FEATURES • PEER REVIEWED

IDENTIFY AND ACT

Early detection of gingivostomatitis in
cats can aid the veterinary team in starting
therapy and working toward remission.

PRESSLAB/shutterstock.com

Abstract
Feline chronic gingivostomatitis (FCGS) affects around 0.7% to 12% of the feline population and is a source of
frustration for the affected pet, pet owner, and veterinary team. The exact etiology of the disease continues to evade
the veterinary community, making it difficult to explain to pet owners. Past and present studies are making progress
toward identifying a link to the exact causality of this disease and have opened the door to multiple therapeutic
modalities. Although surgical intervention in conjunction with medical management is still the gold standard, other
options are now available to veterinary professionals. New modalities are discussed alongside current research
detailing the long history of FCGS in cats today.

64 • WINTER 2023 • todaysveterinarynurse.com

 PEER REVIEWED • FEATURES

DENTISTRY

Feline Chronic
Gingivostomatitis:
An Update
Sheena Davis, LVT, VTS (Dentistry), Veterinary Cannabis Counselor
Big Apple LVT Consulting & Education, New York City, New York

F
eline chronic gingivostomatitis (FCGS) is a
debilitating inflammatory disease affecting
the oral cavity of cats. This disease is
marked by severe to chronic inflammation of the
gingiva, mucosa, and surrounding tissues that line
the oral cavity.1 Chronic gingivostomatitis affects
approximately 0.7% to 12% of the general cat
population.2-4
There is a great deal of frustration regarding the
diagnosis and treatment of this oral inflammatory
disease. The frustration is due in part to the high
frequency of inflammatory diseases in the oral
cavity of cats and veterinary professionals’ limited
understanding of their etiology.5
Many studies are dedicated to the discovery of the
true etiology of FCGS. Unfortunately, the exact
cause of FCGS is currently unknown, but
thankfully a decade’s worth of investigation has
advanced the knowledge and treatment of this
debilitating disease.
ETIOLOGY
This complex multifactorial condition does not
have a simple etiologic agent. Several studies have
found that FCGS is caused by an exaggerated
immunologic response to antigenic stimulation.6
The causes of this stimulation can be exaggerated
by viral diseases such as feline leukemia virus
(FeLV) infection, feline immunodeficiency virus
(FIV) infection, calicivirus infection, feline

Take-Home Points

z The etiology of feline chronic z Environmental stressors z Regenerative therapy (currently in

gingivostomatitis (FCGS)
is unknown and most likely
multifactorial.
z FCGS can affect any breed of cat,
regardless of age or sex.
z FCGS is an exaggerated immune
response to antigenic stimulation.
(especially in multicat households)
can play a role in FCGS.
z Current treatment options involve
partial- to full-mouth extractions,
with or without medical
management.
z Medical management alone is not
acceptable.
development) shows promise for
management of FCGS.
z Nutritional support (via a feeding
tube) may be indicated in severe
cases.

