Hello, everyone. I would just like to start by saying that I'm very sorry that I can't be live with you all today, but thank you very much for still asking me to present my lecture. And today I'm going to talk to you all about canine chronic ulcerative stomatitis, and, and this can pose a great challenge in veterinary practise.
I'm mainly going to focus today on the practical aspects of the diagnosis and treatment of the of the condition and to show you some examples of cases which we have treated at dental desk. So can and chronic ulcerative stomatitis is a spontaneously occurring inflammatory disease of the oral mucosa. This means that it can occur at any time in a dog's life, often with no clinical signs before the onset of the condition.
Historically, the condition has also been known as ulcer stom stomatitis and canine ulcerative parental stomatitis, which was also referred to as cups. However, recently this term has been discouraged. The studies have shown that up to 40% of lesions can actually occur adjacent to the areas with no teeth, which are therefore not para dental.
So now the term canine chronic ulcerative stomatitis, which is also referred to as cuss, is now the widely accepted term for this condition. It is a chronic and progressive and debilitating painful inflammatory oral condition which poses a great challenge to all veterinary surgeons, general practitioners and specialists alike. This is because it can be extremely difficult to diagnose and can be unresponsive to the current therapeutic approaches, and it has a completely incompletely understood pathogenesis and aetiology.
Thus, is a clinically characterised by chronic and severe oral pain associated with focal or diffuse oral mucosal ulceration of various sizes and degrees of inflammation and ulceration. Often the patients, when you first see them, will not tolerate any sort of oral examination due to the associated oral pain. The clinical signs, which are most commonly seen with this condition are halitosis.
Often with these cases, this is one of the first clinical signs that the owners will notice at home. And when you see these patients in your surgery, you'll understand because you can often smell these cus cases the minute they come into the surgery and walk into your consulting room. Hypersalivation, this is due to the severe oral pain.
When you initially see the dogs, they can be soaking with saliva underneath their chin and down their chest. This saliva can also be mucoid and stained brown colour. Often the patients will have saliva staining around their muzzle, chest, front legs, and paws, and this is how you can tell that they have been hyper salivating even if the owners haven't noticed.
In this image on the right hand side here, you can see the type of hyper salivation which can be seen. This dog came to us with severe oral pain and constantly hyper salivating, so much so that when the owners were out with the dog or taking the dog anywhere, they had to carry around paper towels and constantly wipe the face of the dog. Weight loss can also be seen, and this is often one of the main reasons why the dog will first be presented to you, as the owners will notice the dog becoming thinner and reluctant to eat.
The weight loss is due to anorexia or dysplasia, which is due to severe oral pain. Often the dog will appear to want to eat, but then will either go to the bowl and then leave it, or will pick up the food and then drop it almost immediately due to the contact with the oral or inflammation, a bit like when you see horses quitting. Often by the time we see these dogs at dentals, they are underweight and often only eating soft or liquidised food.
Coat changes can also be noted in many of these patients. Often the dogs will appear scruffy or unkempt when you first see them. Again, this is due to the severe oral pain, preventing the dogs from grooming, getting the correct nutrition and hyper elevating over their coats.
Lymphadenopathy is noted. Generally this is bilateral and of the mandibular lymph nodes. If you see no unilateral lymphadenopathy, this should be investigated.
Oral oscillation. In less severe cases, this will be in areas that contact the two surfaces. Typically, the ulceration occurs on the alveolar and buccal mucosal surfaces opposite the teeth with the accumulated plaque and often calculus.
In severe cases of cus, the ulceration and the inhalation can also be distributed throughout the muse, not necessarily associated with the teeth. This occurs in areas such as the tongue, glossoparine folds, and the mucousous border of the lips. And again, you can see this in this image that this is a severe case of cus, and what you can see is the oral ulceration is actually spreading all the way around the mouth and even in the areas where there is no teeth, they still have associated ulceration.
Calculus and plaque accumulation are usually present and severe during the initial examination. Consequential paradoxes may also be evident in many of these cases. Initial biochemistry and haematology blood tests commonly reveal hyperglobu anaemia, leukopenia, and neutrophilia as the more common findings.
Many studies have reported different breeds to be predisposed to the condition. Maltese dogs were reported to be predisposed to cuss, and analysis of the pedigrees showed that the affected. Individuals revealed a familiar incident.
