Stomatitis / Periodontal Disease
Definition and cause
Stomatitis represents an inflammatory condition of the oral cavity, and occurs in both dogs and cats. Mucosal inflammation in stomatitis can be generalized or focal involving any region of the mouth. This is a descriptive diagnosis. Successful therapy depends upon an accurate diagnosis, which means that diagnostic processes are usually necessary.
In this text we represent stomatitis and periodontal disease as the more chronic version of gingivitis, whereby the local tissue and the immune system and its response have progressed to the next phase of disease and continual vigilance and a combination of medical and alternative therapies may be required. In addition, because of the chronicity, other organs and systems may be in a similar state of inflammation and degeneration (see Gingivitis, above, for a more detailed description of the inflammatory process).
Medical therapy rationale, drug(s) of choice, and nutritional recommendations
Correction of underlying causes is essential for control. Treatment of periodontal disease (See gingivitis for medical rationale), removal of infected teeth, correction of nutritional deficiencies, and use of antibiotics to control infection and corticosteroids to reduce inflammation are all indicated.
Prognosis is related to the underlying cause, the compliance of treatment, and the animal’s immune status. In a chronic condition, there is often associated degeneration secondary to inflammation and or infection in other organ systems, which can affect the prognosis.
Integrative veterinary therapies
The oral cavity contains a wealth of autonomic nerve fibers and is integrated into the central control centers. Gastrointestinal, immune, neurological, endocrine, musculoskeletal, and vascular elements smoothly coordinate a large number of vital functions.
From a phylogenetic viewpoint this makes sense, as the jaw and tongue appear to originate with the development of bivalves. Neurological supply and coordination through the modern tongue and the bivalve’s muscular foot are similar in function. Numerous chemoreceptors exist in the mouth and transmit information to the brain, which in turn coordinates secretion of gastrointestinal organs of digestion, as well as hormonal events and blood supply.
The “DAMN IT” acronym is useful in approaching diagnosis of stomatitis (each letter stands for the following potential categories of disease causation: Degenerative, Anatomic, Metabolic, Nutritional, Neoplastic, Immune-mediated, Idiopathic, Infectious, Traumatic, and Toxic). A careful examination and history are necessary in all cases. Anatomic issues can predispose to development due to failure of the form to function properly. As an example, anatomic errors such as cleft palate, missing teeth, and malocclusion can lead to drying or damage of the mucosa and subsequent alteration of structure. Regional inflammations may reflect localized dental disease such as trauma (injury, electrical injury, foreign bodies, or envenomization), cervical dental lesions in cats, or periodontal disease in both cats and dogs.
Generalized patterns suggest systemic issues such as metabolic problems (diabetes, hypothyroidism, Cushing’s disease, hypoparathyroidism, hepatopathies, or renal disease), toxicities (chemotherapy, radiation therapy, caustic chemical exposure, metal poisoning, or phytotoxins), infectious immune disease (periodontal disease, bacterial infection, fungal infection, and viral infection), noninfectious immune disease (pemphigus vulgaris, systemic lupus, and other auto-aggressive conditions), nutritional diseases (poor nutrition or vitamin A toxicity), neoplasia (epulis, squamous cell carcinoma, melanoma, fibrosarcoma and osteosarcoma), and idiopathic issues (eosinophilic stomatitis, plasmocytic stomatitis, and vasculitis of other causes).
Laboratory evaluation is suggested in any case that fails to resolve or recurs. Testing for common etiologies can be helpful (FeLV, FIV, Bartonella, Leptospira, etc.).
The integrative approach to stomatitis and periodontal disease is to focus both locally and systemically. The use of therapeutic nutrition, medicinal herbs, and homotoxicology remedies either alone or in combination with medications such as antibiotics and cortisone may be required. The combination of therapies gives the clinician the opportunity to not only control local disease but also to prevent and control secondary disease and auto immune processes that were borne from the inflammatory process in the mouth.
General considerations / rationale
Therapeutic nutrition must be multifaceted and address the inflammatory process in the mouth along with immune system support. Note: Because stomatitis and periodontal disease often act as the nidus for the initiation of inflammation and disease in other organs, it is recommended that the clinician evaluate the blood both medically and physiologically to determine real and impending organ involvement and disease (see site, Nutritional Blood Testing, for additional information).
