“Fidget” was a lovely, very wriggly, comical five-year-old Maltese Terrier. He had been brought in regularly recently for Dental treatments, as he had been constantly drooling and worrying at his mouth, ... and he had the most awful bad breath! “Fidget” previously had already had numerous, repeated Dental clean up treatments at the clinic, which unfortunately had not made much difference to his symptoms.
As his problem was recurrent despite advised dental treatments, he was referred to a Dental specialist clinic where he was diagnosed with "CUPS".
Chronic Ulcerative Paradental Stomatitis (CUPS), renamed recently as Canine Chronic Ulcerative Stomatitis (CCUS), is a very painful and often debilitating disease of the mouth. This condition causes a profound inflammation and ulcerations in your pet’s mouth, involving the gums, mucous membranes of the cheek, palate, lip, tongue, and pharynx. It is common to find significant ulcers on any oral tissue that meets or lies adjacent to the patient’s teeth. Essentially, CUPS is mostly a “paradental” disease. This means that this disease does not usually affect the tissues that connect the tooth but affects the tissues lying adjacent to and overlying the teeth.
These cases do experience severe oral pain, and they may scratch, rub, and paw at their mouths, and be reluctant to open their mouths for any examination. They also have extremely bad breath, can be hesitant to eat and chew their food, and may drool excessively.
Although the exact cause of this condition is often unclear. In most cases, it is believed that the own dog’s immune system is overreacting to bacteria in any dental plaque present on the overlying or adjacent teeth. These bacteria can trigger an antigenic immune response when there is chronic exposure. Normally, a dog’s own immune system can keep response this in check, but patients that suffer from CUPS have an immune response that is extreme and excessive, and local inflammatory reactions are then elevated in these individuals even to a small amount of dental plaque formation, leading to a very painful ulcerative inflammatory response and symptoms. Often the condition is referred to as a plaque “intolerance”, or plaque “hypersensitivity”.
Dogs of any age can be affected, though it is rarely seen in dogs under a year old. Certain breeds such as Maltese Terriers, Cavalier King Charles Spaniels, Labrador Retrievers, German Shepherds, and Greyhounds, are breeds more commonly affected.
Cases with CUPS will have oral pain, be reluctant to open their mouths, have bad breath, drool excessively and have a loss of appetite. Many pets will have had recent previous dental treatment and cleanings that no longer seem to help. These patients may have mild to moderate plaque, advanced gum inflammation and classic typical cheek “kissing lesions,” which are ulcerations on the cheek tissue mucosa that lie adjacent to and touch the tooth surfaces. These patients have developed severe ulcers on the inside of their cheeks, and some may also have lesions on their tongue.
Other severe autoimmune inflammatory disorders and immunosuppression due to other underling diseases can cause oral lesions and appear somewhat like CUPS. So, a complete physical examination and blood tests are also advised.
Initially cases require a complete dental prophylaxis, which involves a comprehensive oral health assessment and dental clean up under carefully monitored anaesthesia. This will include scaling and polishing the teeth to remove the plaque and calculus, full dental X-rays, periodontal probing of each tooth, and extraction of any diseased teeth or teeth in the worse affected inflamed tissue areas. Biopsies of affected oral tissues may be taken for histological examination.
After dental treatment the pet owner must then carry out rigorous twice daily oral hygiene and tooth brushing ongoing at home. Often this plaque control is combined with some medical therapy to dampen this immune response. These patients need to be re-examined regularly to assess response to therapy. The two main goals when treating CUPS are to provide immaculate oral hygiene and to achieve long term comfort. Anti-inflammatory or immunosuppressive medications and sometimes pulse antibiotic therapies are required. The better the level of home dental hygiene care, the fewer drugs will be needed to keep the CUPS under some control.
When this is not successful, or the mouth ulcerations are long-standing or advanced, multiple tooth extractions are necessary as often the only treatment for CUPS, is the extraction of every tooth that is causing the inflammation. In some cases, extracting the upper and lower back teeth (the premolars and molars) will be sufficient, while with others, unfortunately, full mouth dental extractions are required. Pain medications and steroidal or non-steroidal anti-inflammatories give these cases some relief before and after dental surgery. For patient safety and comfort any full mouth extraction cases may be separated into two separate procedures, with the emphasis on pain control and optimal healing. Over 90% of these cases will achieve clinical remission, which is the resolution of the oral ulcers and a return to comfort and eating well again.
It is important to note that CUPS is a chronic condition that does require lifelong therapy and patient monitoring. Regular dental cleaning is advised, and a rigorous twice daily oral hygiene program is required when the goal is to save any remaining teeth.
Wee “Fidget” had to have all his molar teeth and some front incisor teeth extracted. However, he was much happier, and much more comfortable afterwards, and his breath was lovely! He had regular dental check-ups and scale and polish treatments at the clinic and his owner kept up with rigorous twice daily, on-going dental hygiene at home. “Fidget” soon became used to his routine, and he seemed to know that this was what was required now for him to have a comfortable mouth.
If you are concerned about your dog’s dental and oral health, please arrange an appointment for an initial check-up at your Vet Practice.
Alison Laurie-Chalmers
Senior Consultant
Crown Vets