This indicates to us that there may be a genetic aspect to this condition. Another study reported that cuss most commonly affected male neutered dogs, those who weigh less than 10 kilogrammes of terrier breeds. It has also been reported to have a higher prevalence in cavalier King Charles spaniels, greyhounds, and Labradors.
At den of vets, we also consider cocker spaniels to be one of the most commonly affected breeds that we see. This being said, I think the take home message from this is that most breeds can be affected by this condition, and that each case should be assessed individually with no preconceptions or assumptions made until a full examination has been performed. Over the years we have seen multiple breeds with this condition, and although there are some that are more prevalent, every breed needs to be considered a possibility for this condition.
Although the definitive aetiology of cus is generally still unknown, an immune-mediated pathogenesis is suspected. It is widely believed to be caused by hyperimmune response to normal levels of plaque on the teeth. Immature plaque accumulates within hours of the teeth being cleaned and brushed.
Unaffected patients can tolerate these normal levels of plaque accumulation on their teeth. However, patients with cuss cannot tolerate any plaque on their teeth, and in response to this plaque accumulation, inflammation and ulceration develops on the gingiva and mucosa initially opposing the teeth. As the condition continues and becomes chronic.
The ulceration and inflammation can also spread to areas of the mouth which are not associated with the teeth. The reason why dogs with cuss do not respond, as we would expect to normal levels of plaque accumulation is purely understood. Therefore, it is a hypothesised that the defence mechanisms and or the immune system responses to plaque may be different in these cus affected dogs.
In an attempt to understand the aetiology, examined cus lesions featured a wide variety of infiltrating leukocytes with moderate to large numbers of T cells, B cells, interleukin-17 cells, macrophages, and mast cells. Therefore, from this, we assume that these cells play a part in aetiology. However, the concern is that we still don't really understand what part these cells play in.
The development of costs. So now we need to look at how we treat these cases when they present to us. The first stage of treatment for a cus case is a conscious oral assistance and physical examination.
In some patients, an oral examination may not be possible due to the severe oral pain they are experiencing. They will often not tolerate any handling of their head or mouth, even by their owners. The initial physical examination should identify if there's any other reason for the clinical signs exhibited, especially the weight loss and hyper salivation.
The whole body should be assessed? Do I identify any other areas of inflammation, ulceration, or lymphadenopathy? At this point, biochemistry and haematology blood tests should be run to identify any underlying conditions or pathology.
And as previously mentioned, hyperglobulin anaemia, neutrophilia, and leukopenia are often present due to the chronic inflammation and localised oral infection. Next, an anaesthetized oral examination should be performed. The entire mouth, and particularly any affected areas should all be imaged.
This allows you to monitor the changes in the mouth over time and compare the changes and any improvements with previous or future examination images. It is also very useful with these challenging cases to have images to show the owners during the consultations. We tend to find the owners comply better with proposed treatment plans when they can see for themselves the images of the inflammation and alteration, to understand the condition and see any improvements or deterioration from themselves.
For this, you don't need anything fancy. This image here is the camera that we use day to day at Dental deck. It's a small handheld point and shoot camera.
The only stipulations is it does help if you have an autofocus and a macro setting, as these help to avoid blurry images. We have one camera per table so that patients do not get confused with what images you have taken. We then also save all these images onto our system, for each patient, and we also send them back to their foreign vets or any other vets treating the case so that everybody has the images and a record for the camera.
We also use these images to create photo reports at the end of each appointment, and to give to the owners. This allows the owners to visually look at the photo reports once they get home and to again, discuss the condition and think about the treatment plan. During this oral examination, the mouse should be charted and the areas of inflammation and ulceration measured and noted.
The calculus of plaque accumulation are also scored. The calculus is scored in the usual manner with 1 value per tooth and a score of 0 to 3 applied in the dental chart. Plaque accumulation is measured by applying plaque disclosing solution to show up the levels of plaque on the teeth.
Immature plaque forms within hours of toothbrushing, so the presence of immature plaque is considered normal, but chronic plaque accumulation is what will exacerbate the symptoms of cuts. Plaque disclosing solutions should be applied during every visit when treating patients, as it determines how well the owners are brushing the patient's teeth at home. Black Search from Henry Shine is what we use and it's readily available and cheap.
