Thanks, Antony. Thank you all as well for, for registering and logging on tonight. I know it's hard after a busy day at work to, to come back and think about more work things, but, well, especially as the sun is still actually shining, so well done for, for, for coming in indoors.

Anthony gave a very thorough description of my sort of history. As he said, I qualified from Edinburgh in '97 and we didn't really have any dentistry, to speak of. I think we had one clinical club lecture and Maybe an afternoon Scaling teeth with the anaesthetist.

So I got into small animal practise and seeing obviously a lot of dentistry cases and didn't really know what I was doing and felt that it was all quite brutal. So I did some CPD with the British Veterinary Dental Association. And of course, like most things, when you learn how to do something properly, you get much more enjoyment from it.

And I could see immediately that the animals were much better off the dentistry, and, and, you know, they made much quicker recoveries and the clients would often comment that the animals were, you know, back to the, back to their old selves. So I've stuck with dentistry and I find it's a fascinating subject because it's, it's so common. There are so many dental problems out there.

To be detected, and I feel that we can make a massive difference to our patients if we detect problems and treat them adequately. So as Antony said, these webinars have been kindly and generously sponsored by pedigree, and I'm very happy and excited to be working with them on this project because pedigree are certainly Dedicated, to researching oral disease in dogs and cats, but they're also dedicated to education and they're dedicated to educating the general public, but also vets as well. Now some of you or most of you may have seen these flip charts, and they're very, very useful, they're nice to have in the consulting room.

And they, they stand up and you can flip the chart over and it goes through various things. If you are not too hot on your sort of oral anatomy, this gives you a little pinpointer there. It gives you all the the tooth numbers if you're not sure about the Trid down numbering system, this gives you a refresher.

And then it goes through oral diseases, in particular periodontal disease and you can show the client exactly what's going on in their pet's mouth. So. These are nice tools to have in the consulting room, particularly when you're making recommendations to clients for treatment options.

And if anyone hasn't got a flip chart and would like one, then the contact at pedigree is Mary Louise, and that's her email address. I will put that at the end as well. So if you don't have a pen at the moment, you can jot it down at the end.

There is a cap version as well, which is also really useful. So thanks again to Pedigree. And let's get started.

I'm going to go back to basics now and as Anthony predicted, there might be some big furry creatures in here that we're not used to treating. This is Zia. She's an Asiatic tigress that I helped Lisa Milla.

Treat at the Isle of Wight Zoo. Now if you look at the size of her canines, you can see they're pretty much the same size as my fingers. They're, they're huge.

So have a think about what actually keeps teeth in the jaws. Z's designed to be a killing machine to go out and catch deer and pigs and things like that, and she really doesn't want her teeth to to come out of her mouth when she's, she's doing that. So.

Have a think about what keeps the teeth in the jaws, because if we want to extract teeth, then obviously we need to overcome those forces. Hopefully you will have all have thought of the periodontal ligament. And the periodontal ligament is essentially attached on one side to the bony socket, the alveolus.

And the ligament fibres sort of sling across the socket and then are embedded within the cementum, which is the covering of the root surface. So if enamel covers the crown. Cementum covers the root.

But then the tooth is also attached to the jaw by the ginger, and I think a lot of vets forget this. The gingiva is a soft tissue which is attached to the actual tooth surface, and we'll talk about that more in a moment. There are other things that carnivores have have used in the evolutionary pathway to help keep their teeth in their mouths.

So we have multi-rooted teeth. So here in this mandible, we have several teeth that have two roots. In the maxilla, of course, we have 3 rooted teeth.

So here's the upper 4th pre-molar and the 2 maxillary molars with their 3 roots. Dogs and cats also have quite divergent roots, unlike human roots that are relatively sort of straight, carnivore teeth, as I say, need to be kept in the jaws, so the roots tend to diverge, and anyone that's familiar with woodworking will be quite familiar with the dovetail joint. My father was an amateur carpenter, so I kind of grew up seeing his dovetail joints.

And these of course help teeth from being pulled straight out of the mouth. So if we're trying to extract a multi-rooted tooth, then we need to section it into separate crown and root fragments and then extract it as if it were a single rooted tooth. We also get anatomical variations and these can pop up, not uncommonly, and they can fool us if we, we don't have the luxury of, radiography.

Here we've got 3 teeth that we're expecting to see 2 roots, and in actual fact, what we can see on each of these teeth is that there is a 3rd root snuck in there which if we didn't take a radiograph, we would be unaware of and we could potentially leave that root segment behind. Here's another slight variation. This root is bent.

It's what we call a dye laceration. And again, if we don't take an X-ray and we're not aware of this, we could be running into trouble when we're trying to extract this tooth because we're not aware of its presence. Some teeth also have grooves in them, and they're designed to stop the tooth from rotating.

So this lower mandibular first molar, if we look at an extracted root, we can see there's a groove running down the middle of it. And again, that's designed to stop the tooth basically from moving out of the jaws. So when we take teeth out, when we extract teeth, we've basically got to overcome all of these forces.

But we want to do that in a way which is a traumatic for the patient. We also want to try and optimise a rapid and comfortable healing period. We need to be conscious of giving our patient the maximum amount of pain relief that we can.

And we also need to use techniques that are consistent with what would be considered current recommended techniques. Now, a colleague of mine did a locum recently in a practise, and this was the equipment that she was faced with in the dentistry box. And if you're not sure, then this is probably not current recommended techniques.

So we do need to keep up to date with things. And, and certainly a hammer and chisel is, is pretty much mediaeval, so. If you've got any lurking around in your den in little boxes, I would suggest you go and throw them away tomorrow.

So what I'm going to talk about now is, is essentially the, the two different extraction techniques that we have. And then what I'd like to do is to talk about how we make decisions when we're faced with a clinical case, how do we decide, am I going to extract that tooth or not? And if so, how am I going to extract it?

We have what's called closed extractions, and we also have open extractions. In the past, we used to refer to them as either surgical or non-surgical. Now that's a bit of a misnomer really, because any extraction is an act of oral surgery, and I think that's quite an important point to think about.

We're all used to the term dental. We're used to sort of saying that we've got 3 dentals today or we've got to do a quick dental before lunch, but the term dental doesn't actually tell us much at all, if anything, about what we're about to do. And certainly the client will not understand the term dental if you tell her that fluffy needs to come in for dental next week.

However, if you describe extracting teeth as as oral surgery, then it puts a lot more emphasis on, on what you're actually doing, and it helps to, It it helps to back up really what you're asking the clients to, to pay for the, the treatment. So if we think about closed extractions to begin with, as I said before, if we've got a multi-rooted tooth, we're going to section it. And then what we're going to do is to sever the gingival attachment to the tooth.

Now, remember, the gingiva is attached to the tooth. So what I use to do that is either a number 11 or a number 15 scalpel blade. I'm just going to insert that into the gingival sulcus all the way down till I feel the alveolar bone and then go all the way around the tooth so I'm, I'm cutting that attachment.