Nutrition / glandular: In addition to the nutritional remedies recommended in the gingivitis protocol (vitamin C, folk acid, betasitosterol, and coenzyme Q10), the following is recommended:
Colostrum: Colostrum has been shown to improve intestinal health and digestion and help balance intestinal flora. In addition, colostrum can improve the immune status of the intestinal tract, which can, via intestinal production of globulins, help the overall immune competency of the body. In addition, Giannobile (1994) showed that there is significant improvement in healing from surgery and improved osseous formation and periodontal regeneration in dogs supplemented with a combination product that contained colostrum.
Chinese herbal medicine / acupuncture
General considerations / rationale
According to traditional Chinese medicine, stomatitis is caused by Heat rising from the Stomach and Spleen, leading to Yin deficiency. This causes oral mucosal damage. The Stomach opens to the Mouth, in traditional Chinese medicine theory. When there is Heat, or inflammation in the Stomach, the Mouth, as the associated organ, may manifest the inflammation. This is revealed as red, swollen gingiva. Long-term inflammation damages the fluids (Yin), which upsets the balance between the Yin and Yang. The decrease in Yin makes the Yang seem excessive. More Yang means more Heat (inflammation). This, in Western terms, can be described as inflammatory mediators creating more inflammation, and worsening rather than resolving the condition. Thus, stomatitis tends to be chronic. Therapy is aimed at decreasing the inflammation and removing or controlling the cause of the inflammation.
Appropriate Chinese herbs
Alisma (Ze xie): Enhances immunity and decreases inflammation (Dai 1991).
Anemarrhena (Zhi mu): Increases the corticosterone level in serum and decreases inflammation.
Angelica (Dang gui): Has antiinflammatory action, yet does not cause immunosuppresion. In fact, it increases phagocytic activity of macrophages.
Cinnamon (Rou gui): Normalizes the immune system. It decreases production of nonspecific antibodies. At the same time it increases the reticuloendothelial system’s ability to phagocytize foreign material. It has been proven to have antiinflammatory effects on both acute and chronic inflammatory conditions.
Crataegus (Shan zha): Enhances immunity. It increases serum lysozyme levels, serum antibody levels, and T cell activity. It also has direct antibiotic activity on some bacteria.
Forsythia (Lian qiao): Reduces edema and inflammation by decreasing capillary permeability. It has demonstrated antiviral and antibacterial effects.
Honeysuckle (Jin yin hua): Has antibacterial activity, mainly due to chlorogenic acid and isochlorogenic acid. Anti-inflammatory effects have been demonstrated experimentally in rabbits and mice.
Isatis root (Ban Ian gen): Possesses antiviral activity. In some cases it is as effective as ribavirin. It also has antibacterial efficacy. In addition to direct effects on pathogens, isatis root also stimulates the immune system. It seems to affect both humoral and cellular immunity.
Licorice (Gan cao): Contains glycyrrhizin and glycyrrhetinic acid. These chemicals have approximately 10% of the steroid effects of cortisone. In addition, glycyrrhizin has shown activity against several viruses and therefore may be of use in viral-mediated stomatitis.
Ophiopogon (Mai dong): Has demonstrated the ability to inhibit several types of bacteria.
Oriental wormwood (Yin chen): Contains capillarin, which has antiinflammatory properties.
Phellodendron (Huang bai): Has antibacterial actions against a variety of bacteria.
Plantain seeds (Che qian zi): Decrease inflammation by decreasing capillary permeability.
Red peony (Chi shao): Stimulates cellular immunity by enhancing proliferation of T cells.
Rehmannia (Sheng di huang): Increases the plasma levels of adrenocortical hormone. This may increase the amount of cortisol in circulation, and corticosteroids are commonly used to treat stomatitis by Western practitioners. Rehmannia has been shown to reduce swelling and inflammation.
Scrophularia (Xuan shen): Inhibits many strains of bacteria.
Sophora root (Shan dou gen): Stimulates the humoral immune system, resulting in increased levels of IgM and IgG. It also has activity against several types of bacteria.