This is it here. We dispense it into small pots and use a little bit per patient, and for each bottle, it's only about 3 pounds 50 currently. To apply the plaque disclosing solution, a cotton bud is coated with the liquid and then it is painted onto the teeth.
Then allow the flat disclosing solution to sit on the teeth for a couple of minutes and then slowly wash it off with. And with your water from the air water syringe. Do not use too much pressure or you will blow the whole stain off the tooth.
This then stains the tooth to see the plaque, which would otherwise not be visible. If the disclosing solution turns the tooth blue, similar to this one that you can see down here, then that indicates mature plaque. If you see a pink lighter tinge, then this indicates immature black.
During the same examination, any abnormalities such as ulceration and probing deaths should also be noted on the dental chart, such as pictured here. These are our dental charts that we use at dental desk, and we use them each time for, for each patient, and at each review appointment. At this point, a full mouth intraoral dental radiograph should also be performed.
This is to identify any teeth with pathology, such as periodontal disease, fractures, tooth absorption, which may be causing or exacerbating the oral inflammation and ulceration. So during this examination, this is when any of the teeth with pathology that could be causing or exacerbating the inflammation should be treated. These teeth are generally treated by extraction, or in the case of fractures, root canal therapy can be performed if that if that is an option for you.
A canine chronic ulcerative stomatitisse activity index chart has been developed by Professor Jamie Anderson and colleagues. This assesses the mouse and the areas of pathology. It quantifies the disease severity and therefore response of the patient to your treatment over time.
Due to this, it is important that the disease activity index chart is performed at every clinical examination to assess if the inflammation and ulceration is improving or worsening, and if your treatment plan needs to be altered or adjusted. It is based on a similar scoring system used for feeling chronic gingival stomatitis. It combines the usually recorded parameters of calculus and plaque accumulation.
Down here. And also peron peritonitis stage with an objective assessment of the ulcer, number, size, location in the mouth, and characteristics such as presence of the pseudo membranes and stria. For the calculus of plaque accumulation, an average of teeth should be taken and used for the scoring system.
The owner's perception of the patient is also included in the score. The owner's subjective score. OK.
Is based on a fair attitude, giving a score of one. Poor appetite and lethargy, giving a score of 2, or suffering, which is a score of 3. A pain scoring system.
OK. Based on the Glasgow composite pain score is also assessed based on the owner's observations at home and also your observations in the clinic. Mild pain score is 1, moderate pain gives a score of 2, and severe pain gives a score of 3.
Often your assessment of the dog in the clinic and the owner's assessment of the dog at home can be markedly different, but after discussions with the owner, you need to decide which one is best for this. The possible range of the scoring system ranges from 0 to 32, and this quantifies the severity of each case at that point in time. Having a score like this and hopefully means that by then, the next time you see this patient, this score will have increased if your treatment is not helping the situation and you come up with a different treatment plan, or if your score has decreased less than the previous recorded score, then you may want to continue with the further treatment plan, and you know there is some improvements in the oral inflammation and ulceration.
Once the mouth and teeth have been fully assessed or charted, and any teeth with pathology treated, then a deep and thorough scale and college should be performed. This will eliminate any calculus and plaque accumulation at that point. Biopsies of the affected tissues are now also advantageous at this stage to rule out an autoimmune disease or any neoplastic causes.
After this, the dog is woken up from the anaesthesia, and the treatment now continues with the woman at home. Daily toothbrushing by the owner should now commence once or even twice a day using a toothbrush and a chlorhexine based toothpaste. At this stage, it's imperative that the owners must be aware that the treatment for this condition relies on them providing strict oral hygiene each day at home to keep the plaque levels low and avoid reoccurrence of the oral inflammation.
Often this dream will be lifelong. You need to discuss with the owners if they are prepared for this, or if they need to go to the next step of treatment without even trying the oral hygiene at home. Often it is not that the owners do not want to comply, but often the dogs will not tolerate it, or often if the owners have, say, illnesses such as arthritic fingers, then they are unable to perform toothbrushing at home.
For the toothbrushing, chlorhexine products that the dogs would tolerate can be very difficult to source. We tend to use Keystone bright Bar and the picture on the right top corner here. This has a 0.12% chlorhexine concentration.
