addition to substantial improvement); and 3, resolution (3a, complete resolution of previously reported clinical signs and clinical examination findings following FME or PME; 3b, EMM for some finite period, discontinued prior to final recheck examination in addition to resolution). For statistical evaluation of surgical and medical treatments, patients receiving an EOT score of 2 or 3 were considered to have a positive response to treatment.

Statistical analysis—Descriptive statistics were calculated. Normally distributed variables were expressed as mean ± SD, and those not normally distributed were expressed as median (range). Categorical data were expressed as frequencies. A Fisher exact test was used to evaluate the association of EOT with FME or PME; preoperative treatment with analgesic, antimicrobial, or anti-inflammatory medications; categorical duration of clinical signs; and categorical time to recheck evaluation.

To determine the effects of multiple variables simultaneously on a positive response to treatment (EOT score 2 or 3), logistic regression analysis was used. Univariate analysis was performed initially, and variables with a value of P ≤ 0.20 were evaluated in a multivariable model. The addition of each variable to the model was evaluated for significance and confounding. A variable was retained in the model when the value of P was ≤ 0.05 or it was determined to be a confounder on the basis of changing model coefficients by > 15%. Two-way interactions among the main effects were also investigated. After estimation, the fit of the model was evaluated with the Hosmer-Lemeshow statistic, and a specification link test for single-equation modelsa was used to detect specification error. All analyses, including plotting of graphs to evaluate logistic regression model assumptions, were performed with the aid of statistical software.b

Results

The initial review of medical records identified 285 cats with stomatitis, of which 95 fulfilled the inclusion criteria. Most patients were excluded because of lack of follow-up. Median age at time of tooth extraction for the 95 cats was 72.7 months (range, 13.2 to 182.2 months). Other patient characteristics were summarized (Tables 1–4). Effectiveness-of-treatment scores were summarized (Table 5).

Table 1—

Signalment and environmental characteristics of 95 cats with stomatitis.

VariableNo. (%) of cats
Sex
 Sexually intact female2 (2.1)
 Spayed female47 (49.5)
 Sexually intact male3(3.2)
 Castrated male43 (45.3)
Breed
 American shorthair80 (84.2)
 Maine Coon5 (5.3)
 American longhair3 (3.2)
 Siamese or Siamese mix3(3.2)
 Persian or Persian mix2 (2.1)
 Russian Blue2 (2.1)
Environment
 Multiple cats in house75 (78.9)
 Related cats in the house with stomatitis9/75 (12.0)
Table 2—

Seropositivity to infectious diseases for 95 cats with stomatitis.

VariableNo. (%) of cats
Tested for FIV or FeLV73/95 (76.8)
 FIV positive3/73 (4.1)
 FeLV positiveNone
Tested for Bartonella spp16/95 (16.8)
 Bartonella spp positive6/16 (37.5)
Tested for feline calicivirusNone
Tested for feline herpesvirusNone
Table 3—

History, clinical, and laboratory findings of 95 cats with stomatitis.

VariableNo. (%) of cat
History
 Decreased appetite or anorexia63 (66.3)
 Signs of oral pain63 (66.3)
 Preference for wet food (vs kibble)49 (51.6)
 Weight loss30 (31.6)
 Ptyalism30 (31.6)
 Halitosis26 (27.4)
 Lethargy25 (26.3)
Clinical findings
 Enlarged mandibular lymph nodes84 (88.4)
 Signs of pain on oral examination49 (51.6)
 Ptyalism or thickened saliva27 (28.4)
 Unkempt coat24 (25.3)
 Signs of upper respiratory tract infection24 (25.3)
 Halitosis18 (18.9)
 Oral bleeding11 (11.6)
Laboratory findings
 Hyperglobulinemia60 (63.2)
Table 4—

Oral findings in 95 anesthetized cats with stomatitis and histopathologic findings in 26 of the cats that underwent stomatitic lesion biopsy.

VariableNo. (%) of cats
Clinical and radiographic oral examination findings
 Gingivitis and periodontitis92 (96.8)
 Retained root remnants60 (63.2)
 Proliferative stomatitic lesions49 (51.6)
 Pharyngeal swelling18 (18.9)
 Sublingual swelling10 (10.5)
Distribution of stomatitic lesions
 Caudal portion of the oral cavity95 (100.0)
 Alveolar and buccal mucosa92 (96.8)
 Soft palate23 (24.2)
 Dorsal aspect of tongue19 (20.0)
 Sublingual mucosa15 (15.8)
 Labial mucosa10 (10.5)
 Hard palate5 (5.3)
Histopathologic characterization of stomatitic lesions
 Plasmacytic and lymphocytic inflammation26 (100.0)
Table 5—

Effectiveness of surgical and medical treatment for 95 cats with stomatitis.

