As soon as I walked into the exam room, I knew the patient on the table was in trouble. The odor emanating from the dog’s mouth was overwhelming. When queried, the owners said they had barely noticed and had only noted that their dog had stopped eating. Putrid saliva flowed onto the exam table (Figure 1A).
The 14-year-old Maltese cross had an advanced case of contact mucositis with ulceration. The dog’s owners had been dealing with it for years. Multiple professional teeth cleaning visits with the dog’s primary veterinarian, antibiotics, corticosteroids, a few extractions and even immune modulators met with little success. Lately, the dog had been in so much pain that tooth brushing was out of the question.
What is CUPS?
Chronic ulcerative paradental stomatitis (CUPS), also called contact mucositis, contact mucositis with ulceration and kissing lesions, affects the paradental mucosal tissues that lie next to the teeth. The oral mucosa, palatal mucosa, lining of the buccal pouch and epithelial lining of the tongue are most commonly affected (Figures 1B-1D).
The lesions may present as solitary or multiple discretely circumscribed or diffuse areas of inflammation with or without ulceration (Figures 2A, 2B and 3).
The lesions may also present with fresh fibrinous pseudomembranes (Figure 4), pustular pseudomembranes (Figure 5) or chronic pseudomembranes with evidence of hemorrhage and necrosis (Figure 6).
In cases in which the tongue’s lateral surfaces are severely eroded, the patient is often in so much discomfort that it stops eating (Figure 7).
Occasionally the paradental infection is so marked that the necrotic buccal mucosal damage extends through the skin (Figures 8A-8C).
Contact mucositis with ulceration differs from periodontal disease that affects the socket holding the tooth—the cementum, periodontal ligament, alveolar bone and gingiva. Some patients have both contact mucositis and periodontal disease (Figure 9).
The specific etiology is unknown. Maltese, Cavalier King Charles spaniels, Labrador retrievers and greyhounds are overrepresented. Affected animals may have a hyperimmune response to the bacteria and proteins in plaque. Other syndromes that may mimic contact ulcerative mucositis include autoimmune diseases such as mucous membrane pemphigoid, bullous pemphigoid, pemphigus vulgaris, epidermolysis bullosa and epitheliotropic T-cell lymphoma. Additionally drug reactions (early toxic epidermal necrosis) and foreign bodies appear similar. Keep in mind that in cases of pemphigus, other mucous membranes including the inner surfaces of the eyelids and the rectum can also be affected.
Unfortunately most affected patients are in so much pain they will not allow an oral examination. As part of patient assessment, laboratory tests including organ function profile, thyroid function, urinalysis and lesion biopsy should be performed. Expect elevated protein concentrations due to the chronicity of disease. In patients in which elevated alkaline phosphatase levels are reported, tests to rule out Cushing’s disease should also be performed.
The treatment of patients with CUPS lesions involves medical intervention, surgical intervention or a combination of the two.
Medical. Affected patients are extremely sensitive to plaque. Even a small amount can initiate the ulcerative inflammatory reaction. Initial care involves dental scaling—both above and below the gum line—irrigation and polishing followed by diagnostic probing and intraoral radiography. Extract teeth with grades 3 and 4 periodontal disease. A dental sealant is recommended to help decrease plaque accumulation.
Antibiotics approved for dental infections are indicated to help treat severe presentations. Pentoxifylline (patient < 7 kg: 100 mg t.i.d.; 7 to 16 kg: 200 mg t.i.d.; > 16 kg: 400 mg t.i.d.) can be prescribed to decrease inflammation. Niacinamide with equal dosages of tetracycline (patient < 20 kg: 250 mg t.i.d.; > 20 kg: 500 mg t.i.d.) may also be helpful. Pain relief medication is also indicated. Pulsed antibiotic therapy (antimicrobials administered the first five days of each month) is not recommended.
The use of corticosteroids to control CUPS is controversial. Home care, including brushing the pet’s teeth twice daily, applying a gel or an oral rinse containing zinc and applying plaque prevention gel (OraVet Plaque Prevention Gel—Merial), helps with plaque control and ulcer treatment.
Surgical. Photovaporization with a carbon dioxide laser helps in the treatment of contact mucositis and mucositis with ulcerative lesions when combined with strict plaque control. The laser should be set between 3 and 6 watts in continuous mode (Figures 10A-10C).
In advanced cases in which the owner cannot provide twice-daily plaque control or if such care does not meet with clinical success, removal of the teeth adjacent to the ulcerated areas (Figures 11A an 11B)—and in some cases all the teeth, as in the case of the dog discussed at the beginning of this article (Figure 12)—results in rapid elimination of all infection and pain. This may seem over the top, but giving your client a “new dog” that smells great, eats well and can truly enjoy life is worth it.