Our Blog
CUPS - Bella Saved from a Life of Intense Oral Pain
By Dr. Caroline Kiss
Bella is a sweet and gentle 10 year old female Australian Shepherd mix that was hiding a problem so severe that it would 
cause any human with a similar disease process to be expressing absolute misery. Yet, Bella was outwardly a happy and active dog who was well taken care of and very loved. Bella illustrates how well our beloved pets can hide even severe oral pain and how appropriate treatment can stop the pain and let them truly enjoy life.
Bella and her family recently moved to Asheville from Tennessee. Her mom, Holly, was concerned because in spite of having professional dental cleanings every six months and having excellent oral homecare including daily tooth brushing, Bella developed severe halitosis and bleeding from her gums within two months after professional cleaning. At her initial visit here at Animal Hospital of North Asheville, Dr. Earley called me in to evaluate the inflammation seen in Bella’s mouth. Bella had severe inflammation of her oral cavity consistent with a disease process called Chronic Ulcerative Paradental Stomatitis (CUPS) as well as severe, end stage periodontal disease. See pictures 1 and 2.
Pictures 1 and 2
Unlike periodontal disease which affects and destroys the gingiva (gums), the periodontal ligament (lining the tooth socket), the alveolar bone (forms the socket) and the cementum (covering of the tooth root), CUPS affects any tissue in the mouth that comes in contact with plaque or tartar (including the inside of the mouth and tongue). Sores called “kissing lesions” (See picture 3) are common. The disease is characterized by SEVERE inflammation of tissues and occurs due to the pet’s immune system becoming hypersensitive to plaque. CUPS is reported to occur more frequently in certain breeds of dogs like Maltese, Cavalier King Charles, and Greyhounds, but Dr. Thompson and I have seen the disease in many other breeds of dogs including mixed breeds.
Picture 3
CUPS can develop slowly over years or suddenly, and as was the case with Bella, often concurrently causes severe periodontal disease. A dog with CUPS may exhibit severe halitosis, drooling, bleeding from the mouth and gums, reluctance to have their mouth or muzzle touched, reluctance to play with toys, difficulty eating, dropping of food, or decreased food intake.
The disease is diagnosed by having a thorough oral examination, ruling out other disease processes, and the possible biopsy of affected tissue. In mild or early cases, aggressive prevention of plaque buildup on the teeth may be an effective treatment. However, this can prove quite difficult as it requires semi-annual professional cleanings, a minimum of once daily tooth brushing (twice daily is more effective), the application of a tooth sealant called Oravet, the use of dental diet and treats, and the use of an oral antibacterial rinse. Unfortunately, despite attempts at preventing plaque buildup, CUPS often persists or progresses. In these cases, the best treatment is extraction of some or often all the teeth in the mouth that provide a surface for plaque to accumulate on. While this may sound extreme, this disease is extreme, and the quality of life of a pet with CUPS can be dramatically improved with this appropriate treatment. Unfortunately, Bella’s veterinarian(s) in Tennessee did not diagnose the disease, and while cleanings were performed, the disease continued to progress. The necessary treatments were not discussed with Holly and Bella continued to suffer.
Pictures 4 and 5
After Bella’s initial evaluation here, a more thorough oral evaluation under anesthesia was scheduled. Very typically, these patient’s mouths are so painful that the mouth cannot be examined at all unless they are under anesthesia. I found Bella to have severe inflammation of her oral tissues AND end stage periodontal disease. (See pictures 1 and 2.) In Bella’s case, it was obvious that good homecare and professional cleanings were not enough to control her disease and the decision was made that the best treatment for Bella was to extract all her teeth. Due to the extensive nature of the surgery, it was done in two separate procedures.
The resulting rewards are obvious. Pictures 4 and 5 demonstrate how Bella’s mouth looked immediately after the extractions were performed and pictures 6 and 7 show her mouth once it was healed. What a dramatic difference!! Also note that the large fang that remained after her first surgery, seen in picture 6, was still inciting a large degree of inflammation. This tooth was extracted during her second surgical visit.
Pictures 6 and 7
After the first surgery was performed, Holly stated that Bella had a very good recovery and appeared to have more energy than previously. After the second stage of the surgery was performed, Holly stated that Bella was "bounding around like a two year old!” While Holly understandably had concerns about the procedure beforehand, she is very happy with the outcome and Bella is happier and healthier than ever.
Aggressive pain control is used post-operatively and dogs undergoing such a procedure have a comfortable, rapid recovery. Once the extraction sites are healed, many dogs with no or few teeth are able to still eat dry kibble, play with toys, and lead very normal (and better) lives.
We are all very happy for Bella and her family!! Please allow us to evaluate your dog’s mouth at least once yearly so that we can ensure they have the best quality of life possible.
Read Holly Hutchinson Weinman's testimonial about Bella's experience here.