General considerations / rationale
Early presence of homotoxins leads to reaction by the mucosal elements in the form of Inflammation Phase disease. The mucosa recovers rapidly if these homotoxins are removed. This makes a massive case for early and aggressive home care, as well as competent professional prophylaxis. As homotoxins accumulate and are deposited the oral mucosal structure, function becomes altered. In Impregnation Phase homotoxicoses we see chronic and poorly responsive disease forms, which may not recover fully and frequently recur, frustrating client and veterinary professional alike. These conditions can progress into Degeneration Phase disease and resultant tooth loss. Degeneration Phase disorders include congenital malformation of the mouth and associated structures. Some homotoxins may lead to neoplastic changes in Dediffer-entiation Phase disease.
Because most cases represent advanced homotoxicoses, management of the chronic condition, rather than cure, is often a realistic treatment goal. Some cases resolve early and represent Excretion or Inflammation phase conditions, but most cases involving cats and elderly pets involve more significant disease. Consultation with an internist or veterinary dentist may prove helpful in cases that are poorly responsive. In addition to good quality dental and internal medicine practices, homotoxicology may assist these pets. Most need long-term detoxification and symptom support. A proper diet consisting of limited antigen diets can assist some cases, and this may be associated with true allergic responses as well as adverse reactions to food ingredients or additives. The author has seen several cases improve when a raw food diet of limited ingredients is fed. Clients opting for biological therapy should be informed that some cases will not respond, while other cases will begin to respond after therapy lasting more than a year, especially when they have been kept on the Deep Detoxification Formula for several months.
Pulsatilla compositum and Traumeel are used in regulation rigidity cases, and stomatitis frequently fits this description of a disorder that is unchanging or poorly responsive. These agents can sometimes shift cases toward healing. Engystol N seems helpful and makes one wonder about impregnated viral particles, which may trigger chronic inflammatory pathways as the immune system attempts eradication of viral elements from chronically infected tissues. Feline immunodeficiency virus, Feline leukemia virus, feline calicivirus, and Feline herpes virus may cause disease in this manner, but their individual roles are unclear. Because such viral elements are present in vaccine components, research is warranted into the involvement of vaccinations in this condition, and at least some cases may be adverse reaction to vaccinations. Most holistic doctors advise reduced use of vaccinations when faced with chronic, unresponsive conditions, a practice which is in agreement with most manufacturers’ written recommendation to avoid vaccinating unhealthy animals. This seems prudent considering what we currently understand about auto-aggressive pathogenesis.
So-called “Alternative Phase” disease can present as stomatitis. In these cases more severe disease lurks internally and signals its presence through inflammation near the body’s exterior. Many homotoxins can damage the GI system’s ability to perform its duties. Both toxins and other therapeutic agents can result in progressive vicariation. Corticoids and nonsteroidal antiinflammatory drugs both damage intestinal mucosal elements. This can result in frank ulcer or in “leaky gut syndrome,” which is linked to many other medical syndromes. In leaky gut, antigens are not properly digested into smaller molecular-weight polypeptides before gaining access to the immune system. This issue can lead to chronic inflammatory diseases such as inflammatory bowel disease and allergic syndromes, and, in this discussion, chronic stomatitis.
Successfully treating stomatitis involves providing a nonaggravating diet and clean water, while working at reducing stress, allowing homotoxins to be excreted successfully, supporting organ function, draining homotoxins, and providing metabolic support while repair occurs. Patients will be observed to cycle in and out of inflammatory states, and this is highly desirable. As in other discussions, the position of the patient on the phase table assists in determining proper therapy. In the first two phases, symptomatic treatment is often successful. As homotoxins gain deeper access and do further damage, the use of compositae class antihomotoxic agents becomes necessary to stimulate regressive vicariation.
Appropriate homotoxicology formulas
Anacardium homaccord: The namesake ingredient has been shown to have powerful antiinflammatory and immunomodulatory effects. Treats hunger pain, mucosal catarrh including laryngeal and pharyngeal inflammation, duodenal syndrome, constipation, oral vesicles, and gastric / duodenal ulcers. Anacardium as an herbal extract has been shown to be antiviral against simian rotovirus.
Arsuraneel: A cellular phase remedy that treats enteritis and diarrhea (Arsenicum album). May be useful in arsenic poisoning in areas with contaminated groundwater. Also used in chronic disease, tumors of mucous membranes (Marsdenia cundurango), and diabetes mellitus (Acidum phophoricum).
Belladonna homaccord: Indicated in intensely red and inflamed conditions, especially Inflammation Phase conditions. Supports immune function.
BHI-Nausea: Contains Anacardium orientale, a potent antiinflammatory agent.
