Updates in Canine Chronic Ulcerative Stomatitis (CCUS) By Jennifer Tjepkema, DVM, DAVDC
CCUS is a poorly understood chronic autoimmune disease in dogs.1,2 It was initially believed to be a hyperreaction to plaque, but new studies suspect that the etiology is more complex.1,2 Clinically, erosions, ulcerations, or white striae can be observed in the mucosa opposing the dentition.1,2 Most commonly, lesions are observed in the labial mucosa opposing the canines, maxillary fourth premolars, and mandibular first molars or the mucosa of the tongue that contact the teeth. CCUS is thought to be similar to oral lichen planus (OLP) in humans. 1,2 OLP is a chronic immune-mediated disease that affects oral mucosa and skin in people. Like feline chronic gingivostomatitis, this disease is chronic and can be approached medically or surgically. Neutered males are most commonly affected. Maltese, Cavalier King Charles, Spaniels, Labrador Retrievers, Greyhounds, and Terriers are the most commonly affected breeds.1,2,3 These patients are typically very painful on presentation and have a foul odor coming from their oral cavity. The primary goal of treatment is decreasing the bacterial load in the oral cavity. Accurate and early diagnosis is essential. Differentials include lupus erythematous, pemphigus vulgaris, bullous pemphigoid, erythema multiforme, epitheliotropic lymphoma, and uremic stomatitis. 1,2 Each dentist approaches these cases differently, with some favoring medical and others surgical management. Regardless of which treatment modality is favored; dentition with stage 2 or greater periodontal disease should be extracted. In my hands, I approach each CCUS patient differently, keeping in 12 | Keystone Veterinarian
mind plaque control as the number one goal. I look at the systemic and overall periodontal health of the patient, breed, age, and capability of the owner at performing at-home care and willingness to come back for follow-up. For example, in a young Great Dane with mild lesions only opposing the maxillary fourth premolars, I would surgically treat less aggressively and try medical management after a Comprehensive Oral Health Assessment and Treatment (COHAT). Whereas, I would treat an older terrier with generalized stage 3 periodontal disease, multiple lesions, and extreme pain surgically more aggressively. In some patients, all of their dentition will need to be extracted. The stomatitis disease index (CCUSDAI) can be used to help guide response and therapy. There are two medical protocols that are currently being used by some dentists and are listed below. These protocols are to be used in conjunction with daily brushing and at-home care. They are started after a professional cleaning and extraction of dentition with stage 2-4 periodontal disease.
Protocols: 1.
PDN protocol: These medications can be combined together in a liquid or a pill and are typically well tolerated: • Pentoxifyline 20 mg/kg PO BID • Doxycycline 5 mg/kg PO BID • Niacinamide 200-250 mg PO BID
2.
Atopica and metronidazole: Liver enzyme should be monitored when taking Atopica. Atopica concentrations should also be checked to ensure achieving immunosuppression. Gastrointestinal side effects are the most common. • Atopica 5 mg/kg PO BID • Metronidazole 10 mg/kg PO SID
References: Anderson JG, Peralta S, Kass PH. Clinical and histopathologic characterization of canine chronic ulcerative stomatitis. J Vet Path. 2017;54(3):511-519. 1
Anderson JG, Kol A, Bizilova P, et al. Immunopathogenesis of canine chronic ulcerative stomatitis. PLoS One. 2020;15(1):eCollection. 2
Maxillary osteomyelitis in two Scottish terrier dogs with chronic ulcerative paradental stomatitis. J Vet Dent. 2011;28(2):96-100. 3
About the Author: Jennifer Tjepkema, DVM, DAVDC is a board-certified veterinary dentist who joined the Animal Dental Center in October 2017 after completing her residency in San Diego. Dr. Tjepkema enjoys all aspects of veterinary dentistry but has specific interests in endodontics and oral surgery. Her research has concentrated around odontogenic tumors, specifically Ameloblastomas. She is happy to announce the addition of a cone beam computed tomography (CBCT) to the York, PA, office. She can be reached at the Animal Dental Center, 2615 Joppa Road, Suite 101, York, PA 17403, by calling 410.828.1001 or emailing Jennifer.Tjepkema@animaldentalcenter.com.