EOT scoreDescriptionTreatmentNo. (%) of cats
0No improvement or worseningFME or PME and EMM continued at final recheck examination6 (6.3)
1Little improvementFME or PME and EMM continued at final recheck examination25(26.3)
2Substantial improvement (free of clinical signs)  
2a FME or PME10 (10.5)
2b FME or PME and EMM discontinued prior to final recheck examination27 (28.4)
3Complete resolution (clinical cure)  
3a FME or PME10 (10.5)
3b FME or PME and EMM discontinued prior to final recheck examination17 (17.9)

Of the cats that received an EOT score of 2 (substantial improvement) or 3 (complete resolution), most required EMM (EOT score, 2b or 3b) because of ongoing clinical signs consistent with unresolved stomatitis. None of these patients were still receiving medical treatment at the time of the last recheck examination. Of the 27 cats with complete resolution, 17 required EMM (8 received antimicrobials, 5 received anti-inflammatory drugs, 1 received analgesics, 2 received both antimicrobials and anti-inflammatory drugs, and 1 received both antimicrobials and analgesics). Of the 37 cats that had substantial improvement, 27 required EMM (9 received antimicrobials, 7 received anti-inflammatory drugs, 3 received analgesics, 5 received both antimicrobials and anti-inflammatory drugs, 1 received both anti-inflammatory drugs and analgesics, and 2 received all 3 medications).

Regarding the extent of tooth extraction, 35 (36.8%) cats were treated with PME, and 60 (63.2%) cats were treated with FME. No significant (P = 0.377) difference was found in overall EOT categories between patients treated with PME or FME.

Medical management of stomatitis prior to initial evaluation included antimicrobial, anti-inflammatory, and analgesic medications. Sixty-seven of 95 (70.5%) cats were administered antimicrobial treatment. Twenty-three of the 67 (34.3%) cats had been treated with multiple antimicrobials, and 18 (26.9%) were currently receiving antimicrobial medication at the time of initial evaluation. Treatment with antimicrobials prior to or at the time of PME or FME was not associated with the overall EOT scores of 2 (P = 0.206) or 3 (P = 0.175). Thirteen antimicrobials were prescribed and most commonly included clindamycin (37/67 [55.2%] cats), amoxicillin-clavulanic acid (17/67 [25.4%]), and cefovecin (11/67 [16.4%]). No individual antimicrobial had better effectiveness that could be considered clinically relevant. Fifty-five of 95 (58.0%) cats were treated with anti-inflammatory medications prior to initial evaluation. Twelve of the 55 (21.8%) cats had been treated with multiple anti-inflammatory drugs, and 28 (50.9%) cats were currently receiving anti-inflammatory medication at the time of initial evaluation. Treatment with anti-inflammatory medications prior to or at the time of PME or FME was not associated with overall EOT scores of 2 (P = 1.0) or 3 (P = 0.105). Five anti-inflammatory medications were prescribed, and most commonly included prednisone (23/55 [41.8%] cats), methylprednisolone acetate (20/55 [36.4%]), prednisolone (13/55 [23.6%]), meloxicam (7/55 [12.7%]), and cyclosporine (2/55 [3.6%]). No individual anti-inflammatory had better effectiveness that could be considered clinically relevant. Twenty-one of 95 (22.1%) cats were treated with analgesic medications prior to initial evaluation. Of this subset, no cats (0%) had been treated with multiple analgesics, and 6 of 21 (28.6%) were currently receiving analgesic medication at the time of initial evaluation. Treatment with analgesic medications prior to or at the time of PME or FME was not associated with overall EOT scores of 2 (P = 1) or 3 (P = 0.218). Three analgesic medications were prescribed and most commonly included buprenorphine hydrochloride (18/21 [85.7%] cats), tramadol hydrochloride (1/21 [4.8%]), and butorphanol tartrate (1/21 [4.8%]). No individual analgesic had better effectiveness that could be considered clinically relevant.

