I love the phrase “it is not uncommon.” If trying to convey that something is not uncommon, it would be more efficient grammatically to refer to the object in question as “common.” However, it seems the phrase has morphed over recent years to describe a middle ground between common and uncommon. I am as guilty as the next person in using the phrase when describing this month’s topic: canine stomatitis. Canines and CUPS When we think of stomatitis in veterinary patients, what first comes to mind is the feline species, which is appropriate considering their prevalence of oral inflammatory diseases. However, I see a good number of canine patients with stomatitis; some show clinical signs, and some show no clinical signs at all. What causes canine stomatitis? Sometimes we can’t pinpoint a specific cause, but similar to cats affected by stomatitis, many canine cases appear to be an aberrant response of the immune system to plaque that accumulates on the teeth. The most common type of stomatitis I encounter in my canine patients is what has been referred to as chronic ulcerative paradental stomatitis (CUPS). This condition also has been referred to as contact stomatitis, which describes the typical distribution of the lesions. Occurring most commonly on the mucosa of the lip and cheek areas, this condition results in ulceration and sometimes very deep erosions of the areas that lay against the larger teeth of the mouth such as the maxillary canine tooth and the maxillary fourth premolar tooth (Figure 1). Surprisingly, most dogs with this condition show no overt clinical signs. Biopsy of these areas often shows the typical lymphocytic-plasmacytic infiltrates but also can show areas of necrosis in the center of the lesions. Though these patients may not be showing overt clinical signs, they are likely painful. John Lewis, VMD, FAVD, Dipl. AVDC Figure 1: This middle-aged dachshund exhibits chronic ulcerative paradental stomatitis (CUPS). This case of contact stomatitis was severe enough to cause clinical signs of oral pain. Figure 2: In this middle-aged male neutered Maltese dog with severe lymphocytic-plasmacytic stomatitis, glossitis, cheilitis and glossitis, full-mouth extractions. What to Do? Treatment involves strict plaque control, starting with an excellent professional dental cleaning and assessment of whether selective extraction of teeth may be warranted. Extraction of the teeth that the ulcerated mucosa is laying against usually is curative. If extraction seems unnecessary based on pattern of inflammation and clinical signs, an alternative might be strict home care after a thorough dental cleaning (twice daily brushing) and possible placement of sealants on the teeth at the time of cleaning to minimize plaque accumulation. Topical rinses and other anti-plaque strategies also may be helpful, if they do not contain ingredients that may be irritating to the ulcerated mucosa. Anti-plaque sealants (not to be confused with light-cured sealants used to prevent caries) may provide a barrier to prevent plaque accumulation. Even if homecare is meticulous, frequent dental cleanings will be necessary. Subantimicrobial doses of doxycycline have helped to control the disease in some patients. The dog breeds that I see contact stomatitis in most commonly include dachshunds, pugs, Cavalier King Charles spaniels and little white fluffy dogs (LWFD), such as Maltese, Havanese and Eskimo dogs. LWFDs are prone to severe stomatitis (also called mucositis), similar to what we see in the feline species. This differs from contact stomatitis in that the entire mouth, including the tongue and palate, can look fire-engine red (Figure 2). These patients show clinical signs, including drooling, severe “knock-you-over” halitosis, purulent oral discharge and decreased appetite. Often, the lateral surfaces of the tongue that lay against the lingual surfaces of the premolar and molar teeth are ulcerated. Biopsy of these areas also results in finding lymphocytic plasmacytic stomatitis. However, in these cases of full-blown oral inflammation, it is important to consider biopsy to rule out autoimmune disease rather than the more typical immune-mediated disease. Bullous pemphigoid, pemphigus vulgaris, Discoid lupus erythematosus and systemic lupus erythematosus all can result in oral manifestations. In addition to these autoimmune diseases, other conditions, such as erythema multiforme, may result in oral ulceration as a result of reaction to a medication or microbe exposure (Figure 3). Biopsy is important in addition to a search for other clinical signs that may support the diagnosis of autoimmune disease over immune-mediated plaque sensitivity. John Lewis, VMD, FAVD, Dipl. AVDC Figure 3: This 13-year-old male neutered Pembroke Welsh corgi exhibits erythema multiforme. Note the severe ulceration of the tongue, denuding of the tongue papilla and involvement of other mucocutaneous junctions, including crusting around the eyes and the nasal planum. Other clinical signs to look for include painful joints, elevated kidney values, ulceration and crusting at other mucocutaneous junctions, such as the eyes, the nasal planum, the prepuce and the vulva. How is severe stomatitis treated? Just like cats with stomatitis, therapy can be categorized into medical and surgical options. Medical therapy often involves corticosteroids and pain medications. Some patients require chronic medications and surgical extractions. Full-mouth extraction has allowed for complete resolution of inflammation for many of my canine patients with severe stomatitis and glossitis. Recommended Reading Lewis JR. “Stomatitis.” In: Cote, E, ed. Clinical Veterinary Advisor, 3rd ed. Philadelphia: Mosby Elsevier. 2011; 963-965. Anderson JG, Peralta S, Kol A, Kass PH, Murphy B. “Clinical and Histopathologic Characterization of Canine Chronic Ulcerative Stomatitis.” Veterinary Pathology 2017 Jan 1: 300985816688754. doi: 10.1177/0300985816688754. [Epub ahead of print] Lewis JR, Miller BM. “Veterinary Dentistry.” In: Bassert JM and Thomas JA, eds. McCurnin’s Clinical Textbook for Veterinary Technicians, 8th ed., 2014: 1297-1354. Dr. John Lewis practices veterinary dentistry and oral surgery at NorthStar Vets in Robbinsville, N.J.