I could also use a sharp luxator blade to do the same thing. If you've ever tried to extract a maxillary second molar, you know, the very last tooth in the in the top jaw, and you pull it out and you kind of have half the soft, soft palate coming with it, it's because you haven't severed that attachment. We're then going to use hand instruments, so luxats or elevators or both, and we may use forceps as well to deliver either the single rooted tooth or the crown root fragment from the socket from the alveolus.

Suturing is, is, is not essential, but I like it. I suture probably 99% of my sockets when I've extracted a tooth, and most veterinary dentists would do that as well. And we'll talk more about suturing towards the end of the talk.

But essentially it does help the tissues to heal faster. I think the patients are more comfortable for it, and also they don't tend to then get food and other material trapped in the socket which can of course delay the healing. So in this photograph is this sort of several important things to, to look at.

One is that the operator is holding the jaw with their left hand. So we're not pushing down on the jaw on the table with all of our body weight, OK? We're holding the jaw that we're working on so we can feel how much pressure we're applying to that tooth.

And then the hand with the luxator has the index finger extended down the shaft of the instrument very, very close to the tooth. And that, of course, will help if we do slip to stop us from spewing the poor patients to the table. So that's the correct technique for for holding the instrument there.

And then what we're doing is we're, we're advancing that Luxator into the periodontal ligament space to close periodontal ligament fibres. We're working all the way around the circumference of the tooth, and then very often the tooth will almost sort of pop out in your hands as you're doing that, or you can deliver it with some. Extraction forceps.

And here we are we are suturing that socket, so we're just placing one or two simple interrupted sutures just to keep the blood clot in that alveolus. If we compare that now to a surgical or open extraction. The difference is that in this technique, we're creating a muco gingival flap.

So what we're doing is we're taking the gingival tissue, we're crossing the muco gingival junction, and we're extending our flap onto the oral mucosa. We could also call it a muco gingival periosteal flap, because what we're doing is raising the periosteum off the alveolar bone so that it will be the undersurface of our flap when we create it. Now that essentially gives us increased access.

It allows us to remove the, the buckle bone, the lateral bone. We then use hand instruments to again deliver the tooth. And before we finish, we're going to make sure that all the bony edges are smooth.

We don't want anything sharp that will irritate the gum. And then we're going to suture the flap back into position using a tension-free technique, and we'll talk about that more in a little while. Many people or many vets think that a surgical extraction is only for the canine tooth, and many students say that to me as well when I, when I help to teach them.

Excuse me. And I think that's possibly because, the only times that students see surgical extractions is when they're seeing a canine extracted. But I do do, most of my extractions are surgical extractions, .

And particularly in this case, if I'm looking for incisor root fragments in this cat, I'm certainly going to do a surgical approach because it gives me better access. It allows me to see what I'm doing, and it means that I'm not blindly digging around in the poor cat's mouth, creating lots of trauma and not not achieving anything. This incision that you see on the left is what we would call an envelope flap, so there are no vertical releasing incisions.

And if you're wondering where the root fragments were in that incisive bone, there they are. So let's think now about why we might need to extract teeth, and of course you're all familiar with periodontal disease, that's probably the number one reason why we're going to need to extract teeth in practise. It's a very common disease, it's common in cats, it's common in dogs, and of course it's common in people as well.

If we think now about normal periodontal anatomy, this is an area that you should have sort of ingrained in your minds. This is the key area for the whole of periodontal disease, really, particularly that gingival sulcus. So this is a cross section, the illustration was drawn by, David Crossley, who's a veterinary dentist, and has kindly, lent me to use in talks.

So this is a cross section, a longitudinal cross section of a tooth in its sockets. So on the left we can see the soft tissue, the oral mucosa coming up to the mucogingival junction. And then we have the gingiva.

We have attached gingiva, which is attached to the alveolar bone underlying it, and then the free gingiva is not attached to the bone. And then the gingiva reflects back on itself. And it's attached to the tooth, and where you see JE that's called junctional epithelium, and that acts as the attachment of the soft tissue to the tooth, and that's the area that we're really concerned with.

If you think about it, there's nowhere else in the body where the epithelium is actually broached. Here in the mouth, the epithelium is broached by the tooth, so essentially we have direct access down into bone. So it's an essential area for the body to try and keep free from bacteria.

But of course bacteria are ubiquitous, so the oral environment is full of bacteria. And we can think of that junctional epithelium a bit like the collar of a shirt. It's designed to keep a tight seal around the tooth to stop bacteria from entering further down into the periodontal tissues.

The periodontal ligament, remember, is attached on the tooth side at the cementum, and then it's also attached to the alveolar bone, and the periodontal ligament. Essentially acts like a shock absorber. It's like the suspension in your car.

It's there to allow the tooth to move very, very slightly. So when we eat our food, if we're a carnivore, if we go and kill our food, the tooth is allowed micro movements. If it was fused to the jawbone, then it would break very, very easily.

The other important thing to consider when you're extracting teeth is that The majority of the connective tissue in the periodontal ligament is made of elastic fibres, and this picture is to demonstrate the fact that you could stretch an elastic band and let it go and then stretch it again all day if you wanted to, but you wouldn't break that elastic band. To actually tear the fibres in the periodontal ligament, we need to stretch them and fatigue them. And then hold them.

So if you've ever been to a practical dentistry course, you'll be familiar with the phrase twist and hold. And what that means is we're placing our elevator into that periodontal ligament space. We're twisting the instrument to stretch and tear those periodontal ligament fibres, and then as we hold the instrument in that position, the fibres will begin to break down.

What I see some vets doing in practise and some students doing when they're trying to extract teeth, is that they put the instrument in the periodontal ligament and then wiggle. And unfortunately, wiggling is not going to break those fibres. So let's think about how we diagnose periodontal disease.

One of the reasons I love dentistry is, is because diagnosis is, is very, very easy. You use your eyes and, and generally fairly cheap tools. So we need a periodontal probe.

And hopefully, you're all familiar with, with what that is. It's a blunt ended instrument with graduated millimetre markings. This is a 15 millimetre probe.

And then ideally what we're going to use to supplement that is radiography. I'd be interested to know how many of you listening tonight have dental radiography. I think more and more practises now are getting it, and certainly it it really should be seen as a sort of a baseline diagnostic aid really for dentistry.

You can use radiography in so many ways, not only to make a diagnosis, but also when you're explaining the disease to your clients, I think it helps them to understand what's going on in their pets mouths much more easily when they can see what's happening. And here we can see we've got periodontitis happening in this this mandible, and sometimes we can pick up things on radiography that we may not have detected with either our probe or our visual inspection. So if we're going to use our probe, we need to know what's normal in cats we would consider.

Up to 0.5 millimetre is normal. Perhaps a millimetre on the canine tooth.

And in the dog we have sort of a range depending on the size of the dog. So for instance, in a Labrador on the canine tooth, then 3 millimetres would be acceptable. But if I was probing the gingival sulcus in a Yorkshire terrier.

And the incisor tooth had a probing depth of 3 millimetres. I would be very worried about that. So how do we use the periodontal probe?

Well, we're going to insert it into that gingival sulcus very gently until it reaches the attachment to the tooth. We're then going to walk it around the tooth circumference. And we need to make sure that we check the entire tooth circumference.