Ninety-three cats had a documented duration of clinical signs prior to PME or FME. The median duration of signs prior to tooth extraction was 249 days (range, 7 to 1,772 days). Fifty-six of 93 (60.2%) cats had signs for < 366 days, 24 (25.8%) had signs for 366 to 730 days, and 13 (14.0%) had signs for > 730 days. No significant association was found between the overall EOT scores and the time elapsed categories (time from the date of initial treatment to the last reexamination) of < 366 days (P = 0.786), 366 to 730 days (P = 0.493), and > 730 days (P = 0.332).

Eighty-three of 95 (87.4%) cats underwent postoperative healing recheck examination in addition to their final recheck examination. Median time from the date of PME or FME to the postoperative healing recheck examination was 16 days (range, 4 to 91 days). All cats underwent final recheck examination. Median time from the date of PME or FME to the final recheck examination was 231 days (range, 33 to 2,655 days). The time elapsed was < 366 days for 58 (61.1%) cats, 366 to 730 days for 22 (23.2%), and > 730 days for 15 (15.8%). No significant difference was found in overall EOT scores for the time elapsed categories of < 366 days (P = 0.142), 366 to 730 days (P = 0.575), and > 730 days (P = 0.339).

For logistic regression analysis, 16 variables were identified on univariate analysis (P < 0.20) for evaluation in the multivariable model: signalment including body weight and multicat household status; signs of lethargy; physical examination findings of oral bleeding, upper respiratory tract infection, and presence of swelling in the caudal portion of the oral cavity; preoperative treatment with prednisone, antimicrobials in general, and metronidazole in particular; postoperative treatment beyond the initial 14-day postoperative period with anti-inflammatory or antimicrobial medications; surgical treatment with FME; EOT score at the initial postoperative recheck examination; resolution of abnormal behavior at the time of the first recheck examination; substantial improvement in the distribution of stomatitic lesions at the time of the first recheck examination; and resolution of appetite signs at the time of the first recheck examination. Three variables were significant (P ≤ 0.05) in the final model: resolution of abnormal behavior at the time of the first recheck examination, substantial improvement in the distribution of stomatitic lesions at the time of the first recheck examination, and no administration of antimicrobials beyond the initial 14-day postoperative period. Controlling for no postoperative antimicrobial use and substantial improvement in distribution of stomatitic lesions at the time of the first recheck examination, cats with resolution of abnormal behavior at the time of the first recheck examination had odds of a positive outcome (EOT score, 2 or 3) 7.2 times as great as in cats without resolution (95% CI, 1.41 to 36.29; P = 0.018). Controlling for no postoperative antimicrobial use and resolution of abnormal behavior at the time of the first recheck examination, cats with substantial improvement in the distribution of their stomatitic lesions at the time of the first recheck examination had odds of a positive outcome (EOT score, 2 or 3) 3.5 times as great as in cats without substantial improvement in the distribution of their stomatitic lesions (95% CI, 1.10 to 11.40; P = 0.033). Controlling for resolution of abnormal behavior and substantial improvement in distribution of stomatitic lesions at the time of the first recheck examination, cats that were not given postoperative antimicrobials had odds of a positive outcome (EOT score, 2 or 3) 3.7 times as great as in cats requiring antimicrobials after surgery (95% CI, 1.26 to 11.30; P = 0.018).

Discussion

In the present study of 95 cats treated for stomatitis, results indicated that overall response to treatment resulted in substantial improvement (EOT score, 2) or complete resolution (EOT score, 3) in 64 (67.4%) cats, of which 44 (68.8%) required EMM (medical management with antimicrobial, anti-inflammatory, or analgesic medications for a finite period after the immediate postoperative period). Additionally, of the 95 cats, 25 (26.3%) still required and were receiving antimicrobial, anti-inflammatory, or analgesic medications at the time of the final recheck examination because of ongoing clinical signs of stomatitis (EOT score, 1), and 6 (6.3%) cats had conditions considered refractory with no improvement or worsening of clinical signs and signs following tooth extraction and medical treatment (EOT score, 0). The extent of tooth extraction (PME vs FME) did not significantly correlate with the overall response to treatment.