Cantharis compositum: Contains Arsenicum album. Indicated in aphthous stomatitis; when the tongue is dry, red with raised papillae, and possibly coated white, brown, or black; and for violent gastroenteritis with prolonged vomiting and diarrhea, and with unbearable burning stomach-pains after eating. Also indicated for foul-smelling stools. Also contains Mercurius solubilis, indicated in ulcerative lesions of the mucous membranes, and Hepar sulphuris calcareum.
Coenzyme compositum: Contains Citricum acidum, which is useful for dental problems and gingivitis; scurvy; blackening of teeth and heavy deposits of dental plaque; painful, herpetic vesicles around the lips; nausea; painful cramping in the umbilical area; and distension.
Echinacea compositum: When used in infection, supports the immune reaction, particularly in bacterial infections. It is a phase remedy for Inflammation Phase disease. For more advanced conditions consider Tonsilla compositum.
Engystol N: Used for viral origin gastroenteritis (see Parvovirus).
Galium-Heel: Used in all cellular phases, hemorrhoids, and anal fissures, and as a detoxicant.
Hepar compositum: Provides detoxification and drainage of hepatic tissues, organ support, and metabolic support. It is useful in most hepatic and gall bladder pathologies. It is also an important part of Deep Detoxification Formula. Treats duodenitis, pancreatitis, cystic hepatic ducts, cholelithiasis, cholangitis, cholecystitis, vomiting, and diarrhea. This combination contains Natrum oxalaceticum (also found in Coenzyme compositum, Ubichinon compositum, and Mucosa compositum) for changes in appetite and stomach distension due to air. Indicated in nausea, stomach pain with a sensation of fullness, gurgling in abdomen, and cramping pain in the hypochondria. Also used for constipation, sudden diarrhea (particularly after eating), and flatus.
Lymphomyosot: Provides lymph drainage and endocrine support to treat edema. Contains Gentiana for chronic gastritis. Treats flatulence; diarrhea; and distension of stomach with eructations, nausea, retching, and vomiting. The component Geranium robertianum is also useful for nausea, particularly after eating, with distension or sensation of fullness. Myosotis arvensis is also contained, which also has indications for bloat and distension.
Mercurius-Heel S: Used for viral and bacterial issues, suppuration, and tonsillitis.
Mucosa compositum: Broadly supportive for repair of mucosal elements. Used in cellular cases and in recovery periods following active disease. This remedy contains a useful component in Kali bichromicum, indicated for ulcers found on the gums, the tongue, the lips, and even on the gastric mucosa (gastric or duodenal ulcer). The tongue may have a thick, yellow, mucous coating, or in ulcerative stomatitis or tonsillitis it may be dry, smooth, shiny, or fissured. Kali has been used effectively in acute gastroenteritis associated with vomiting of clear, light-colored fluid or quantities of mucous bile, and in cases with hematemesis, flatulent colics, and dysenteric stools with tenesmus.
It contains Hydrastis, with mucosal support for oral problems such as stomatitis, mucosal suppuration accompanied by ulceration, inflammations and colic of the hepatobiliary system and of the gastrointestinal tract, and polyp formation.
The Kreosotum component can be used in chronic gastritis with gastric hemorrhages and vomiting of brown masses. It also has a dental implication in cases with spongy gums and carious teeth, neuralgias proceeding from them causing a burning toothache with deep caries, black patches on the teeth, and fetid discharges. The single remedy Phosphorus is broadly useful for dyspepsia and for jaw problems in dental disease. Phosphorus is found in many other remedies including Ecbinacea compositum and Leptandra Homaccord. It is rich in suis organ preparations for mucosal support, plus a large variety of remedies with indications in the gastrointestinal sphere. Argentum nitricum (also in Atropinum compositum, Diarrheel, Duodenobeel, Gastricumeel, Momordica compositum, BHI-Nausea, and several other combinations) is included in this broad remedy for distension in the upper abdomen, gastro-cardiac symptom-complex, and amelioration from eructations. It is also used for gastric crises.
Nux votnica homaccord: Treats liver and gastrointestinal disease. Useful in gingivitis. It is also used after smoke inhalation, and is a commonly used formula for detoxification as part of the Detox Kit.
Osteoheel: Provides support of bony healing and treats periostitis and periodontal disease.
