Canine chronic ulcerative stomatitis (CCUS)
This chronic and painful oral disease is characterised by severe, debilitating and protracted oral inflammation and ulceration in dogs. CCUS is one of the most frequently misdiagnosed oral conditions we see in dogs. Unfortunately, many patients are managed for an extended period of time as if they have periodontal disease.
CCUS is classified as an immune-mediated condition. The prevailing theory suggests that in dogs with CCUS, the immune system exhibits an exaggerated reaction to bacteria found in plaque. Patients with CCUS demonstrate an immune response to plaque that appears to be excessive and heightened. Even minimal plaque formation can trigger elevated local inflammatory reactions in these individuals.
While the precise cause of CCUS remains elusive, individuals with this condition are intolerant to any accumulation of bacterial plaque on their teeth. Even minor build-ups of plaque can instigate an excessively destructive and painful ulcerative inflammatory response.
Dogs with CCUS suffer with moderate to severe oral pain, they may have a reduced appetite or changed food preferences, preferring softer food items; resent being handled especially around the mouth; paw at their mouth; salivate or drool; have difficulty swallowing; be irritable or withdrawn and suffer weight loss. Many also have severe halitosis or bad breath.
CCUS is differentiated from gingivitis and periodontitis when the inflammation also affects the buccal mucosa (cheeks), paradental tissues (soft tissue in contact with the teeth), lateral aspect of the tongue, lips and palate. This means that not only the gums and periodontal tissues are inflamed as in gingivitis/periodontitis but also the mucosa (mouth tissue) next to it. The tissue is friable and bleeds readily when touched, there may be grey/white plaques of the paradental soft tissue and often excessive, soft smelly plaque present on the teeth.
CCUS appears to be more prevalent in certain dog breeds including Maltese terriers, Cavalier King Charles Spaniels, Greyhounds, and Cocker Spaniels and breed of dog however can be affected.
Treatment
- Very strict plaque control – this involves regular professional dental treatment – periodontal therapy, extraction of periodontally diseased teeth in addition to excellent home care. Home care should include daily brushing of the teeth with use of Hexarinse or an alternative chlorhexidine oral rinse.
- The alternative is extraction of all teeth or those in contact with ulcerated mucosal surfaces. Full mouth extractions result in resolution of the mucosal ulceration in most cases. If teeth remain excellent home care and ongoing regular professional intervention is required.
Medications are not classically a main stay of treatment and are generally reserved for non-responders or those with acute flare up of clinical signs prior to or in combination with dental intervention. If required we may recommend doxycycline antibiotics for short term use following/in combination with a dental procedure. Analgesia for patients undergoing dental treatment or those with oral ulcerations will generally consist of NSAIDs (if appropriate), paracetamol +/- opiates.
Following dental treatment/extractions it may take a number of weeks for the oral ulceration to resolve. We generally recommend a recheck 2 weeks post dental procedure and again 8 weeks following the dental (in cases of extractions) to ensure the inflammation has resolved.
A biopsy may also be performed if not already carried out as in some cases to exclude other causes of oral ulceration including other immune mediated conditions and epitheliotropic lymphoma.
Supportive care is essential for patients with CCUS as many patients experience moderate to severe oral pain. Provision of suitable pain control, nutritional support, assistance with grooming and specific antibiotic therapy can aid in managing patients pre and post operatively for those undergoing extractions.
Thankfully, unlike a similar condition in cats treatment in dogs with selective to full mouth extractions is almost always successful in reliving the inflammation and clinical signs.
Prevention
Until the cause of CCUS is clearly understood, no prevention is possible. Research is ongoing into potential causes and alternative management options.