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 FEATURES • PEER REVIEWED
infectious peritonitis, herpesvirus infection, and
panleukopenia virus infection as well as bacterial
organisms such as Bartonella henselae.6
The systemic and local consequences of FCGS are
suggested by the presence of lymphocytes and plasma
cells in affected oral tissues, with fewer neutrophils,
Mott cells, and mast cells.7,8 In humans, a known ratio
of low CD4+ to CD8+ T cells is a marker for immune
dysfunction and chronic inflammation. Through this,
we can infer a similar pathologic reaction in cats with
FCGS that have an increased CD8+ (cytotoxic) T cell
count compared with CD4+ (helper) T cell count.
These cells have been detected locally as well as
systemically, supporting the theory of an inflammatory
response, likely a cell-mediated immune response, to
antigenic stimulation probably caused by pathogens
such as viruses.9-11 Recent studies focused on the
shedding of calicivirus as an active virus in clinical cases
of FCGS and found no association of viral shedding
with FeLV, FIV, herpesvirus, and Bartonella.12
A 2021 study examined the oral microbiome of cats to
determine whether an imbalance of the oral flora
played a potential role in FCGS. In this small pilot
study, 14 clinically healthy cats and 14 cats affected by
FCGS were tested.13 A sterile swab was used to obtain a
sample and tested using next-generation DNA
sequencing. A high number of fungal species, such as
Malassezia restricta, Malassezia arunalokei, Cladosporium
penidielloides, Cladosporium salinae, and Aspergillus
species, were found and detected in the FCGS group;
the fungi Saccharomyces cerevisiae was found solely in
the clinically healthy cat group.
This pilot study was able to identify the distinct
differences between the oral microbiome of cats that
were clinically healthy versus those affected by FCGS,
with a potential biomarker identified as Bergeyella
zoohelcum.13 Additional studies are needed to improve
the understanding of the oral microbiome of cats, but
this study supports the idea of a potential imbalance
between the flora of the oral cavity of cats and its
potential role in FCGS.
Additional studies point to a potential link to
nutritional disorders and a breed predilection.14 A pilot
study examined the oral microbiome of cats and the
changes of the microbiome based on provided diets.15
The cats in this pilot study were divided into 2 groups;
1 was offered a dry diet and the other a wet-food diet.
This study discovered that diet indeed had a significant
66 • WINTER 2023 • todaysveterinarynurse.com
influence on the overall diversity and abundance of
specific bacteria in the oral microbiome of cats. The
cats fed an exclusively dry diet had higher bacterial
diversity than the cats fed a wet-food diet. While
differences between the oral microbiome of the cats fed
these exclusive diets were noted, the relationship
between these differences and gingival health remains
unclear. Further studies are needed to determine the
full extent of the “diet factor” and FCGS.
As for breed predilection, unfortunately this disease can
affect any breed, regardless of age or sex.16 Until 2007,
it was believed that breeds such as Abyssinian, Burmese,
Himalayan, Persian, and Siamese were mostly
affected.16 In a survey of almost 5000 cats in
12 practices over a 12-week period, 34 cases of FCGS
were noted, with no breed bias identified.2
A 2019 study noted a possible link between
environmental stressors and FCGS, revealing a higher
incidence in multicat households versus single-cat
households; every additional household cat increased
the odds of FCGS by more than 70%.17 Cats within
this study were indoor-only; therefore, evidence was
missing regarding indoor–outdoor cats within a
multicat home. Further studies focusing on the
interaction between cats in a multicat household, with
access to the outdoors and possible circulation
(reinfection) of infectious agents between housemates,
must be conducted.
CLINICAL SIGNS
“Feline chronic gingivostomatitis” is an umbrella term
used to describe the chronic stomatitis and gingivitis
syndrome of cats. This disease can be further classified
into types 1 and 218:
● Type 1 FCGS has a better prognosis and is classified
by its clinical characteristic alveolar, labial/buccal
mucositis/stomatitis.
● Type 2 FCGS is classified by its characteristic
location along the caudal aspect of the oral cavity,
with or without alveolar and labial/buccal mucositis/
stomatitis.
Cats affected by FCGS can show various clinical signs,
but the most common are halitosis, dysphagia
(difficulty swallowing), pawing at the mouth,
reluctance to eat, anorexia, weight loss, growling/
crying, drooling, blood-tinged saliva, change in
temperament, enlarged lymph nodes, and a lack of
grooming.19,20
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It is important to note the difference between gingivitis

