This is a relatively common and frustrating condition seen in dogs. It is commonly called C.U.P.S.  

Note that this is not the very common disease of periodontal disease but a paradental disease. This means that it does not affect the tissues that attach the tooth to the socket (gingiva, alveolar bone, periodontal ligament and cementum on the root). but those next to it – gingiva plus oral mucosa, tongue, pharynx etc.  Periodontal disease primarily affects the four periodontal tissues.

These images show severe mucosal inflammation in tissues overlying the teeth which don’t look like there is heavy calculus accumulation or gingival recession.

The paradental tissues are the other soft tissues that share the oral cavity with the teeth and which often lie in contact with the crowns of the teeth when the mouth is closed. This includes the mucosa of the buccal vestibule, palate, tongue and the mucocutaneous junctions of the lips.

In normal dogs the oral soft tissues remain healthy in the face of severe, chronic, advanced disease of the periodontal tissues. Conversely, we often find that in severe cases of CUPS the teeth are generally periodontally quite healthy.

 

Note the intense inflammation and ulceration of those areas of oral mucosa that lie against the crowns of the teeth. These are referred to as contact or kissing ulcers.  We commonly also see contact ulcers in the area of the maxillary canines. Note the ulceration and inflammation of the palatal mucosa also.

CUPS and periodontal disease are two separate conditions that may be present on their own or together. Certain breeds such as Greyhounds and Labradors seem more susceptible than the general population.

Owners initially complain of severe halitosis and, possibly, dysphagia but another common signs is excessive salivation of a thick viscous nature sometimes blood stained. In some dogs we also see an extension of the inflammatory process to the skin of the lips folds. The most common findings are therefore oral pain and difficulty eating.

Differential diagnosis would include pemphigus and bullous pemphigoid. While these conditions can result in oral lesions, they also often are associated with lesions of the skin and mucous membranes in other areas of the body.

Since the treatment for other immune-mediated diseases is very different from the treatment for CUPS, it is important to make the distinction early on in the management of the case.

A full haematology and biochemistry panel will help confirm the diagnosis of CUPS and the health status of the patient before initiating treatment. A biopsy of the affected tissues is helpful to rule out neoplasia but often fails to provide any new information other than confirming the presence of lymphocytes and plasmacytes within the inflamed tissues. The blood samples also help with regard to general systemic health and the ability of the dog to undergo medical treatment that may include NSAID’s or corticosteroids.

Swabs for bacteriology are often not helpful. Plenty bacteria can be isolated but their significance can be hard to determine unless they are unusual for the mouth or present in pure culture. Ask the lab before sending your swabs how they want them sent for anaerobic and aerobic culture.

We do not know the precise aetiology of CUPS. We do know that these individuals are intolerant to dental plaque. Any small amount of plaque leads to a greater than normal level of local inflammatory reaction.

The initial focus must be scrupulous plaque control and management of the case always starts with a diligent, professional scale and polish. Teeth that have a limited future, perhaps due to periodontal disease, should be removed.

These cases are very similar to chronic stomatitis syndrome (FCGS) cases in cats as they are also intolerant to normal levels of dental plaque.

Control measures are generally for life. Training the client to use disclosing solution every few days allows them to see how effective their control measures are and, also, where and how much plaque there is on the teeth. They can use iCplaque from Kruuse, or, cheapest of all, a bottle of disclosing solution and a cotton bud from www.drshipp.com

The dye is simply painted on the teeth to show not only the distribution but also the severity of the plaque levels. If you show the client how to do this in the consulting room they will be able to do it at home as often as necessary. The images below show a mouth one week after a scale and polish. Once disclosing solution is applied the owner can see clearly where the problems are. 

Control Measures

Our control measure centre on the following after professional dental treatment has been performed.

1.      Diligent twice daily removal of plaque with a chlorhexidine based product. This can be a spray, rinse or toothpaste.  Good chlorhexidine products have been hard to source after Virbac with drew Parodongyl and Oral Hygiene Rinse from sale in 2011. Our current favourites are the range from Keystone (www.krpvet.com). The product range includes toothpaste (Bright Bark & Meow) and a pump spray (PetORALeze) in addition to a gel for use intraoperatively called Petection.

Toothbrushing may be hard to achieve until the lesions are under control. Once they are, you can advise use of a soft bristle toothbrush cheaply obtained from Boots or Tesco. Beware of some of the ludicrous inventions that masquerade as pet tooth brushes. The toothbrush, as a design, has ben good for 200 years. An inexpensive brush can be thrown away every 6-8 weeks once the bristels are frayed.

 When the lesions are active it might not be possible to brush so wipe the paste inside the lips both sides instead. Brushing should be resumed as soon as possible. The pump spray (PetORALeze) is an alternative as is the aqueous solution from Virbac (Hexarinse™).

2. Frequent professional scaling and polishing when the control measures are failing and soft tissue lesions are returning. This might mean as often as every 3-4 months. 

3. Extraction of teeth severely affected by periodontal disease that are likely to stoke to inflammatory fires further. Some authors advocate full mouth extractions for these cases. In our experience this is rarely necessary as long as control measures are used properly. For some dogs full mouth extraction may be the only solution. 

4. Occasional and controlled medical treatment such as antibiotics and low dose prednisolone. Antibiotics can be useful early in the case but generally do not help much long term. Potentiated amoxycillin, clindamycin, doxycycline and metronidazole are all useful. Lowest effective dose prednisolone might also be necessary for a short time to bring soft tissue lesions under control to allow plaque reduction measures. Don't fogret pain control! NSAID's plus opiates will be required if lesions are severe.

5.  Make sure everyone involved understands the need to demonstrate and control dental plaque. It can’t be seen without disclosing solution

Other Control Measures

What is the role of rinses and other “treatments” for dental disease? 

 Many of these are unproven and sold on the basis of sales literature and so called “trials”. Products that are not strictly medicines do not require rigorous testing for efficacy and safety.

If you think that the product in question is likely to be any good why not ask your dentist if he would use it for you in the same circumstances. That might be enough of a reality check to save you spending cash on snake oil and the like.

The Veterinary Oral Health Council (www.vohc.org) exists to review these products. It is a not for profit organisation in which senior academics and specialists review company literature and provide approval if claims appear to be validated. The website lists products that have this seal of approval.

If it's not there you might want to ask why!