So that means we're going to look on the inside surfaces as well as the outer cheek surfaces of the teeth. So here you can see even the just around that buckle surface of the tooth. And what's interesting here, if you compare the initial picture on the left to when we finished on the right, you can see that we've induced fairly moderate bleeding there.

I've already probed the incisor teeth, and you can see they're bleeding as well. So, We have a diagnosis already. We've got gingivitis, and that is a disease that needs treatment.

And interestingly, if you look at the tooth, it doesn't look particularly doesn't look particularly inflamed. There's not a lot of plaque or tartar accumulation, and yet we're seeing marked bleeding there when we're probing. So this is essentially what we're measuring when we place our probe into the sulcus.

We're measuring that depth. We're measuring from the free gingival margin down to the junctional epithelium attachment to the tooth. Sometimes though, we get abnormal probing depths, and in the cat on the left you can see we've got about a 9 millimetre pocket on that palatal surface of the canine.

You can see there's marked bleeding associated with it. And in the maxillary molar on the right in a dog, we've got again, probably more like a 13 millimetre pocket again on that palatal surface of that tooth. What both of those slides are designed to show you is that you must check those pallatal surfaces.

Don't just probe the outside cheek surfaces because you could miss pathology. So let's think now for a minute about periodontal disease. You will know what periodontal disease, we will hear about it very, very commonly.

But To just to take you back to some basics for a moment, I think is never, never a bad thing. Periodontal disease is a chronic disease. It's an infectious disease, and it's caused by plaque.

Plaque is the etiological agent. We have these two specific diseases. We have gingivitis and we have periodontitis, and the umbrella is periodontal disease.

So what is plaque? Plaque is a bacterial biofilm, and a biofilm is a very clever community of bacteria that have learned to stick to a particular surface and then to congregate together and create a community that can protect itself from external agents, like, for instance, antibiotics. In the oral environment, we know that at least 300, if not 500 species of bacteria are likely to be involved.

But we do know that certain bacteria are more likely to be involved and we term those periodonto pathogens. So species like Porphyromonas, so Porphyromonas gua, Porphyromonas denticanis, and porphyromonas gingivalis, those are all very common pathogens, spirochetes, fusiformes, prevatella. They're all very common perdon to pathogens.

So they start by attaching to what's called this pellicle. Now, the pellicle is a layer of salivary glycoprotein, and it probably acts to lubricate the tooth and give it some initial protection. But unfortunately, bacteria can colonise that pellicle.

And then the early colonisers are able to attract more bacteria, and so we get the biofilm growing and maturing. You can only really see plaque if it's very thick, or if you use a disclosing solution. So remember those pink tablets we used to eat when we were children to see how good we were at brushing our teeth.

There are veterinary specific plaque disclosing swabs that you can get, and these are again are quite nice to have in the consulting room. You can use them to see how well or badly the client is getting on perhaps with toothbrushing, for instance. And you can also use it when you're performing dentistry just to make sure that you haven't left any plaque behind when you've done your scaling and polishing.

Calculus is also known as tarta. It's the same thing. I tend to use the term tarta when I'm talking to clients because I think they understand that.

They, they, they know what tartar is. Essentially, tartar is formed when plaque is not removed. So with time, minerals, so particularly calcium and phosphorus are absorbed onto the plaque, and it hardens to form what we know as calculus.

The most important thing to understand is that calculus itself is not pathogenic. You can autoclave calculus and embed it in the gingiva, and it won't cause periodontal disease. It's the plaque on the calculus surface that creates the disease.

And Calculus in itself is very, very rough, and plaque bacteria like a rough surface to stick to. So essentially, if you've got tartar there, you'll get more plaque, and so the situation will, will snowball. But what a lot of vets will do when they look in dogs and cats' mouths is they see a lot of tartar and they say, Oh my God, your dog's mouth is terrible.

We've got to, got to have him in quick for, for a dental. And then you clean all that, that tartar off and actually the periodontal health is really not too bad at all. On the flip side, you could have a dog with very, very little tartar, but actually have pockets of perdontitis that you would not detect unless you did very thorough probing.

So gingivitis, as I said, is caused by plaque, and gingivitis is essentially inflammation of the gingiva. So here we can see our gingiva has become red and swollen and edematous. And essentially, gingivitis may be reversible.

If we can start removing that plaque on a regular basis, then potentially we can get that gingiva back to normal clinical health. It's important to understand that at this point, the tooth has not lost any attachment. However, gingivitis may or it may not, but it, it could and can in, in many instances progress to periodontitis.

Now this is a chronic progressive disease where we start to see attachment loss for the tooth. And essentially what happens, the epithelial attachment starts to migrate. So whereas it started at the cemento enamel junction, the epithelial attachment migrates towards the tip of the root, so it migrates towards the root apex.

And we typically see bone destruction and periodontal ligament destruction. So here you can see our attachment now is much further down the route. We've created a periodontal pocket, essentially.

Look at the level of the gingiva, that's still in the same position, so we've got no gingiv recession there. So this is what we know as a periodontal pocket. A periodontal pocket is pathological.

A gingival sulcus, on the other hand, is, is normal anatomy. So that's now the depth that we will measure when we insert our periodontal probe into that pocket. So now you can see why we've achieved those deep probing depths on those two teeth, because we've got periodontitis in that area.

We've lost bone, we've lost periodontal ligament, and it's allowed our probe to pass. Much, much deeper than is normal. The other important thing to consider is that the attachment loss is not only driven by the pathogenic bacteria and their toxins, but also the way the host deals with it.

So their immune response will be quite responsible for a lot of this destruction. So many cytokines will get turned on and osteoclasts will get activated and the net result really is that The body is doing a lot of the damage in this disease process. So yes, we need plaque there, but the way the body's response deals with it will determine how aggressive the disease is.

So if we're thinking about bone loss now, how do we detect bone loss? Well, again, it's very simple. We use a periodontal probe and we take radiographs.

There's 2. Basic types of bone loss, there's vertical bone loss, and that's essentially bone loss, which is vertical in relation to the root axis. So here we've got vertical bone loss on this mandibular molar.

So if we look at the uppermost root, which is the, the caudal or distal root, we can see that we've lost nearly all of the bony attachment to that root. And then on the front root, the medial route, we have this pocket that's formed. On the very medial or front aspect of that route.

Now the other interesting thing to notice about this X-ray is look how close that route is to the mandibular cortex. Now with the luxury of digital radiography, we can measure that distance, and that was 0.7 millimetres.

So without radiography, if you wanted to extract this tooth, then you would section it and then the caudal or the distal root would probably be very easy to extract. You would section the tooth, and that root would probably fall out because there is no attachment for it. But have a think now about how challenging that front root is going to be.

We've only lost a little bit of attachment, and the, the rest of the bone is still attached to the root. We've also got that funny little kink in the tip of the root, that dilaceration, and now we've only got 0.7 millimetres of mandibular cortical bone underneath it.