Two previous studies11,27 have examined outcomes following tooth extraction in cats with stomatitis, and their results were consistent with each other. In 1 study,27 there was complete resolution in 60% of cats with stomatitis and substantial improvement with no additional required treatment in 20% of cats beyond the immediate postoperative period. Additionally, 13.3% of cats had little improvement and required ongoing medical management, and 6.7% had no improvement. In the other study,11 57.1% of cats recovered completely following tooth extraction, 23.8% improved, and 19.1% had relapses. No specifics were given regarding the subsequent medical management of the latter 2 groups. These earlier findings are consistent with the general findings in the present study, although more cats in the present study required ongoing medical management following tooth extraction than previously reported. When factoring in that more than two-thirds of cats with complete resolution of stomatitis in the present study required both tooth extraction and EMM for a finite period to have substantial improvement or complete resolution, overall response to tooth extraction alone was lower in the present study (21.0%) than previously reported (80%).27 When comparing response to treatment, the number of cats that had complete resolution of stomatitis (EOT, 3) was significantly (Fisher exact test; P = 0.002) lower in the present study than the prior studies.11,27 Possible reasons for this difference could include a larger, more representative sample population in the present study, variation in the manifestation of stomatitis in the study populations, differences in degree of removal of reactive alveolar bone (which has been hypothesized to potentially impact overall EOT),30 incongruity among investigators in defining what constitutes complete resolution of stomatitic lesions, or a difference in the propensity to intervene with medical management following tooth extraction by the different investigators in their respective study populations. The proportion of cats in the present study that were substantially improved (37/95 [39.0%] vs 20.0%; P = 0.077) or had little improvement (25/95 [26.3%] vs 13.0%; P = 0.214) was higher than previously reported,27 but these differences were not significant (Fisher exact test). No significant (Fisher exact test) difference was found in the proportion of patients with refractory disease in the present study (6/95 [6.3%]) versus the prior study27 (6.7%).

No previous study has examined extent of tooth extraction in relation to overall response to treatment. When combining the populations of cats evaluated in 2 prior studies,11,27 60 of 62 (96.8%) cats were treated with PME; therefore, these studies were unable to compare the outcomes of PME versus FME because of the low number of cats treated with FME. In the present study, no significant (Fisher exact test; P = 0.377) difference was found between cats treated with PME versus FME in terms of overall response to treatment. Reasons for this lack of a significant difference may be related to plaque being a less important etiologic factor in initial development of disease than previously thought1 or that it plays less of a role once chronic disease is established. In the present study; cats treated with PME had less generalized oral inflammation, compared with those treated with FME. These cats potentially represent a subset of the susceptible population whereby the inflammation only advances to a certain extent but causes the same signs, is a less advanced form of stomatitis (treated earlier in the disease process), or is a different disease (with possible different etiologic factors) that causes less oral inflammation. In all these latter potential theories, varying degrees of inflammation would still appear to respond similarly to tooth extraction, as neither group (PME vs FME) had a significantly different overall response to treatment from the other. Age at time of tooth extraction and patient characteristics were consistent with prior studies.1,4,8–11,13,17–19,21,27,31,32

Antimicrobial or anti-inflammatory medical management prior to tooth extraction may be useful in temporarily alleviating clinical signs associated with stomatitis in cats, but these medications have been shown to be ineffective in providing long-term resolution of oral lesions.16 The results of the present study indicated that cats receiving such treatments prior to tooth extraction were not overrepresented in groups that had complete resolution or were substantially improved following surgery.

Prior studies8,10,11,16,33 have evaluated various treatment options. Although medical management as the primary treatment for cats with stomatitis has shown some positive results, these have not been repeatable, and response to individual treatments generally has been poor or difficult to interpret. Factoring in more favorable responses shown for tooth extraction,11,27 the current standard of care in treatment of cats with stomatitis is PME or FME with confirmed removal of all remaining tooth material.1,24 Retained roots or root remnants have been shown to be more prevalent in cats with stomatitis34 and may have affected the response rates in the earliest studies looking at the response to tooth extraction.26 A recent study31 further supports a surgical approach to treating stomatitis by demonstrating that cats with stomatitis have significantly more extensive and severe periodontitis, external inflammatory root resorption and retained roots, or root remnants evident radiographically than cats with oral disease unrelated to stomatitis. All these pathological changes would warrant extraction of affected teeth and would otherwise persist as an underlying source of oral inflammation and discomfort if untreated, despite any transient improvement seen with medical management.

Considering that stomatitis in cats is a disease of chronic inflammation, questions arise as to whether treatment earlier in the course of the disease favorably impacts response to treatment. One source11 advocated for earlier intervention, with the belief that it may result in better success, but no prior study has evaluated duration of signs and the subsequent response to surgical or medical treatment. In the present study, patients were categorized into groups with a duration of signs < 366 days, 366 to 730 days, or > 730 days. No significant difference was found between groups in terms of overall EOT as related to duration of signs.