Another commonly used product in general practise to treat cast cases is dentist set that at the bottom down here. Now, the only problem with the denttacept is that it only has 0.06% chlorhexine concentration.
Now this is half of the active ingredient percentage of the Keystone gel. Therefore, because of this, it is less effective for plaque control. We also tend to find that dent set can be very difficult to apply, as it is very sticky.
When it was first released, it was And described as it being sticky to allow it to stick onto the patient's teeth, but we tend to find that dogs do not tolerate it, and it's very difficult for owners to apply it as they get most of the dentist step all over themselves rather than onto the dog's teeth. We also supply toothbrushes to our clients that any regular toothbrush that can be bought in a pharmacy can be used. Ensure that the clients are replacing their toothbrush every 6 to 8 weeks so that the bristles remain effective.
The toothbrushing at home can be very challenging for the owners until the painful lesion is under control. Therefore, the chlorhexine toothpaste can also be applied with a finger or a softer child's toothbrush, if this is better tolerated by the dog than the adult toothbrush. Maxigar chlorhexta wipes that are pictured here are also available and are perhaps easier to use while the dog has severe oral pain.
The wipes can be used on the tooth surfaces and inside of the lips to keep the keep the to apply to the teeth. However, they are still not a replacement for toothbrushing, and it is important to try to move the patient onto the toothbrushing after the oral pain has resolved. We also advise the use of a few other products to help to reduce the antigenic burden and reduce the plaque accumulation, especially if toothbrushing at home is not possible.
Sinus is a polymer which is applied to the gingival sulcus post anaesthetized prophylaxis. It works by blocking the access to the sulcus of the antigens. We find it very useful if daily brushing is unlikely to be permitted in the short to long term.
When dietary issues do not preclude it, we would also recommend feeding a diet shown to complete plaque levels at the post prophylaxis. This can be diet such as your Hill's TD. Which mechanically cleans teeth whilst it is eaten to help prevent plaque from calculus accumulation.
Again, these treatments cannot replace toothbrushing, but they can be used in conjunction with it. So although treatment is based on oral hygiene, We also medically manage the condition alongside the oral hygiene protocol. When we initially see these cases, we are that to withdraw current control medications if possible, except the pain relief, so that we can assess the true severity of the condition.
After the initial anaesthetized examination of prophylaxis, we then generally initiate a triple combination of entoxyhyine, niacinamide, and doxycycline for the next 4 weeks before the next oral review. Pentoxyhyine is given at 20 milligrammes per kilogramme twice a day. This will increase the blood flow to the most, heal the areas of inflammation and ulceration, and hopefully prevent any further inflammation occurring.
Ninamide, which is this 1 B3, is given at 200 to 250 milligrammes per dog twice a day, and doxycycline is given at 5 milligrammes per kilogramme twice a day to reduce the oral bacterial load. One aspect of management of this condition, which should be initiated from the start of the treatment is pain relief. Non-steroidals are required for pain relief too, and also to reduce the associated oral inflammation.
In some severe cases, opioids and gabapentin can also be considered due to the severe oral pain that these dogs are experiencing. Dulam oral spray, which is pictured on the top right here, which again can be bought in your local pharmacy or ordered through your stockers such as Centaur, can also be used if the dogs will tolerate it being squirted into the mouth or onto the areas of oral ulceration. It acts as a local anaesthetic on extremely painful areas which squirted onto.
The dogs which tolerate this and react very well and it's a good pain relief, but often it's the noise of the spray that the dogs actually won't tolerate. So again, some of this can just be squirted into the palm of your hand or into just a small tub and then applied to the area using a finger or . Small cotton but.
The patients then continue with the oral hygiene and medications at home for the next 4 weeks, and then we see the dog back for a further anaesthetized review. During this review, again, the mouth is fully assessed and the stomatized disease activity in high school is repeated to see if the treatment is improving the clinical situation. The disclosing solution is also applied again, and this will show how much plaque has accumulated over the last 4 weeks and help to demonstrate to the owners how the toothbrushing is getting at home.
This disclosing solution can also be given to the owners at home so that they can monitor their own progress and show them the areas that they need to concentrate on with the toothbrushing. Ideally, at this stage, there should be only immature plaque present, although this is very rare. And as you can see from the case on the top right here, what you can see, this is a dog that came to us after 4 weeks of toothbrushing at home and medical management.
