Episode 28 - Gum On Down!

Show Notes

To celebrate Pet Dental Health Month, the Skin Flints team looked a bit further afield this month, exploring gum health and Canine Chronic Ulcerative Stomatitis with Hannah van Velzen.

Chapter 1 – Understanding the Oral Mucosa and Inflammation

(02:53) John welcomes Hannah, who introduces herself and her journey into veterinary dentistry, from her studies in the Netherlands to her current role leading the dentistry referral service at Fitzpatrick Referrals. She highlights the small but growing number of veterinary dentistry specialists in the UK.

(05:46) Sue asks for a basic overview of the oral mucosa, as it plays a key role in CCUS.

Hannah explains that gingiva surrounds and seals the teeth, preventing bacteria from entering the body, while mucosa covers the rest of the mouth. The mucogingival junction marks the boundary between the two and helps differentiate between gingivitis and mucositis.

She describes the different types of mucosa, including lingual (tongue), palatal (roof of the mouth), alveolar (bone covering), vestibular (cheek and lip folds), buccal (cheeks), and labial (lips). These structures vary in thickness and function, with keratinized areas like the tongue and hard palate providing protection, while thinner, non-keratinized areas aid in saliva flow and bacterial clearance.

(13:24) John then asks Hannah to define common inflammatory conditions affecting the mouth, including:

• Gingivitis – Inflammation limited to the gingiva, without mucosal involvement.
• Mucositis (stomatitis) – Inflammation affecting the mucosa, which is central to CCUS.
• Periodontitis – Inflammation of the structures supporting the tooth, which can lead to tooth loss.

Hannah emphasises the importance of accurately defining oral lesions to guide diagnosis and treatment. 

Chapter 2 – What is CCUS? How Can It Be Diagnosed?

(18:43) John introduces Canine Chronic Ulcerative Stomatitis (CCUS), asking how it relates to previous terms like CUPS (Canine Ulcerative Paradental Stomatitis) or contact mucositis.

Hannah explains that CCUS was formerly known as CUPS, but the name changed as research showed that 40% of lesions occurred in areas without teeth, making the term "paradental" inaccurate. The condition is chronic, meaning it develops gradually rather than suddenly.

(23:22) Sue asks how a primary care vet should determine whether a dog with oral ulcerations has CCUS or another condition, such as pemphigus vulgaris, lupus, or uremic stomatitis.

Hannah acknowledges that many inflammatory and autoimmune diseases look similar and that no single exam finding confirms CCUS. She advises vets to follow key diagnostic steps:

1. Perform a thorough dental cleaning and radiographs to rule out periodontal disease.
2. Differentiate gingivitis (gum inflammation) from mucositis (mucosal inflammation).
3. Take a biopsy if mucosal inflammation is present, as periodontal disease should not cause mucositis.
4. Look for "lymphoplasmacytic infiltrates" on biopsy, which strongly suggest CCUS.

If the biopsy findings suggest CCUS, referral to a dentistry specialist is recommended. If results are inconclusive, a dermatologist may need to investigate potential autoimmune conditions.

(27:33) Sue asks whether "kissing lesions" (ulcerative lesions where mucosa touches the teeth) strongly indicate CCUS.

Hannah agrees that they are a key sign, but notes that plaque build-up can also cause similar inflammation. A dental clean should be performed first—if inflammation persists despite clean teeth, CCUS is more likely.

(28:31) Sue then asks if certain breeds are predisposed to CCUS.

Hannah confirms that small breeds and terriers are overrepresented, particularly:

• Cavaliers, Labradors, Maltese, and Greyhounds.
• Greyhounds are prone due to poor dental health and periodontal disease.
• Spaniels may also be affected, though this is not yet confirmed in literature.

Some affected dogs have severe gingivitis and mucosal inflammation despite excellent dental hygiene, making CCUS harder to recognise.

(31:33) John asks how easy biopsies in the mouth are Hannah stresses that biopsies should always be done under general anaesthesia for pain control and a thorough oral exam. She typically uses a punch biopsy, ensuring a portion of normal tissue is included to help distinguish inflammatory from autoimmune causes.

She highlights the importance of sending clear photos and case details to assist pathologists in interpreting results. Additional tests like immunohistochemistry may sometimes be useful.

Chapter 3 – Treating CCUS: What Are the Options?

(35:44) John asks how CCUS is treated and whether treatment varies by severity.

Hannah explains that CCUS treatment is multi-step and includes:

1. Dental Cleaning & Plaque Management:

• Full dental cleaning is the first step.
• Extractions are considered only for teeth that contribute to inflammation.
• In mild cases, cleaning + home care (brushing, antiseptics) may suffice.

1. Home Management & Pain Control:

• Some owners can maintain oral hygiene, others cannot.
• Pain relief options include NSAIDs, paracetamol, gabapentin, or amitriptyline.
• Feeding tubes may be used in extreme cases for pain-free nutrition.

1. Medical Management for Severe Cases:
   Two main protocols exist:

• Cyclosporine + Metronidazole (immune modulation & bacterial control).
• Doxycycline (low dose), Pentoxifylline (ulcer management), and Niacinamide (vitamin B3).

The choice depends on vet preference and patient response.

1. Long-Term Management & Research Gaps:

• Some dogs may eventually stop medication once inflammation is controlled.
• More research is needed to determine which cases respond best to which treatments.
• Avoiding full-mouth tooth extractions remains a key goal.

(45:14) Sue highlights the lack of published research on CCUS and urges vets to seek specialist advice before extracting all teeth.