So if we don't have that X-ray and we go in a little bit too heavy handedly with our elevator, we could quite possibly end up with an iatrogenic jaw fracture. The other interesting thing is that if the periodontitis continues on that front route, then that in itself could destroy that mandibular cortical bone, and we could end up with a pathological jaw fracture. So the, the dog is there eating his morning breakfast, bumps into another dog, and another dog comes and bumps into him, and he ends up with a jaw fracture.

And we know from research that in small breeds of dog, the root of the mandibular molar takes up a much bigger proportion of the mandible than in a larger breed of dog. So in your Yorkies and Maltese, the mandibular molar root is quite likely going to take up to 90 or 95% of the height of the mandible, whereas in a bigger breed of dog like a Labrador, maybe 50 or 60% of the height of the mandible. So that's why we, we, we are very worried about sort of periodontitis in small breeds of dog, particularly on that, that mandibular monlar tooth.

Horizontal bone loss is where we have bone loss, basically running at right angles to the long axis of the root. So essentially parallel to the the mandibular cortex and the alveolar margin. And in this example, we can see we've both got vertical bone loss and horizontal bone loss.

The blue line is the, the horizontal bone loss. This is what a normal mandible should look like, and there's there's various things that we can look at on that to know that the good, the alveolar margin, that bone should be slightly sort of convex or or rounded. It certainly shouldn't be concave or scalloped.

The blue star is what we call thefacation area, that's where the two roots divide. That area should be filled with alveolar bone. And lastly, if we look at the periodontal ligament, which is the black radiolucent line surrounding the tooth roots, that should be an even width all the way around.

What we don't want to see is any widening of that periodontal ligament space. Sofacation involvement, so the area in between the roots where they diverge, we may see the ocation, it may be visually obvious, but we're going to check that area with our periodontal probe. If our periodontal probe can start to move into that vacation area, we know that there is bone loss.

We know that there's periodontitis there. So here in this dog, the upper 4th premolar, I've now turned my periodontal probe at 90 degrees towards the tooth, and I've inserted it into that ocation there and it's gone all the way through the ocation. And if we look at the X-ray, we can.

See that that upper 4th premolar has got bone loss not only in the vacation area, but also around that that caudal or what we call distal route. And then also the 2nd premolar has also got bone loss in that vacation area. It's very common in these small breeds of dogs where their teeth are rotated and crowded together for them to get advanced preydontitis, because the plaque finds it much more easy to stick to teeth that are that are crowded and rotated.

We can judge how much ocational bone loss there is, if we are just detecting the facation, then we would call that an F1 lesion. If we can get our periodontal probe up to about halfway through that vacation area, it would be an F2. And if my probe goes all the way through to the other side, we'd call that an F3.

And we can see that in this, this cat's tooth there. And the point is you may not see that vacation, but unless you're testing that area with your probe, you won't know that there's a problem there. Tooth mobility is another reason why we may need to extract teeth.

This again is further evidence of attachment loss for the tooth. And I think historically and perhaps even to this day, one of the ways that we've performed dentistry is to take out the mobile teeth and then clean what's left. And, and that is again, it's quite a mediaeval approach to dentistry.

You can't imagine any human dentist doing that. . If we look at mobility, we can again, we can describe how much mobility there is, there is, dentists like scales of 3.

So most things will have a scale of 1 to 3. The mobility score of 1 would be the initial sort of first movement that you can see, so less than a millimetre. A mobility score of 2 would be over a millimetre of movement, and then a mobility score of 3 would be marked movement either horizontally and or vertically or any movement in a 3 rooted tooth.

So we shouldn't expect a 3 rooted tooth to move. If we've got movement in a 3 rooted tooth, it means we've lost a lot of the attachment. Here's a video, I hope that you'll be able to see it for.

In that that first molar there. So those are pretty obvious cases, but the important thing is that we're checking that vacation area to see for any bone loss. Gingival recession is a is another .

Finding that that will tell us that there's attachment loss, and we're going to measure that that gingival recession again with a periodontal probe. And what we do is we measure from the gingival margin to the cemento enamel junction. So that's the distance that we're measuring.

When we see that recession and that again will go down onto our our our dental chart that we're recording. And I would urge you all, if you're not using dental charts to start using them, they are a medico-legal documents, so they should form part of the patient's clinical records. But if you ever get the misfortune to be involved in a complaint against you regarding dentistry, the first thing that anyone will want to see is your dental chart, and they shouldn't just be naughts and crosses.

They shouldn't just be this tooth was missing and we extracted this tooth. If you're extracting teeth, you should make very, very clear. Evidence about why you're extracting that tooth.

So there may have been an F3 and a mobility of 3, or there may have been a 10 millimetre probing depth, but make sure you record everything accurately. The other reason that that's important is that you can then monitor that patient. So if you get the same patient in a year down the line, you can get out your old dental chart and you can see is the disease getting worse or is it stationary.

So let's try and think now about how much attachment loss there actually is. Normal teeth obviously don't have any attachment loss. Attachment, sorry, early periodontitis, we would see less than about 25% attachment loss.

Moderate periodontitis, we're going to see somewhere between 25 and 50% attachment loss. And then with severe disease, we'll see over 50% attachment loss. And the way we just decide that is to take a radiograph and we look at the bone height.

Now if you look at these in sizes, this is from a dog. The blue lines basically represent at one end, the cemento enamel junction and at the other end, the tip of the root. And essentially we want that area to be filled pretty much with alveola bone.

And if we actually look where the alveolar margin has come to. We can see that we started to get quite marked attachment loss for these three teeth. So on the, in the upper tooth in the lateral incisor, we've lost a small amount of bone there, maybe sort of less than 10%.

In the middle incisor, we've lost maybe up to sort of a third on one side and approaching maybe 50% on the other. And then in the The first incisor there, we literally only have about 1/3 of the amount of attachment that we should have. So how does that help us make a decision?

Well, we need to consider several things. We need to consider the tooth's functionality. And if we consider a dog's mouth with it having 42 teeth, there are really 8 teeth that are important and the same for the cat with its 30 teeth.

We've got 4 canines and 4 carnassios. Those are the really important teeth that we would like to save if possible. But we then need to consider the client.

Is the client somebody who is committed to home care, who wants to save as many teeth as possible, and they're perhaps already brushing their, their pet's teeth and using other aids as well, or there may be a client that, that really can't be bothered or doesn't want to brush or can't brush, or for whatever reason, they would rather you extract teeth, you know, in, in the first sitting. And that's the conversation that you really need to have at the outset with your client. The other thing I would urge you to do if you have spoken to a client and said to them, Well, I don't think there'll be any extractions, and then you get the pet on the table under the anaesthetic and you examine it and you realise you actually need to take 345, 10 teeth out.

I would urge you to always phone the client, take a minute out of your anaesthetic time to call the client and discuss it with them and warn them. Because clients will much prefer that than turn up to pick their pet up only to be told that Fluffy had 20 teeth extracted when they weren't expecting that. So keep the client up to date with what you're doing.

So essentially if we want to make a decision about whether a tooth stays or goes, then These are the kind of guidelines for, for what is a recommended idea for definitely extracting teeth. So if you've got over 50% attachment loss, if the tooth is severely mobile, or if you've got stage 3, so that's through and throughfacation exposure. So these would be absolute recommendations.

