Building a treatment plan
Stomatitis in dogs is a painful condition generally poorly responsive to conservative management. Frequent professional dental
prophylaxis is the initial approach to therapy followed by strict adherence to a home-care regimen. Brushing a minimum of
once daily is the basis of conservative therapy. Chlorhexidine daily gel, plaque-retardant sealants, water additives and enzymatic
chews may serve as adjunctive therapy. In many cases, strict adherence to home care alleviates signs only for three to six
months before professional prophylaxis is required. Immunosuppressive agents may offer short-term benefits; however, long-term
therapy generally is unrewarding and has obvious detrimental long-term effects.
In some cases, extraction of teeth adjacent to affected areas is indicated. In generalized cases, this may require full-mouth
Now that you have thoroughly discussed primary stomatitis, we are ready to make our therapeutic recommendations. Or are we?
What clinical signs normally present with cases of stomatitis just don't fit this case?
Profound nasal mucositis and generalized palatal involvement are not commonly seen. Typically the palatal mucosa is affected
immediately adjacent to the tooth/palate interface. In this case, the entire mucosa was affected. Nasal discharge might be
a secondary factor or a separate entity, but the degree of hyperemia strikes an unusual chord in this case.
Immune-mediated disease, renal insufficiency, liver disease, viral, bacterial and fungal organisms, eosinophilic granuloma
complex, foreign-body reactions, chemical and thermal insult should be included in our list of differential diagnoses.
In an attempt to determine a specific etiology, a biopsy was taken of the nasal mucosa, including a portion of the alar fold,
the lip margin and oral mucosa, and submitted for histopathology. Consultation with dermatology resulted in a trial of immunosuppressive
doses of prednisone and a broad-spectrum antibiotic. Interestingly enough, both samples in this second biopsy were consistent
with erythema multiforme, which is a rare ulcerative dermatosis associated with host-specific T lymphocyte cell-mediated hypersensitivity.
(See suggested reading, p. 10S.)
Infections, drug therapy and food have been implicated. However, a large percentage of cases are idiopathic. Vesicles and
ulcerations are common oral mucosal changes. Ulcers commonly are covered by a gray-white film consistent with those seen in
this case. The oral mucosa is a common site for lesion predilection with this condition.
Spontaneous regression has been reported in a matter of weeks to months. Definitive resolution occurs if the cause can be
determined and resolved. The use of immunosuppressive drugs is not without controversy and is usually reserved for more severe
cases where a cause cannot be determined. Anecdotal evidence suggests that cyclosporine may be of benefit in canine idiopathic
Response to therapy
Two weeks later, the dermatology service reported much improvement in the degree of stomatitis. The doctor tapered the dosage
of prednisone and discontinued the antibiotic. Two weeks after a recheck with the dentistry service, the doctors noted an
appreciably positive response in the palatal mucosa (Photo 4, p. 9S). But the caudal buccal mucosa showed epithelial sloughing
and severe stomatitis (Photo 5, p. 9S). No other potential causes co-existed with onset, and the initial biopsy didn't show
changes characteristic of erythema multiforme.
Photo 4:The patient showed a dramatic response in the palatal mucosa following immunosuppressive doses of prednisone.
Taking into consideration historical and clinical aspects of this case, it might be logical to speculate that the stomatitis
was the primary disease, subsequently resulting in erythema multiforme. It is, however, impossible to make this conclusion
definitively. The etiology of individual cases of this disease is difficult to determine.
Photo 5: Severe stomatitis and gray-white plaques (adjacent to the fourth premolar) were seen two weeks following prednisone
Another diagnostic consideration is chronic ulcerative paradental stomatitis (CUPS) which resembles stomatitis and has similar
histopathology. With CUPS, mucosal irritation occurs in regions where the tissue contacts the tooth. Unfortunately, original
classification was not possible in that we did not observe this patient until after the erythema multiforme was present.
At this point in the work-up, the owners opted to maintain this patient on immunosuppressive doses of prednisone. If stomatitis
is the inciting factor, extractions would likely result in complete resolution. Unfortunately, we may not have the opportunity
to find out. Updates regarding any change in owner sentiment resulting in a different long-term plan will be discussed in
Our next article will address a more classic case of CUPS.
Dr. Beckman is acting president of the American Veterinary Dental Society and owns and operates a companion-animal and referral
dentistry and oral surgery practice in Punta Gorda, Fla. He sees referrals at Affiliated Veterinary Specialists in Orlando
and at Georgia Veterinary Specialists in Atlanta, lectures internationally and operates the Veterinary Dental Education Center
in Punta Gorda.
For a complete list of articles by Dr. Beckman, visit