Canine Chronic Ulcerative Stomatitis?

RE: Canine Chronic Ulcerative Stomatitis?

Clare Smith — Sun, 25 Sep 2022 19:54:18 GMT

Dear Rachel, These are a couple of recent photos of Bertie's mouth.

He isn't the easiest patient to examine conscious but he is much more comfortable about having his mouth examined now that the CCUS soft tissue lesions have healed and the teeth affected with resorptive lesions have been removed. Unfortunately the owner is reluctant to continue with immunomodulatory medication and to have reconstruction of the lip as the insurance pot has run dry. However, I will keep in touch with her and advise that she is watchful for recurrence of symptoms.

RE: Canine Chronic Ulcerative Stomatitis?

Clare Smith — Wed, 24 Aug 2022 19:26:48 GMT

I'm afraid this photo doesn't show the inside of his lip: it was mainly for me to make an assessment of how to close the skin defect. The ulceration has completely healed. I'll take more photos and update you when he's with us for lip reconstruction. Thanks again for your advice Rachel. There's no halitosis now and he's a much happier dog, apart from his Pseudomonas otitis :(

RE: Canine Chronic Ulcerative Stomatitis?

Rachel Perry — Wed, 24 Aug 2022 07:02:55 GMT

Thanks for the update. I’d be interested to see recent photos if you can post - I’m sure lots of people would find it interesting to see.
definitely a risk of recurrence so I would consider anaesthesia in 3-6 m for assessment and periodontal therapy (scaling, polishing, subgingival debridement where needed) and continue the immunomodulatpry drugs and whatever plaque control the o can manage

RE: Canine Chronic Ulcerative Stomatitis?

Clare Smith — Tue, 23 Aug 2022 21:22:52 GMT

Hello Rachel. I wanted to give you an update on Bertie. The inner lip lesions have completely resolved. He's now just on a reduced dose of pentoxifylline. Yesterday I extracted the teeth with resorptive lesions and I plan to reconstruct his upper lip once he's recovered from that. I'm hoping that there won't be any recurrence but I guess there's no guarantee.

RE: Canine Chronic Ulcerative Stomatitis?

Clare Smith — Tue, 26 Jul 2022 20:15:53 GMT

Hello Rachel. I'm pleased to report that Bertie's lip lesions have improved substantially since I last posted. I will update you again when he comes for removal of the teeth with resorptive lesions. Do you think there could be any connection between the affected teeth and the mouth ulceration? I think that lip reconstruction will have to wait until everything else has settled down.

RE: Canine Chronic Ulcerative Stomatitis?

Clare Smith — Tue, 05 Jul 2022 18:11:41 GMT

Super, thanks. I'll let you know how things go.

RE: Canine Chronic Ulcerative Stomatitis?

Rachel Perry — Tue, 05 Jul 2022 07:30:11 GMT

You could go up to the licensed dose of 25mg/kg BID

RE: Canine Chronic Ulcerative Stomatitis?

Clare Smith — Mon, 04 Jul 2022 14:56:16 GMT

Thanks Rachel. Tissue culture revealed Pseudomonas Aeruginosa and a profuse growth of mixed anaerobes. We are continuing the metronidazole and have added in Marbofloxacillin. Would you stick to the modest dose of metronidazole with which we started?

RE: Canine Chronic Ulcerative Stomatitis?

Rachel Perry — Mon, 04 Jul 2022 10:53:35 GMT

Hi,

There doesn't appear to be a any osteomyelitis or osteonecrosis in incisive area. I think the resorption will need addressing at one of your rounds of anaesthesia. The lesion in the labial mucosa does appear better, so keep going. If the client can source liquid niacinamide that's fine.

Keep us posted!

RE: Canine Chronic Ulcerative Stomatitis?

Clare Smith — Sun, 26 Jun 2022 13:58:01 GMT

I reexamined Bertie yesterday. He seems to be irritated by the right upper lip which still has some necrotic-looking tissue, but I am encouraged that the left side has a more healthy granulation tissue type appearance. He is coming for sedation to enable tissue sampling for culture and a repeat debriding of the worst affected area. Have you ever used a liquid formulation of niacinamide? The owner is struggling with tablets. Thank you.