Those teeth really have to go. And I was chatting to Antony before we started, and he said his dermatologist's view of dentistry was, if in doubt, take it out. And I think there is a certain ring of truth to that.

I would much rather we take teeth out than leave a tooth behind that is either going to be painful or a source of infection for the pet. And we can see a number of things in this X-ray. So the Mandibular first molar, that medial roots are the left hand route.

We've lost 100% of attachment for that root. The molar behind it has lost 100% attachment for that first root again. We've got horizontal bone loss.

We've got facation exposure. And interestingly, with the mandibular first molar, we've also got other pathology that we can see as well. The red circle is an area hopefully you can see there's some lucency within that tooth.

That's because the infection has tracked down through the periodontal ligament, gone in at the tip of the root, and entered the inside of the tooth, the endodontic system of the tooth, and we've now got internal resorption. That has then resulted in a lesion on the other roots. So it has what we call a perioendo lesion.

So it's got an abscess on the other roots because of the periodontitis around that, that. Front root. So now I'm gonna move on to other indications for extractions.

You're all familiar with tooth that are fractured, and these are potentially challenging because remember the tooth is not mobile. The tooth is not periodontally compromised or it may not be. And these are what we call complicated crown fractures, so the pulp is exposed in both of these cases.

These are painful. If the pulp is exposed, they're painful. The nerve fibres in pulp, are essentially just no receptors.

They're just pain receptors. The other important thing is that pulp exposure will allow bacteria into the inside of the tooth, into the endodontic system, and really there are two treatment options for this. You either extract the tooth or you refer it for root canal therapy.

In both of these cases had root canal therapy. But that might not be something that the client wants. Just to sort of sidestep very slightly fresh fractures in young dogs, so dogs that are under 18 months of age and cats as well.

Ideally, we should see those within 24 hours. And the reason for that is very young teeth have not had a chance to mature properly. If you look at the X-ray on the right, the dentinal walls are very, very thin and The pulp is basically what causes the dentinal walls to get thicker as the animal matures.

And if you look to try and see the tip of the root there, you won't be able to see it because it hasn't actually formed yet. So in these young animals that break their teeth, if we can get to them quickly before the pulp gets infected, Apply a dressing and then restore the tooth, potentially the pulp will stay alive and that will allow the tooth to mature and achieve its normal, normal strength. So I'd like to ask you all a quick question now.

This is a 3 year old female neutered Labrador. She doesn't have any facial swelling. There's no sinus tract, and the client reports that the dog is eating well and is absolutely fine.

Now, there's 4 potential things that you could say to the client, and I don't want you to Tell me what you think the right answer is, because there isn't really a right answer. So have a look at the question and the answers. And what would you say to this client if you saw this client walk through your consulting room door tomorrow?

So if we could launch the poll, please. I've launched that poll for you, Rachel. So the poll is on everybody's screen.

The question is, what would you tell the clients? You can just select your answer by clicking onto the screen. So the first option is, let's monitor it, it doesn't seem to be causing any problems or examine the tooth under an anaesthetic and take an X-ray.

Refer to a veterinary dentist for an opinion. Or the last option is we need to extract the tooth. So if you can just select which answer you'd like.

If you are joining the webinar on an iPad, I'm sorry, you can't, click your select your answer, you can just type into the question box. Just read the results out to you, Rachel. Everybody else should be able to, to see those.

13% of people have said they would recommend the client, let's monitor it. It doesn't seem to be causing any problems. 64% have said examine the tooth under anaesthetic and take an X-ray.

3% refer to a veterinary dentist for an opinion, and 20% of the audience have said that we need to extract the tooth. OK, that, that's interesting. I, I would be happy with, with answers B, C, or D.

The the answer that I'm not happy with is, is let's monitor it. It doesn't seem to be causing a problem. Because what I'd like to ask you is what are we actually waiting for?

What are we monitoring it for? And I think what most of the time we're waiting to see is either some kind of facial swelling or perhaps some kind of sinus tract. So let's have a look at this, this dog's X-ray.

And what we can see, hopefully you can see that there are 3 routes to that upper carnassial, and hopefully you can see that there are radiolucent areas around each of those 3 roots. And that is essentially consistent with an abscess on each of those two roots. And this dog did not have a facial swelling and it didn't have any sinus tract.

And probably why that happens is that if there is an area for the, the gases that the bacteria that are there are producing, if there's an area for them to vent, then it's unlikely that we're going to see either a sinus tract or facial swelling. So in this case, So there was quite a nice open venting area for those, gases that are produced by the bacteria. So that's why we didn't see any swelling or sinus tract.

But this dog was undoubtedly in pain with this too. So this tooth needs treatment. So how are we going to extract a tooth like that?

It's not mobile, it's periodontally sound, and it's got three roots. So this is perhaps one of the more challenging teeth to extract. And what I'd like to do now is just sort of run you through a way of extracting the maxillary 4th premolar.

A little bit of anatomy just to refresh your your minds on the left is a skull. We've got the infraorbital canal which runs above that maxillary 4th premolar. Don't forget we've got an artery vein, and nerve in there.

And the tooth roots actually will lie very, very close to that in orbital canal. So we don't want to be either slipping with our instruments or going too far if we're drilling because we're going to end up either damaging the nerve or artery or vein. And in fact, the canal can actually run between the two most rostral routes there.

A little bit further back, if we look at the oral mucosa there, we've actually got salivary ducts. Now that's obviously more pertinent if we're taking the, the first molar tooth out or the second molar, but it's also important to be aware of that if you're working in that area. So what I'm doing here, I'm making my, releasing incision for my mucogingival flap.

So my incision on the gingiva is, is sort of perpendicular to the gingival margin. And then when I reach the oral mucosa, I'm just diverging very slightly. So I've got a nice wide base for my flap.

And my left thumb in the, in the top left corner of the photograph is, is holding that neurovascular bundle out the way when I make that incision. And that will also tense that oral mucosa so that it makes my incision much easier to make. And I'm gonna make that incision right down onto the bone, making sure I cut through the periosteum as well.

I'm now going to use my periosteal elevator to raise the flap, and I've got all sorts of different sizes of periosteal elevators. You shouldn't just have one in the drawer, you should have a variety because you need to treat cats, large dogs, small dogs. So it's a good idea to have a range and also keep those instruments nice and sharp.

And what you'll see is I've made a triangular flap, so we've got one rostral releasing incision. And there is no cordal releasing incision, we've just elevated the ginger there off that first molar. I'm then using my high speed drill, my high speed handpiece with a water called burr to remove some of that buckle bone.

Some veterinary dentists will never use a high-speed drill when cutting birds. Because we can't have sterile water coming through the high speed handpiece. So some veterinary dentists will use the low speed handpiece, and they will get the nurse to sort of trickle saline on as they're drilling, or they'll use a specific oral surgery unit.

Many veterinary dentists that I do know do use a high speed hand piece as well. So if you're using a high speed, make sure that you have water cooling so we don't get thermal necrosis of the bone. And essentially what I'm doing here, I have removed some of the buckle bone.