and FCGS in cats affected by this disease. Gingivitis is
inflammation of the gingiva and does not extend
beyond the mucogingival line, whereas true stomatitis
will extend into the alveolar, labial/buccal, lingual, and
caudal aspects of the mouth as well as the palatoglossal
folds.12 Caudal stomatitis is present in 85% of cats
affected by FCGS.18
SIGNALMENT
The average age of cats that are presented with FCGS is
approximately 7 years.18 A juvenile form of this disease
known as feline juvenile gingivitis/periodontitis
typically presents in cats after the eruption of the adult
teeth, from 3 to 6 months of age. As the patient
matures and eruption is complete, this form of
stomatitis typically resolves around 2 years of age.19,20
DIAGNOSTIC WORKUP
To determine if a feline patient has FCGS, the
veterinary team must obtain a thorough history
(including nutritional history), perform a physical
exam, and perform diagnostic testing. Any patient that
has suspected FCGS should have a complete blood
count, serum biochemical profile, bleeding time test,
serology (FIV/FeLV), T4 (thyroxine) test, and urinalysis
test performed.
The purpose of these tests is to rule out underlying
conditions that can affect anesthesia rather than
diagnosing the disease. Testing for calicivirus and
Bartonella is not recommended because results do not
change the therapy.18 Although some cats with FCGS
are positive for Bartonella species, a cause-and-effect
relationship has not yet been established, as there is a
high rate of antibody-positive cats within a healthy
population due to flea exposure.18
Gingivitis is inflammation of the
gingiva and does not extend
beyond the mucogingival line,
whereas true stomatitis will
extend into the alveolar, labial/
buccal, lingual, and caudal
aspects of the mouth as well as
the palatoglossal folds.12
the extent of any dental disease, such as periodontal
disease, tooth resorption, retained roots, and missing
teeth—conditions that are often present in conjunction
with FCGS (FIGURE 2).18 These radiographs will also
assist the veterinarian with extractions and treatment of
FCGS (FIGURE 3).
Histopathology
Because of the proliferative and ulcerative presentation
of FCGS, collecting a biopsy specimen of the mucosa
and submucosa is advisable and will help the
veterinarian diagnose FCGS. Similar oral lesions, such
as eosinophilic granulomas, indolent ulcers, and
squamous cell carcinoma, can grossly present as
FCGS.21 The histopathologic results concurrent with
FCGS reveal plasma cells and a diverse number of

In a study of 60 cats with FCGS, 7% were positive for

FeLV and 8% were positive for FIV.18 Often,
hyperglobulinemia and increased total protein are
noted on serum biochemical results in patients with
FCGS.12,16 Conversely, neutrophilia is not a
hematologic finding in cats with FCGS.12

Radiographs
Intraoral radiographs are always warranted and should
be obtained on any patient undergoing a dentistry
FIGURE 1. Oral radiology during a dental examination.
procedure (FIGURE 1). The radiographs help determine

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Studies have shown that partial-
mouth (all premolar and
molar teeth) or full-mouth
extraction provides the best
long-term results. 22-24
lymphocytes, mast cells, Mott cells, macrophages, and
neutrophils.18 Often, neoplasia can be seen concurrently
with FCGS and should always be ruled out.
MEDICAL MANAGEMENT VERSUS
SURGICAL INTERVENTION
There are 2 main approaches to treating FCGS:
medical management and surgical intervention.
Although medical management is an option, it often
yields limited and unfavorable outcomes, making
surgical intervention the preferred treatment of choice.
Depending on the severity of the disease, the option for
partial-mouth extractions over full-mouth extractions is
warranted on a case-by-case basis.
Studies have shown that partial-mouth (all premolar
and molar teeth) or full-mouth extraction provides the
best long-term results.22-24 Approximately 70% to 80%
FIGURE 2. Gross presentation of dental disease with
moderate localized gingivitis surrounding 407.
68 • WINTER 2023 • todaysveterinarynurse.com
of cats will show substantial improvement or resolution
of FCGS, with minimal or no improvement in
approximately 20% to 30% of cats.18,22-24 Although
surgical intervention yields the best therapeutic results,
it is still important to provide medical management
alongside surgical treatment.
For patients that have mild to moderate anorexia due to
FCGS, the placement of a pharyngostomy or
gastrostomy tube is indicated to provide nutritional
support, both before and after surgical intervention, or
until the patient can eat on its own.18
Antibiotics
Antibiotics are recommended only when used in
conjunction with surgery. An antibiotic will decrease
the bacterial load and help the gingiva heal to some
extent, so that at the time of surgery the veterinarian
has less friable tissue to work with. The antibiotic of
choice for the oral cavity is one that will target both the
gram-positive and gram-negative organisms in the
mouth.
The antibiotics that are approved by the U.S. Food and
Drug Administration (FDA) for use in FCGS are
clindamycin and amoxicillin/clavulanate potassium.18
Although not approved by the FDA for use in feline
dental disease or infections, metronidazole is another
antibiotic of choice.18 Use of antibiotics alone for
treatment/management of FCGS is not recommended
and will only increase the likelihood of bacterial
resistance.
FIGURE 3. Radiograph of 407, showing the presence of
tooth resorption with moderate periodontal disease (as
noted by the >50% bone loss).

