By Dr. Becker
Chronic ulcerative paradental stomatitis, or CUPS, is an extremely painful, difficult-to-treat condition of the mouth primarily seen in dogs. It's also referred to as ulcerative stomatitis, idiopathic stomatitis and lymphocytic-plasmacytic stomatitis, which is more often seen in cats. "Stoma" in Latin means mouth, and "–itis" means inflammation, so wherever you see those two words together, you know there's an inflammatory disease of the oral cavity.
Paradental disease and periodontal disease are different things. Periodontal disease affects the tissues and other structures of the gums. Paradental disease affects the soft tissues that come in contact with the crowns of the teeth, including the mucous membranes lining the oral cavity, the palate, the inner cheeks, tongue and lips. Pets can have periodontal disease without CUPS, CUPS without gum disease or both. However, they are distinctly different problems and must be managed differently.
CUPS can occur in any dog, but certain breeds are thought to be predisposed, including the Maltese, Cavalier King Charles Spaniel, Scottish Terrier, Cocker Spaniel, Bouvier des Flandres, Dachshund, German Shepherd and the Greyhound. The condition can occur even in young pets who under normal circumstances would not be old enough to develop oral or dental disease.
Symptoms and Diagnosis of Chronic Ulcerative Paradental Stomatitis
The cause of CUPS isn't known, but it occurs when an animal's immune system mounts an inappropriate hypersensitive response to the bacteria found in the plaque that accumulates on the teeth. Pets with this condition are unable to tolerate bacterial plaque on the crowns of their teeth. Even minor plaque buildup can result in an overwhelming, destructive and extremely painful inflammatory response in the mouth.
A pet with CUPS will invariably have very stinky breath. Typically, the gums are swollen and there's inflammation in the back of the mouth. The mouth and gums are flaming red. Other signs include ulcerations of the inner cheeks and on the gums where they meet the lips, and excessive drooling of thick, ropey, saliva.
There may or may not be plaque on the teeth, and there can be exposed bone where the gums have receded. The gums may also bleed. Because the mouth is so painful, many pets with CUPS lose their appetite as well. Your veterinarian will order a complete blood count (CBC), blood chemistry evaluation and urinalysis.
Since it's very important to rule out other immune-mediated diseases that affect the oral cavity, such as pemphigus, your vet will also want to perform a physical exam to check for lesions of the skin and mucous membranes in other parts of your pet's body.
Initial Treatment Procedures
If no underlying diseases are identified and CUPS is suspected, the next step is a comprehensive oral health assessment under anesthesia. This involves a very detailed examination of your pet's mouth, including probing and charting of each tooth, as well as a full set of dental x-rays. All compromised teeth, meaning those that are dying, dead or loose, will be removed, along with teeth that are crowded, because they can be plaque magnets.
The need for multiple extractions surprises many pet parents because often what is visible on the surface of a cat's or dog's mouth can appear minor compared to what's happening below the surface. The remaining teeth will be thoroughly cleaned both above and below the gum line, and polished. Biopsies are also frequently taken to make sure there are no other diseases present.
Most veterinarians also apply either a dental sealant or a product that leaves a waxy coating on the teeth to help inhibit accumulation of bacterial plaque on the crowns.
This protocol may sound extreme, but those of you who have pets with this painful condition realize how much better they feel after their mouths have been cleaned, infected teeth have been removed and they begin to heal. It's a very important step in relieving your pet's suffering and preventing additional degeneration.
Ongoing Care of Pets With CUPS
After the healing period, which is usually two to three weeks, your dog or cat should be feeling noticeably better. This is when you must begin a very aggressive, consistent routine of removing plaque from your pet's teeth.
It's not just a matter of tooth brushing, but rather a twice-daily disinfecting program to minimize the amount of bacteria that accumulates in your pet's mouth. It's important to remember that CUPS isn't a problem of plaque buildup as much as it is an immune system response to the presence of plaque and specifically, bacteria. Any amount of plaque can trigger inflammation.
Twice-daily brushing with a nylon bristle toothbrush is recommended. Most veterinary dentists agree that no mouth rinse, gel, paste or water additive alone can control plaque to a sufficient degree in CUPS patients. These products can be used in conjunction with brushing, but daily brushing is an absolute must if you hope to prevent a recurrence.
I recommend a solution of coconut oil, colloidal silver and probiotics swabbed over the surface of the teeth twice a day, which can be quite effective in reducing plaque buildup after the initial dental procedure. I also suggest giving the supplement Standard Process Bio-Dent, as well as a daily pet probiotic.
Dogs and cats with CUPS should be seen regularly by a veterinary dentist for professional oral exams and cleanings. If degeneration continues to occur, a full mouth extraction to remove all remaining teeth may be warranted. This may sound like a radical solution, but it's important to remember that a pet with uncontrolled CUPS is in constant pain and has a significantly decreased quality of life, even while you're doing the time-consuming task of twice daily brushing and disinfecting.
Removing all the teeth provides immediate, dramatic relief in most cases. Most pets respond well and after their mouths heal, their quality of life greatly improves. Pet parents say things like, "he acts like a new dog," or "she's back to being a kitten again." Your pet may need to eat soft food for the rest of his life, but at least he'll be eating without pain or discomfort.
Dietary and Other Considerations
Addressing your pet's diet and removing all potentially allergenic and pro-inflammatory foods, including carbs and starches, is also very important. A GMO-free fresh food diet is ideal, because it's soft in texture and contains whole food nutrients that are effective against inflammation.
I also recommend talking with an integrative or holistic veterinarian about natural anti-inflammatories. I suggest an esterified fatty acid complex, as well as insuring your pet's diet is rich in omega-3 fatty acids. I also use plant-derived sterols, as well as proteolytic enzymes to help manage inflammation naturally.
I also suggest giving ubiquinol, which is a cellular antioxidant that helps support gum and soft tissue health. I recommend removing all potential toxins from your pet's environment that could negatively influence the immune system. Pets with CUPS absolutely should not be vaccinated. Their immune systems are already struggling, and additional vaccines will only complicate the situation.
In some cases, early intervention, excellent homecare and a very aggressive integrative protocol can help manage mild to moderate cases of CUPS without the need for full-mouth extractions.