I've also Gone down onto where the periodontal ligament is so that I can see the periodontal ligament. And then I've used a slightly different burr. I was using a round burr to remove the bone.

I've then changed to a tapered fissure burr. And the size I like to use is a 701. And I've sectioned the tooth, and what I've done is I've sectioned that caudal root from the front two roots there.

So the dog's nose is facing towards the left and the back of the head is towards the right. And then what I'm going to do at that point is remove that quarter root. Here I'm using a luxator.

So again, look, my index finger is at the very end of the instrument and I'm introducing that into the periodontal ligament, and the luxator is designed to cut the periodontal ligament. So I'm advancing it apically. And my index finger will hopefully mean that I shouldn't slip.

I'm going to also do that on the the rostral surface so I can go through the space that I've created by sectioning the tooth. Once I have some mobility in that fragment, I can then use forceps, and I'm going to apply the forceps as far down the crown as I can towards the root, and I need to ensure that the beaks of the forceps have got good 4 point contact with that tooth segment. Now, Extraction forceps are designed really for human tooth extractions, and if you look at a dental catalogue, you'll see that there's all sorts of shapes and sizes, and that's because you use a specific forcep for a specific tooth.

Now, not all human extraction forceps are suitable for dog or cat teeth. One of the patterns that is suitable is a 76 or 76N which has slightly narrower beaks. They provide good, stable contact with the tooth, and they would be certainly appropriate.

And what I'm doing, I'm not doing any fence post wiggling because that will probably break the root. What I'm doing is applying very gentle rotational force whilst applying traction. And then again, I'm not going to wiggle, I'm going to just apply that force and then hold it in that rotated position.

And that again will help to break down the periodontal ligament fibres. Once I've got that caudal root out, you can see there's a nice blood clot in the socket, which is what I want. And then at that point, going to section the front two roots, the rostral or medial two roots, and you can see I've made my section there at a kind of 45 degree angle.

And what I've actually done to make it more easy for myself is to remove the whole crown of that segment so I can see where to section it more clearly. At this point, I'm then going to remove that outer or buckle root. I'm going to leave the palatal root to the very end.

Again, the same technique I'm going to use my luxator or my elevator to work around that circumference of that tooth root fragment. And again, when we're finished, we've got a nice healthy blood clot. What we need to do now is extract the palatal root, and there is a shelf of alveola bone between those two front roots.

So what I'm going to do is use my drill now to remove some of that alveolar bone. That's removing some of the attachment for that tooth. So it should make it easier to actually get that last fragment out.

So I've got all three separate crown root fragments out. I'm gonna take an X-ray to make sure that I haven't left any bone fragments behind or of course tooth root fragments. And then I'm going to close my flap, and what we do initially is to smooth all the bony edges.

If you run your gloved finger over that area, just have a feel for any sharp points. Imagine what it would feel like in your own mouth if you left any of those sharp points behind. Here I'm using a diamond burr, a fine diamond burr.

Just to smooth off those bony edges, you could also use Rojour, which are very nice. They collect the bony fragments in the beaks, and so there's no sort of bone fragments that are gonna end up in your, your sockets. The other thing to notice on that image is that I'm holding the flap out of the way.

I'm just, I'm not holding the flap, I'm just gently sort of retracting it. I could use a retractor for that as well. I don't want that flap to get caught up in my drill when I use it.

I'm now using my periosteal elevator just to gently elevate that mucosa on the palatal surface. Essentially, I want something to be able to switch to. So just a millimetre or two, just elevating that mucosa off the underlying bone.

This is probably the most important step. This is releasing the periosteum. This is going to allow us to close the flap without tension.

So if you remember when we make our flap, we're raising the periosteum off the underlying bone. So the underside of our flap should be periosteum. And periosteum is very inelastic.

So what I'm doing here is I'm using my scissors in a, in a blunt sort of dissection to, to make a window or fenestrate that periosteum. And as you do that, you hopefully will feel the flap extend in your fingers. You can use a blade to do that as well.

I do do that. You just need to be careful that you don't slice through the whole flap and end up with it in your left hand, because that will be quite distressing. What I'm doing now is I'm placing the flap back into position and I'm, I'm just looking at it, and I want to see, does the flap retract on its own?

Does it pull away from the margins? Because if it does, then Flap will be under tension and it will probably break down. So by placing the flap into position and just looking at it for a moment, I can see whether it's likely to have tension on it or not.

If the flap retracts even by 1 millimetre, that will mean that there's tension and you need to do something about releasing that tension in the periosteum. So either with your scalpel blade or your blunt dissection with your iris scissors. Once I'm happy, then I'm going to place my sutures and as you can see, we've completely covered, covered the alveolus.

The clots are nicely protected in there, and this will now heal as primary intention. So it should give the dog nice, quick and comfortable and rapid healing. Just going to quickly talk about fractured deciduous teeth.

I'm conscious of the time. I don't want to keep you too long because I do want you all to have a life as well. And fractured deciduous teeth.

Many vets will say, Oh, he's broken a baby tooth. Let's just leave it because it's going to fall out soon anyway. Well, I think we should adopt a different approach because these are painful.

And the most important thing is that infection can get into these teeth and can actually affect the permanent tooth bud. There's also a couple of anecdotal reports of dogs or puppies, sorry, getting tetanus, and the only potential route of entry was, was thought to be a broken deciduous tooth. And here's a case, this is a dog that had a broken poppy tooth.

And the infection has caused enamel dysplasia. So the infection has interrupted the enamel development in the permanent tooth bud, and we've ended up with with enamel dysplasia in that tooth, and that had actually allowed infection through the dentin into that tooth and had disrupted that tooth. Growth, so that tooth needed to be extracted.

And the reason for that, if we look at this X-ray, whenever I look at X-rays of deciduous teeth with permanent tooth buds, I'm always marvelled at how amazing bodies are and how we get things right so much of the time. I wonder why things don't go wrong more of the time, but there we are. Anyway, so if we.

This deciduous tooth, you can see that the permanent canine tooth bud is sitting right underneath it. It's very easy for bacteria to track right down, and the amyoblasts, which are the cells responsible for enamel production, and they're very easily disrupted by, by infections and pyrexia. And I would certainly recommend we consider, well, definitely radiograph, but consider some kind of either surgical or open extraction so you can see what you're doing.

Use sharp instruments for luxation rather than lots of elevation or rotation, and just be aware of your anatomy. So in this X-ray, look, we've got that first premolar in green, and we've also got the permanent canine in blue there. So just be, be conscious of that when you're extracting this deciduous tooth.

This is a 2 year old Labradoodle that I saw a few years ago, and you can see a fairly obvious what looks like possibly a sinus tract there. But this, this case was interesting. And when I looked at this dog initially, I, I knew that something wasn't quite right, and I couldn't pinpoint it.

But he's, he's a big Labradoodle. He's not a little Labradoodle. He's 2 years just Cut the counts on the canine tooth.