RE: Canine Chronic Ulcerative Stomatitis?

Clare Smith — Tue, 21 Jun 2022 13:49:15 GMT

Thank you again Rachel. I don't want to flood your inbox with too many radiographs but these are a selection which show the resorptive lesions, as well as the maxilla before and after incisor extraction.I had intended to remove the teeth affected by resoorption but I felt that the lip lesions were so severe that I wanted to try to address that before embarking on a major dental procedure if we weren't able to control the lip pathology.

I will start Bertie on the medication regime which you have suggested.

RE: Canine Chronic Ulcerative Stomatitis?

Clare Smith — Tue, 21 Jun 2022 13:44:10 GMT

RE: Canine Chronic Ulcerative Stomatitis?

Clare Smith — Tue, 21 Jun 2022 13:43:08 GMT

RE: Canine Chronic Ulcerative Stomatitis?

Clare Smith — Tue, 21 Jun 2022 13:42:31 GMT

RE: Canine Chronic Ulcerative Stomatitis?

Clare Smith — Tue, 21 Jun 2022 13:40:19 GMT

RE: Canine Chronic Ulcerative Stomatitis?

Clare Smith — Tue, 21 Jun 2022 13:39:35 GMT

I think I'll have to attach radiographs individually as I'm incompetent, sorry!

RE: Canine Chronic Ulcerative Stomatitis?

Rachel Perry — Tue, 21 Jun 2022 08:20:32 GMT

The above article may be helpful- click on the scholar link

RE: Canine Chronic Ulcerative Stomatitis?

Rachel Perry — Tue, 21 Jun 2022 08:19:35 GMT

scholar.google.com/scholar

RE: Canine Chronic Ulcerative Stomatitis?

Rachel Perry — Tue, 21 Jun 2022 08:18:39 GMT

The first picture looks like classic CCUS. The second one looks like out of control CCUS and I remember one case like this- with necrosis causally in buccal mucosa and it was really challenging- needed multiple rounds anaesthesia for surgical debridement of necrotic tissue then disappeared from my radar so not sure the outcome- but have a cautious / guarded prognosis .

pentoxifylline 20mg/kg BID

niacinamide 200-250mg BID (vitamin B3)

Metronidazole 15mg/kg SID instead of doxy

RE: Canine Chronic Ulcerative Stomatitis?

Clare Smith — Mon, 20 Jun 2022 20:56:52 GMT

Thank you very much for your reply Rachel. I will try to post radiographs shortly. No other mucocutaneous junctions appear to be involved, his tongue looks normal and he has not been pyrexic. When he was first examined in April there was another small ulcer of the inner lip adjacent to one of the upper molars but this had improved when checked last week. Bertie has had a couple of episodes of malassezia otitis but that was thought to be associated with adverse food reaction or atopic skin disease and is not currently a problem. Would you be thinking about using metronidazole in addition to or instead of low dose doxycycline? I will certainly start him on pentoxifylline and niacinamide. What doses do you recommend?

RE: Canine Chronic Ulcerative Stomatitis?

Rachel Perry — Mon, 20 Jun 2022 17:23:06 GMT

Hi Clare,

Poor Bertie! This looks horrendous. Can you post radiographs please?. Are any other mucocutaneous junctions or cutaneous areas affected? What about other areas of oral mucosa including tongue? Is he pyrexic?

I would certainly add in pentoxifylline and niacindamide, but I'd also start on metronidazole. Doxycyline should be at sub-antimicrobial dosing rather than normal dosing, so I usually go for 2-5mg/kg SID.

Ideally tissue cultures rather than swabs, and you really need to rule out multi- resistant bacteria such as MRSA- I'd want these results before starting on preds or cyclo- because if you start on immunosuppressive doses you will probably need to hit hard. I'd start with MNZ and warn owner regular GA/sedation may be needed for debridement of necrotic tissue.

There was a case that described osteomyelitis in the rostral maxilla, so you'll definitely want to rule that out too.