Similarly, questions remain regarding the impact of time elapsed following treatment on the long-term overall response. Clinically, we have appreciated that most cats continue to have some inflammatory response to the plaque-retentive qualities of the suture material in the weeks following tooth extraction. No prior study has evaluated whether positive response to treatment correlates with increased time between initial tooth extraction and the final recheck examination. In the present study, patients were categorized into groups on the basis of time elapsed: < 366 days, 366 to 730 days, or > 730 days. No significant difference was found between groups in terms of overall EOT as related to time elapsed. Considering that these time points were chosen arbitrarily, future studies evaluating the data collected may be warranted to determine whether differences exist between shorter periods of elapsed time.

For logistic regression analysis, 16 variables were analyzed in the present study. Three variables remained significant and are worth considering regarding their impact on the overall response to treatment. These included resolution of a cat's abnormal behavior or substantial improvement in the distribution of the stomatitic lesions at the time of the first recheck examination as well as no perceived need for postextraction antimicrobial use. Abnormal behaviors were those described by owners during anamnesis not directly related to food and eating and included unfriendly disposition, perceived signs of pain, vocalization, hiding, lethargy, halitosis, decreased grooming, bruxism, or oral discharge. Abnormal behaviors in feline patients are considered to have a potential underlying medical etiology; therefore, improvement in these noted behaviors could be related to improvement in the degree of oral inflammation and associated oral discomfort associated with stomatitis. Improvement in abnormal behavior or severity of oral inflammation earlier in the postoperative period could signify that cats with an earlier positive response to tooth extraction might represent a subset that will have a better overall long-term response. It follows that cats with a positive response sooner are less likely to be perceived by the attending veterinarian as warranting additional medical management. All 3 variables potentially illustrated that cats responding earlier in the postoperative period were more likely to have a more positive long-term response to tooth extraction.

Several limitations in this study should be considered. As with any retrospective study, inherent issues are present throughout, including how individual veterinarians determined which types of diagnostic testing and what extent of surgical or medical treatment would be performed on individual patients as well as documentation and interpretation of historical information. Given that this study spanned a 14-year period and only included patients treated at 1 institution, there were likely periods when specific diagnostic tests or treatments were favored or discouraged. A subsequent institutional bias could be present, resulting in cats treated or not treated with certain medical or surgical treatments, and this could have affected results of the data collected. Examples include that none of the patients had been tested for feline calicivirus or feline herpesvirus, diagnostic tests that are not widely performed at our hospital. No direct correlation has been shown to link either virus with the etiology of stomatitis in cats. A potential relationship has been shown by others,4,9,13,17,21,23,32 and a possible relationship between viral status and outcome could have been missed. Similarly, cyclosporine and interferon-ω, both of which have been shown to have potentially positive impacts on cats with stomatitis,2,35,36 were not widely used in the study population, so their impact on stomatitis and what, if any, role they play as a treatment option are not discernible in the present study. All medical records were reviewed and all data collected by 1 individual (MWJ) to limit inconsistencies, but interpretation bias is a potential concern with a single reviewer of records.

Results of the present study may help better characterize treatment approaches to stomatitis in cats. The findings emphasized the importance of tooth extraction as a logical approach for definitive treatment. They also showed that most patients will require EMM following tooth extraction to achieve substantial improvement or complete resolution of this chronic inflammatory disease. This point underlies the importance of emphasizing the chronic nature of stomatitis in cats when veterinarians speak to owners about treatment options to ensure owners understand the potential need for additional medical management following tooth extraction. Albeit important in helping control oral pain associated with stomatitis, medical management prior to tooth extraction did not appear to impact the overall response to tooth extraction and is likely to only temporarily alleviate some of the discomfort associated with stomatitis in cats. The extent of tooth extraction (PME vs FME) did not correlate with overall response to treatment, and an approach of extracting teeth only in areas where inflammatory lesions are present was supported by the results of this study. Patients with a positive response to tooth extraction at the time of the first postoperative recheck examination may have a higher likelihood of achieving a long-term clinical cure. Future prospective studies are warranted to fully investigate the differences between medical and surgical management strategies of stomatitis in cats.

ABBREVIATIONS

CI

Confidence interval

EMM

Extended medical management

EOT

Effectiveness of treatment

FME

Full-mouth tooth extraction

PME

Partial-mouth tooth extraction

a.

linktest, Stata, version 11, StataCorp, College Station, Tex.

b.

Stata, version 11, StataCorp, College Station, Tex.

References

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