That doesn't seem right to me, particularly when you look at the other teeth. When we cleaned that tooth, hopefully you can see that there is a hairline crack on that tooth. Now that's why there was tartar on that tooth, because plaque had stuck to the rough surface and then it had matured into the tartar.

And what had happened with this dog, he'd had a deciduous tooth that was extracted and unfortunately, the permanent tooth was damaged during that extraction. Allowed infection in and again, we've ended up with this peri apical lucency, which is consistent with an abscess or or granuloma. Just to finish up now, I promise I'm nearly finished, suture material.

A lot of people ask me what to use. Well, what we want in the mouth is something that's going to be rapidly absorbed without causing much tissue reactivity. We want something that's nice and strong in the short term.

Particularly in sutures that have got a very small diameter. We don't want them to be plaque retentive. We don't want them to wick bacteria.

Ideally, we will have good not security, low tissue drag and something that's easy to handle. And the suture material that fulfils most of those requirements is monocrol. And Virol, remember, is braided.

I know they coat it to make it essentially monofilament, but it is multi filament and it does tend to last too long. You can use Viryl rapide as an alternative, but I've found that quite brittle, in the past. It tends to snap easily.

So my suture material of choice is monorel, and I use relatively fine sutures. So in cats, I'll use. 50.

And in dogs, I'll use either 40 or 50. And if you want to jot down those codes, those are the codes that I tend to use. The difference between the, the 3203 and the 3209 is really the diameter of the needle.

The 3209 is a bigger needle, so it's quite nice for dogs. The 3203 is a much more, a smaller diameter needle, and it's much easier to get into tiny little mouths, so cats and small dogs. Use a reverse cutting needle and as I say, 40 or 50.

Simple interrupted, is, is absolutely fine, fairly wide bites of your mucosa or gingiva, and roughly 3 to 4 millimetres apart or or however many sutures you need to, to, to keep the flap, secured. And keep the blood clot in your alveolus. So the benefits of suturing are that it, as I say, stabilises the blood clot in the alveolus.

That's what we want for primary intention healing. It allows tissues to heal faster. I think patients are more comfortable, and it also reduces the risk of what we call alveolar osteitis, which is, is dry socket.

If any of you have had it, it's pretty painful and it probably happens because your blood clot falls out of the socket and then you get an infection in the socket in the bone, and that's quite, quite painful. So thank you. I'd like to thank the webinar vet for, for hosting these webinars.

And of course, again, a big thank you to, to Pedigree for, for getting involved. . Thank you for listening.

I'm on Twitter, webinar that on Twitter, pedigree on Twitter. My email address is there, and if you need Mary Louise's email for the flip charts, then that's there as well. So thank you all for listening.

I'm sorry that I've gone over, by 5 minutes. I hope you can forgive me and and tune in again on Wednesday. Thanks, Rachel.

That was fantastic. We, we haven't had many people leaving, so, everybody stayed pretty much to the end. So thank you so much for that.

That's been excellent. We have had a couple of questions coming in, people asking about the certificates and the replays. We will be sending you an email out in the next couple of days just to let you know where to go to find the replays and the certificates.

A few people asking about the PowerPoint, . So I think, Rachel, you, you're happy for us to put that on the the website or some of the pictures, aren't you? Do you mean a PDF or?

Yes, yeah, PDF. That should be fine. Yeah, great.

Well, we'll send an email out about that. If you would like your certificate to have your name on, then you should join our silver membership, which is a free membership. It gives you 6 hours of free CPD, but it allows our computer system to recognise you as logging in and we'll then personalise your certificates if you'd like that.

You just need to go to the front page and you'll see the the silver sign up. As Rachel said, the next webinar is on Wednesday, again at 8 o'clock, and I'm really looking forward to this one because it's entitled Dentistry is for Life. Very much looking through, you know, all the ages from the young dog, perhaps with the fractured vious tooth as as we've talked about going through, you know, adult life and, and then into the, Geriatric senior dentistry.

So I'm really looking forward to that next session. If, any of your friends, you know, would like to come on, obviously they can just register, so do let them know the URL and and people can register onto that. And similarly, if you do, if you are on Twitter then do follow us and I, I actually have a Twitter account which is just Anthony Chadwick, so you'd spot me there as well and.

That way we retweet, we'll get the message out, but I really enjoyed it. I think that's that's everything there. So let's see if we've got some questions coming through.

Actually just while I'm getting those questions up, just as a little point of interest, I'm just gonna set up another poll which is just asking you where are you listening from. So are you listening from the UK? Are you in Europe?

I know the UK is part of Europe. I do get told off, but you know what I mean, at North America, Asia and Oceania or elsewhere. So that would be great if you people can fill that in while I'm pulling up the questions and having a look at those.

There were quite a lot of questions. I'm sure there'll be a barrage coming through as well. Are you happy to stick around for a while, aren't you, Rachel?

I am. I mean, if people want to email me privately, I'm, I'm absolutely fine with that as well, so. Because I'm aware that people want to sort of get off and enjoy the rest of their evening.

Well, you know, the beauty of this is, of course, people can slink out of the virtual lecture theatre and nobody will. So, we'll, we'll leave, if people are staying there, I think they're still keen to hear from you. So let's, ask a few of those questions.

Sam is asking when removing molars and pre-molars, especially if you remove all of one arcade. Would you then remove the ones from the other arcade to prevent further trauma to pallets, etc. Especially if, say a canine is missing, to, you know, saying will that affect the bite?

That's a really good question. I don't routinely do it unless the teeth are diseased, but I think it's something to be aware of and to monitor, particularly in cats, I find. For instance, if you remove the upper carnaseal very often, then the lower molar can really bite into the to the palate and cause problems.

So potentially with cats, I might do that if I'm anticipating a problem, but I think it would depend on the tooth and just be aware of it so that if you're noticing a problem afterwards, you need to go back in and do something about it. What dogs and cats tend to do if they've had a number of teeth extracted on one side, if they've got a lot of teeth left on the other, they tend to just cope and they, they chew on, on that, that better side, which they were probably doing before anyway, because if those teeth were diseased, they probably weren't chewing on that that side of the mouth anyway. Because they were probably paying, weren't they?

Exactly. And we've, we've just, finished, or I'll just finish the poll. 84% are coming from the UK, 13% from Europe, 1% from North America, 1% from Asia and Oceania, and 1% from elsewhere.

So, a nice mixture and hopefully everybody's, you know, enjoyed that from, from outside the UK as well. So, pleased to have you on. Right, Christiane has asked, do you think it is OK to crack the calculus in the consult room if the pet cannot be anaesthetized, or is it just best to leave it as it is?

I know that's fairly common practise, but to be honest with you, you're not doing anything for the pet at all. It might make you feel better that you're doing something. It might make the client feel better, but you're not going to be able to reach the subgingival tart or plaque, and that's where the disease is happening.

The disease is happening in that gingival sulcus or periodontal pocket. And if you just remove supra gingival tartar, so the the the tartar that you can see, you're not doing anything to stop the disease process. So it's, it really is, is a waste of time.