Anti-inflammatory Medication
Although not considered for long-term therapy and
treatment, a corticosteroid injection will provide some
clinical relief but can decrease a patient’s ability to resist
the inflammatory process while increasing the chance
for diabetes mellitus.18
Prednisolone is often the short-acting steroid of choice
to control inflammation and provide relief for patients
affected by FCGS. Prednisolone is often used on an
as-needed basis for symptomatic treatment on a
tapering dose in patients with refractory FCGS.12,25
NSAIDs (nonsteroidal anti-inflammatory drugs) such
as meloxicam and robenacoxib are often used for
postoperative care, although use in patients with
contraindications such as hepatic or renal disease
should be avoided. Meloxicam is a great short-term
NSAID; however, repeated doses of meloxicam over
time has been associated with acute renal failure in cats.
Close monitoring and avoidance of long-term use are
advised.12,18
Cyclosporine
Cyclosporine is an immunosuppressive drug that exerts
its effect through inhibition of T-cell activation,
reducing interleukin-2 expression, and increasing T-cell
numbers within the body.26,27 Cyclosporine may have
an inhibitory effect on B cells as well.28
This medication is most often used to decrease
inflammation in refractory (nonresolving) cases of
FCGS after full-mouth extraction. Due to its
immunosuppressive effects, it should be used solely on
indoor cats because cats that venture outside will be at
a higher risk of infection. The positive effects of
cyclosporine can be noted within 4 weeks of treatment.18
Vomiting and diarrhea are the most common side
effects seen with patients taking this medication.
Interferon
A group of signaling proteins that can interfere with
viral replication is known as interferons. Recombinant
feline interferon omega (rFeIFN-ω) was the first
interferon licensed for use in cats in veterinary
medicine.29
rFeIFN-ω is available in the United States solely
through the FDA Expanded Access/Compassionate Use
Program.12 This medication is imported on a strict
PEER REVIEWED • FEATURES
individual basis.12 It is used to treat retroviral
infections, with studies reporting that interferon
delivered via oral mucosal absorption was as effective as
prednisolone in decreasing clinical signs in refractory
cases of FCGS.12,25
Bovine Lactoferrin Therapy
Lactoferrin is an antimicrobial and anti-inflammatory
that helps to decrease the proliferation of mononuclear
cells and downregulating inflammation.18 In a study of
13 cats with caudal FCGS, 77% of the clinical signs
were improved with treatment.30 The protocol used was
a combination of piroxicam and bovine lactoferrin
spray given once every other day for 4 weeks.
Mesenchymal Stem Cell Therapy
Mesenchymal stem cells (MSCs) are a promising
therapy for immune-mediated/inflammatory disorders,
due to their potent immunomodulatory properties.11
MSCs inhibit activated T-lymphocyte proliferation.18
In a study of 9 cats affected by refractory FCGS,
patients were given 2 intravenous injections of
20 million autologous adipose-derived MSCs every
other month. Seven of the 9 cats completed the study,
with 5 cats achieving substantial or complete remission
and 2 cats with no clinical response to the treatment.11
A follow-up study testing the effects of autologous or
allogenic cell fusion given twice a month every other
month resulted in the cure/remission in more than
60% of the cats affected by refractory FCGS.10
As promising as these results are, more testing is
needed. Reasearchers at the University of California,
Davis, are conducting ongoing trials with MSCs and cats
affected by FCGS. The cost of MSC therapy typically
ranges from $2000 to $4000, with many pet insurance
companies not offering coverage for treatment.31
Carbon Dioxide Laser Therapy
The use of carbon dioxide (CO2) laser therapy for
FCGS has been met with favorable results when
combined with quality home care. The energy from the
laser decreases pain while enhancing healing through
protein synthesis, cell proliferation, and migration.
Some veterinarians opt to use CO2 laser therapy at the