Hot Spots - 'Tis the Season
By Dr. Dennis Golden
Sam is a beautiful 12 year old male Golden Retriever with the amazing personality that you would expect from the breed. He 
is “happy go lucky,” loyal, loves attention, and is particularly fond of shamelessly sneaking over and eating his feline roommate's cat food when nobody is watching! Unfortunately, as a Golden Retriever, he also has an increased susceptibility to a common skin condition of dogs commonly known as hot spots. Recently, Sam’s owners discovered a hot spot under his right ear that seemed to develop, literally, overnight.
“Hot spot” is the common name given to a frequent skin condition of dogs that routinely appears very abruptly, often in less than 24 hours, with almost no early warning signs. Hot spots are characterized by a moist, ulcerated superficial skin lesion that is often covered by matted hair that has become stuck to the underlying skin lesion. These lesions can occur in well groomed pets and are not necessarily a sign of neglect because the lesions occur very quickly. Frequently, the lesion will go unnoticed in the early stages until the moist area or matted hair that is covering it is identified or the infection produces an odor, and it is determined that there is a serious skin lesion below the hair covering. As the hot spot lesion progresses, the hair in the central areas of the lesion will fall out, exposing the raw, moist, irritated tissue associated with the disease. The lesions can be very painful and are often associated with intense itching.
Medically, hot spots are classified as a form of “acute moist (exudative) dermatitis.” This name implies that the lesions develop very quickly (acute), are characterized by production of a moist drainage in the early phase of the disease, and results from an inflammation of the superficial layers of the skin (dermatitis). While some lesions can remain relatively small, many are rapidly progressive and can expand to involve very large areas of the body. Since hot spots can be painful and very itchy, they are often made worse by licking, scratching or rubbing. The skin usually becomes infected due to the moisture and trauma on the surface of the skin. Despite the frequency of this disease, the exact cause for hot spots remains unknown. Factors that increase the incidence of hot spots include hot humid weather, underlying allergies (food allergy, flea allergy, and environmental allergies), parasites (fleas, ticks), excessive coat moisture (like swimming), ear infections, and unkempt hair coats. There is a definite increase of this problem in the spring and early summer months.
While any dog can develop hot spots, they occur more commonly in dogs less than 4 years of age and develop more frequently in certain breeds such as Golden Retrievers, Rottweilers, Saint Bernards, and German Shepherds. Hot spots can occur in cats; however, the frequency is very rare.
Sam's owners first noticed that he had a moist matted area of hair under his ear that didn't smell very good, so they made an appointment for Sam to be seen by his primary veterinarian, Dr. Golden. In Sam's case, as in most cases, hot spots can be diagnosed based on the history of the lesion and the characteristic appearance. However, other disease processes can mimic the appearance of hot spots, and a hot spot can be associated with another disease that must also be addressed as part of their treatment and prevention, so any dog suspected of having a hot spot should be examined by a veterinarian. Examination is also important to help determine appropriate therapy, as differences exist in the extent of the treatment necessary based on the severity of the lesion and any potential underlying factors. Typically, the lesion should be clipped to allow access and air flow, and cleaned with antiseptic to reduce infection. Some hot spots are very large or very painful, so some dogs may require sedation in order for us to remove the hair and treat the lesion without causing pain or fear. Once the lesion is clipped, other treatments include topical therapy using an antibiotic/steroid/drying product, and systemic medications such as antibiotics, steroids, or medications to reduce pain or inflammation. Some dogs who are highly motivated to scratch or lick may even require an elizabethan collar for a short time to break the cycle of traumatizing the hot spot. The therapy is dictated by the severity of the lesion, and not every dog will require all the treatment options. For those with recurrent lesions, it is important to try to determine any underlying factors. Fortunately, most hot spots will respond quickly to treatment, but some can take 2-3 weeks to resolve fully.
There are some things that you can try to do to prevent and reduce the incidence of hot spots in your pet and to minimize the severity. Your veterinarian will develop a personalized flea and tick control plan for your dog, which will reduce two major sources of itching that can lead to hot spots. Be certain to dry dogs thoroughly after bathing or swimming. If you have a pet that is prone to ear infections, perform all recommended routine cleaning and treatments, as well as keeping any excess or matted hair trimmed from around the ears. For those pets susceptible to developing hot spots, routine daily examination of the skin and hair coat to detect a lesion in the early stages can lead to earlier treatment and help reduce the severity and recovery time needed for treatment. Because hot spots can progress quickly, if you find an area of moist matted fur, moist red or tender skin, or even a greenish bad-smelling area on the coat or skin, call Animal Hospital of North Asheville for an appointment.
Thanks to Dr. Golden's treatment and the excellent care provided by Sam’s owners, Sam's lesion is on the way to fully recovering. Sam appreciates that he is pain and itch free now, and enjoys the extra attention he gets during “hot spot patrol” checks of his skin by his family!