And, and, and many vets sort of say, well, this, this pet can't be anaesthetized, and we will actually talk about that on Wednesday because, you know, cats that have Kidney disease, hyperthyroidism, they, they can be safely anaesthetized and in actual fighting to feel a lot better for having their mouth sorted. So I think cracking tart off in the consult room, to be honest with you, is, is, is a waste of time. It's the old tip of the iceberg disease, isn't it?

It's what's going on underneath that you can't see that you need to to deal with. And just as a supplementary to that from Christianity said if the tooth is loose because the periodontal ligament has lost its flexibility, but the root of the tooth seems fine, is it best to extract or not? I've noticed this mainly for incisors.

Well, that's a good question. When I was talking about mobility, what I perhaps failed to mention at that time is there is a certain amount of inherent mobility in incisor teeth, and that is very difficult to judge. And I think that comes with with experience.

So what you would need to do with incisor teeth is to match up what you're seeing on the mobility with your probing depths and then ideally radiography as well. OK, you know, Rachel, I think this might be your first webinar, and one of the problems is you can't hear the, the thunder applause at the end as you would usually do in a, in a normal meeting. So, Julius has just said hi and thank you for this very interesting webinar in dentistry.

So, and then he asked the question, any factors that can cause horizontal bone loss versus vertical bone loss? No, and that's that's a good question as well. I mean, there's so much research that's happening not only in dogs and cats, but in people.

There's so many things that we just don't, we don't know. And why would you get horizontal bone loss as opposed to vertical bone loss? I don't think we really know why that happens.

And some teeth, we tend to see vertical bone loss. On more commonly. So for instance, on that palatal aspect of the canine tooth, that's a very common spot to get vertical bonus.

And also on that mandibular molar tooth that I showed you, that's another common spot to get that vertical bone loss. And then we tend to see the horizontal bonus pretty much over the whole arcades, so. But why that happens in some areas and not others, I don't think we know yet.

There is a question here from Anna. She's just saying, would you always remove a tooth if it's got an F3? And if you're a person and you have an F3 lesion on one of your teeth, your dentist will give you a little teepee brush and tell you to brush that area twice a day.

Now, clearly that is never going to happen with our pets. So if you do a good scaling and polishing and maybe even some root planing. You, you will clean that area, but you won't keep that area, clean from periodontal pathogens for very long.

So what I'm trying to say is that the disease will progress. So ideally those teeth should be extracted, yes. We've got a question here, just asking, if there is a tooth fracture, I think you must have been meaning in a young dog, what to do in the instrument till the animal is referred to seal, and if so, how?

I think it's a good idea to give them some pain relief and some antibiotics if you're talking about the young dogs that we need to see within 24 hours. That's what I would do, give it some nonsteroidal if it's old enough to have something or an opioid, and then give it antibiotics, because if we can stop that pulp from getting infected, then we've got a much greater chance of it surviving and being able to mature the tooth. And does that then allow you to, to take a little bit more time, say it happens on a Friday and obviously they can't get in until a Monday.

And there was a good paper recently, and forgive me, I can't remember the citation, but if anyone wants the paper, I can, you can email me and I'll send it to you. And they looked at the success rate, and basically the best success rate is if we see these patients within ideally 24 hours but failing that 48 hours. If you see these dogs after 345 days or more, then the success rate plummets.

Right, OK, you know, I mean, we've, we've still got other questions which I think what we might do is I would hope a lot of these questions will also come up, you know, in the second webinar. I know there was some, . Questions that I, I'm fairly sure you will be covering and we can send those questions over to you as well and we can perhaps at the end of the series, do a a small blog to kind of cover and, you know, as you've offered if, if there is anything that needs A personal email.

I'm just conscious. I know you're going away on on Saturday, Rachel, so I don't want to disturb your preparation times for for India as well. Antony, it's going to be shoving a few pairs of trousers and t-shirts in a bag.

I'm always happy to talk about dentistry. I'm so passionate about it because there is so many dental problems out there that need treatment, and I'm so pleased that so many people have registered and have tuned in to listen because I think we can make a big difference to our patients. We, we'll have two more questions then.

Sophie's first question, and I think this is poss well, actually, I think that will be covered, but we, I'll, I'll say it anyway. Do you reckon using antibiotics for nasty infections? Depends what you mean by nasty infections, but I think probably what you're you're saying is that, do we need to use antibiotics routinely and dentistry and the answer is is no.

If We use antibiotics in periodontal disease. We, we shouldn't ever use them to treat gingivitis. Now, I'm making that as a very distinct difference from gingivo stomatitis that we see in cats because that's a completely different disease.

It is obviously appropriate to use antibiotics in that disease. But if we're talking about periodontal disease, antibiotics are never a treatment for gingivitis. In periodontitis, they can be an adjunct to treatment.

The treatment is scaling. Root planing and extractions. Interestingly, polishing is really only to remove residual plaque.

So antibiotics can be used, but they should be used as an adjunct to other treatments. Alexa's got the question, how do you recognise alveolar osteitis in animals post-extraction? How often does it seem to happen?

I don't know exact figures. I've never seen a case, and that might be because I do suture most of my extraction sites. I think it basically it is quite a painful condition, so you would probably get a pet that's not healing as well as you as you would imagine.

And the extraction socket will look empty. It will probably be full of sort of a horrible infected, not necessarily pollent but a pretty disgusting material, and there are specific, histological signs that can be seen as well. But it will be a non non-healing extraction site.

And this is the benefit of course of getting the, the dog or cat back at least once or twice after you've done the dental because you can keep an eye out for for these sort of complications, can't you? Absolutely, that's right. Great, Sala has said thank you, great webinar.

Holly, brilliant talk and I'm not a dentistry fan. Thank you very much. Not many people are.

I'm one of the weirdos. I know I do the same thing whenever I give a dermatology talk, I say, put your hand up if you're really passionate about dermatology, and it's always a bit sad and then I say you hate dermatology and a lot more people put their hand up, but there you go. Dogs get skin, dogs and cats get skin problems and they get dental problems, so you've just got to get into it.

I, I used to love dermatology as well because it's a very visual subject, just like dentistry, you look at something and you pretty much make your, your diagnosis and dentistry is very much the same and I think, you know, we can both make big differences to our, to our patients, can't we, Anthony? Yeah, no, absolutely. Sylvia, best dental webinar I've ever listened to.

Thank you. Samantha, thank you so much. Great to have so many visuals.

Brian, thanks, Rachel. Brilliant webinar. Thank you.

That's from Caroline. So lots of positive thoughts. You've still got lots and lots of people still on the line, but I think we will call it to a close now.

I do let your friends know about Wednesday. I'm looking forward to a really fantastic webinar with . With Rachel on that, obviously we're looking at dentistry for life, so really from, from cradle to grave, if you, if you've thought it's good and you fancy tweeting or following us or Facebooking, then, feel free, but otherwise I'm looking forward to seeing you all on Wednesday at 8 o'clock.

Rachel, thank you once again, really appreciated it and obviously wouldn't be possible, without the kind sponsorship pedigree that makes a dentist sticks. I know we're going to talk a little bit about that . At the next webinar, so looking forward to seeing everybody on Wednesday and Rachel, thank you once again.