time of initial surgical extraction; CO2 therapy may be
helpful in cases of refractory FCGS as well.18
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 FEATURES • PEER REVIEWED
Cannabinoids
A 2021 study explored the potential for cannabinoid
use in cats by investigating potential cannabinoid
receptors within the oral cavity of healthy cats and cats
with FCGS.32 This study focused on the potential
expression of cannabinoid receptors CB1 and CB2,
GPR55 (G-protein–coupled receptor 55), TRPA1
(transient receptor potential ankyrin 1), and 5-HT1A
(serotonin 1A) receptors. Samples were collected from
8 healthy feline patients and 8 feline patients with
FCGS. Compared to their healthy counterparts, the cats
affected by FCGS presented with markedly upregulated
cannabinoid and cannabinoid-related receptors.
Based on the results of this study, there is evidence to
support the endocannabinoid system as a potential
therapeutic target for patients affected by FCGS.32 This
study is the first of its kind, garnering the need for
further investigation and the application of a
cannabinoid-rich product to determine the efficacy of
this potential adjunct therapy for cats with FCGS.
Opioids
Many of the patients affected by FCGS are in moderate
to severe pain and are typically malnourished.
Managing pain pre-, intra-, and postoperatively is a
major component to providing quality care.
Using a pure opioid to treat moderate to severe pain in
these patients is a must. Opioids such as morphine,
methadone, hydromorphone, and fentanyl are great
options for these patients in the perioperative phase.
Constant rate infusions of an opiate are also warranted
during the intraoperative portion of the procedure.
Due to the nature of FCGS, it is understood that there
is a “wind-up effect” from the pain of having an
inflamed mouth for a long time. If not contraindicated,
the administration of a cyclohexylamine such as
ketamine (1 to 2 mg/kg IV) is recommended and can
be administered during induction or intraoperatively as
needed for pain. Ketamine will help reduce the effects
of windup, unblock receptors, and create a synergistic
analgesic effect.
Another major component to pain management is
providing intraoral nerve blocks for these patients
undergoing a comprehensive oral health and assessment
treatment plan. If not contraindicated,
dexmedetomidine can be added (1 µg/kg) to
bupivacaine (0.5% solution up to 5 mg) as a nerve
70 • WINTER 2023 • todaysveterinarynurse.com
block. This block will enhance the efficacy and
duration of the local anesthetic but may be associated
with dose-related adverse effects, such as hypertension
and bradycardia.33
Another intraoral nerve block combination is
buprenorphine (0.015 mg/kg) added to bupivacaine
(0.5% solution up to 5 mg).34 The addition of
buprenorphine to bupivacaine is known to potentially
extend the duration of analgesia up to 48 to 96 hours
after surgery.34
For the postoperative phase, oral buprenorphine is a
drug of choice to send home with a patient recovering
from FCGS. In a recent randomized crossover study
featuring cats with FCGS, the subjects of the study
were given buprenorphine via oral mucosal absorption,
the result being a significant effect on reduced pain
scores in affected cats and a decrease in plasma
concentration between individuals.35 The subcutaneous
sustained-release formulation of buprenorphine is
another choice for painful patients after oral surgery
and will provide 24-hour pain relief for up to 3 days.
SUMMARY
Although the exact etiology of FCGS remains a
mystery, we have a better understanding of this
condition today thanks to ongoing research and
studies. Educating our clients about this debilitating
disease is of the utmost importance. Early detection
and treatment can be the difference between a patient
suffering in silence and one that is able to undergo
therapy and achieve remission. Surgical management of
this disease in conjunction with medical management is
still considered the gold standard of care for these
patients. TVN
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