Phosphor homaccord: Treats hepatitis, icterus, tenderness over the liver region, pancreatic diseases, ulcerated gums, thirst but vomiting right after drinking occurs, and pale-clay colored stools.
Psorinoheel: Used for chronic illness, and is an Impregnation Phase remedy.
Schwef-Heel: Treats chronic diseases of skin and liver. This remedy should be interposed in most skin and liver cases. Patients that need this remedy may look dirty and have scruffy skin conditions, red lips, white tongue with red tip, and an itching and burning rectal area with morning diarrhea and prolapsed rectum. Sulfur is contained in several other antihomotoxic formulas including Coenzyme compositum, Ecbinacea compositum, Engystol, Ginseng compositum, Hepar compositum, Molybdan compositum, Mucosa compositum, Paeonia Heel, Proctbeel, Psorinoheel, Sulfur-Heel, Tbyroidea compositum, and Ubicbinon compositum.
Solidago compositum: Includes Berberis and other ingredients that support renal function. It is good in Deposition Phase cases.
Thyroidea compositum: A component of the Deep Detoxification Formula; drains matrix and supports endocrine function. It is a phase remedy for Impregnation Phase disease.
Tonsilla compositum: Supports immune organs in Impregnation, Degeneration, and Dedifferentiation phases.
Traumeel S: An antiinflammatory. It also repairs blocked enzymes. It is used for regulation rigidity patients. Human studies show that it controls pain through speeded healing and homotoxin removal.
Ubichinon compositum: Contains Anthraquinone for swelling of gums and GI symptoms such as distention, flatulence, and cramping abdominal pain. Also treats constipation with straining or sudden diarrhea.
Authors’ suggested protocols
Immune and gingival / mouth support remedies: 1 tablet for every 25 pounds of body weight BID.
Betathyme: 1 capsule for every 35 pounds of body weight BID. (maximum 2 capsules BID)
Coenzyme Q10: 25 mg for every 10 pounds of body weight daily.
Additional vitamin C: 100 mg for every 25 pounds of body weight BID.
Folic acid: 50 micrograms for every 35 pounds of body weight (maximum, 200 micrograms).
Colostrum: One-third teaspoon of powdered formula for every 25 pounds of body weight BID.
Chinese herbal medicine / acupuncture
Formula H80 Gingival stomatitis / chronic: 1 capsule per 10 to 20 pounds twice daily. This formula is useful for acute or chronic gingival stomatitis of bacterial, viral, or immune-mediated etiology. In addition to the herbs cited above, H80 Gingival stomatitis / chronic contains aurantium fruit (Zhi qiao), dendrobium (Shi hu), imperata (Bai mou gen), malt (Mai ya), melia (Chuan lian zi), polyphorus (Zhu ling), and sweet wormwood (Qing hao). These additional herbs increase the efficacy of the formulation.
(Dose: 10 drops PO for 50-pound dog; 5 drops PO for cat or small dog)
In addition to proper dental, surgical, and medical management, consider:
Symptom formula: Traumeel S, Echinacea compositum, Mucosa compositum, and Cantharis compositum, mixed together and given TID orally. Consider the following as indicated: BHI-Nausea or Anacardium homaccord (oral vesicles), Osteoheel (periodontal disease and bone loss), Engystol N or Euphorbium compositum (viral conditions), Belladonna homaccord (acute inflammation with intense redness), Mercurius-Heel S (viral or bacterial infections), and Nux vomica homaccord (general gastrointestinal drainage and detoxification).
Deep detoxification formula: Galium-Heel, Lymphomyosot, Hepar compositum, Solidago compositum, Thyroidea compositum (alternate with Tonsilla compositum), Coenzyme compositum, and Ubichinon compositum.
Immune and gingival / mouth support remedies: Animal Nutrition Technologies. Alternatives: Immuno Support — Rx Vitamins for Pets; Immungen — Thorne Veterinary Products; Immune System Support — Standard Process Veterinary Formulas.
Betathyme: Best for Your Pet. Alternative: Moducare Thorne Veterinary Products.
CoEnzyme Q10: Vetri Science — Rx Vitamins for Pets for Pets; Integrative Therapeutics; Thorne Veterinary Products.
Colostrum: New Life Foods, Inc.; Saskatoon Colostrum Company.
Chinese herbal medicine
Gingival Stomatitis (Chronic-H80): Natural Solutions, Inc.
BHI / Heel Corporation