Initial examination and diagnostic tests
When patients are presented for evaluation of clinical signs of CUPS, perform a complete physical examination. Carefully examine
the mandibular lip folds for evidence of intertrigo. Next, perform a complete blood count (CBC), serum chemistry profile,
and urinalysis. Other preanesthetic diagnostic tests, such as thoracic radiography and electrocardiography, may be included
as well. The only laboratory findings commonly associated with CUPS include hyperproteinemia secondary to a hypergammaglobulinemia
(polyclonal) and mild (up to 25,000/ml) neutrophilic leukocytosis. If other abnormalities are encountered in the diagnostic
workup, address them as additional problems.
The differential diagnoses in patients with signs characteristic of CUPS are listed in Table 1. Although CUPS can be presumptively diagnosed based on a patient's history and oral examination findings, a definitive diagnosis
can only be made by histologically examining lesions. Anesthetize the patient, and use a 0.3- to 0.6-mm skin biopsy punch
to obtain samples; try to obtain at least two samples from the representative areas of the oral cavity. Additionally, perform
a thorough oral examination, including charting pocket depth, and note the results on the patient's dental chart. Dental radiography
is important in identifying advanced periodontal disease, and a full-mouth series is warranted.
Table 1 : Differential Diagnoses in Dogs with Signs Typical of CUPS*
Once you've definitively diagnosed CUPS, discuss the long-term prognosis with the owners. This condition can usually be treated
but will require lifelong therapy or total mouth extractions.
The initial treatment plan should include a complete dental prophylaxis: gross calculus removal and ultrasonic crown scaling,
subgingival plaque and calculus removal, polishing, gingival sulcus irrigation with chlorhexidine solution, and a thorough
oral examination including periodontal probing. It is difficult enough to save the healthy teeth in dogs with CUPS, but it
is nearly impossible to treat the diseased teeth and keep the inflammatory disease in check. With this in mind, it is recommended
to extract any teeth with advanced-stage periodontal disease at the time of the initial prophylaxis and oral biopsy. Patients
with CUPS (or presumptive CUPS) are excellent candidates for OraVet (Merial), which is a waxy barrier applied to tooth surfaces
after prophylaxis to retard plaque accumulation.
The two main goals when treating CUPS are to provide immaculate oral hygiene and to achieve clinical resolution by using anti-inflammatory
or immunosuppressive medications. The better the level of home care, the fewer drugs needed. Brushing a patient's teeth and
applying chlorhexidine daily, applying OraVet weekly, and instituting long-term intermittent antibiotic therapy (pulse therapy)
are all home-care tools that can be combined to obtain maximal oral hygiene.
The choice of antibiotics to treat oral infections is based on our knowledge of the common pathogens. Do not perform oral
bacterial cultures because more than 200 species of microorganisms inhabit the oral cavity, and the results will only confuse
the issue. Antibiotic selection should be based on each agent's ability to affect gram-negative anaerobic bacteria. The short
list includes amoxicillin trihydrate-clavulanate potassium, clindamycin, metronidazole, and the tetracyclines. These antibiotics
differ in respect to their being bactericidal vs. bacteriostatic, their tendency to cause gastrointestinal side effects, and,
in the case of the tetracyclines, their tendency to stain the teeth of actively growing dogs. Combination therapy, such as
metronidazole and clindamycin, may be most effective in severe cases. Pulse therapy remains a controversial issue with no
good scientific studies to document its effectiveness. However, there are many anecdotal reports of success. The risks of
creating resistant bacterial organisms must be weighed against the benefits to a patient. If you choose pulse therapy, a common
dosing regimen is 2.5 mg/lb (1.13 mg/kg) clindamycin given twice a day for five days every month.
Prednisone is the drug of choice for suppressing the inflammation associated with CUPS. Start at an anti-inflammatory dosage
of 1 mg/kg given twice a day, and taper the dose by cutting it in half every five days until the lowest every-other-day dose
is achieved. When the prednisone dose is insufficient, the owners will report a recurrence of clinical signs, and the dose
will need to be increased.