We've still got severe oral ulceration all the way around associated with the teeth. And what you can see is we have mature plaque situated here on the teeth. What the learners have managed to do is they've both been managing to partially brush the left max of the can, but avoiding and not managing to get to all the rest of the cheek teeth.
So if there is improvement in the clinical signs at this stage, then the whole oral hygiene regime can be continued. However, the owner should be aware that to keep these cases controlled and frequent professional scaling and polishing when the inflammation and ulceration begin to recur are required, and this is usually every 4 to 6 months. We have many cases that are controlled, but they often, they are coming back to see us every 4 to 6 months, and the owners are very compliant at home and on board of the clinical treatment.
At this stage, if there is no improvement in the clinical signs or if the owners are unable to commit to daily oral hygiene, which is not tolerated by the dog, then the next option is elective teeth cheek teeth extractions to remove the plaque rotten to surfaces. At this stage, we will only extract the cheek teeth and leave the canines and you. Often, the cheek teeth extractions will need to be staged over two separate procedures to allow the dog one side to eat on whilst the treated side heals, and then perform the cheek teeth extractions to the other side of the mouth 3 to 4 weeks later.
We always advise the owners that if they are having stage cheap teeth extractions, then often they will not see any clinical improvement until both sides are treated. So they should not be expecting a dramatic improvement when one side is treated until both sides are treated together. Once the cheek teeth have been extracted, we will then continue with the medical management for the next 12 weeks, whilst the surgical site heal and the owner continues to brush the remaining teeth if tolerated by the dog.
At the next review appointment, if the inflammation and ulceration has improved, then the medical and hygiene regime can be continued. Often once the condition is stabilised, if the management is reduced, the symptoms will recur. So it can be a bit of a balancing game of reducing the medical management as much as possible, but weighing that up against any recurring oral inflammation.
If at this point the oral inflammation has still persisted, then the remaining canines can be extracted. If the persistent inflammation is associated with them. Also, other medical management.
May should maybe be considered to be trialled instead of the triple combination. A double combination of cyclosporin, 5 mg per kilogramme, can be given once a day for 4 to 6 weeks, and every other day for 2 weeks in a combination with 15 mm milligrammes per kilogramme of metronidazole once a day. Apocoil has also been proposed as a treatment option for cuss due to the known involvement of interleukins in the aetiology of the condition.
There is no current peer reviewed research published about its use for costs, although we have refused to have used it in a few cases so far promising results in in conjunction with pentoxihye. It would be a good study to do and if any of you're interested we'd be very happy to discuss kind of future trials and and into looking into this. Corticosteroids can also be used in refractory cases as salvage medication, although we always avoid their use if possible until we've exhausted all other treatment options.
So now I'll show you some of the cases of cost that we have treated a dental vet. This case was an eight year old male neutered Labrador, who was a failed guide dog. He initially presented to us as he was in such severe oral pain that he had become aggressive when examined, and his owners couldn't handle his head or his mouth.
His symptoms and aggression had developed gradually over a year, and when we saw him, he'd already had some left-sided cheek teeth extracted due to a previous trauma down here. His initial assessment showed severe calculus and plaque accumulation that you can see all around on these teeth. And inflammation and ulceration.
This was especially prevalent on the left side of his mouth. You can see associated with this canine and the ulceration around these measures and these teeth. He did have some on the right side of his mouth again associated with right maxillary canine, but predominantly it was the left side that was affected.
So at that time we performed the prophylaxis and radio aggressive of no concerning pathology associated with any of the remaining teeth or the extracted teeth. And at this point we also started him on the triple combination of pentoxyhyine, niacinamide, and doxycycline. We also started him at this point on a dental diet.
The owners were unable to clean his teeth, but they were very keen to keep all teeth if possible and avoid extraction. At his 4 week review with us, the inflammation had improved, and the owners were very pleased with the improvement in his demeanour, and they were also now able to use the chlorhexine wipes at home. You can see now as well with the with here that the plaque had reduced, so they were managing with the chlorhexine wipes and also the dental diet was hopefully doing some good work.
There was inflammation still present and some plaque accumulation, but less than on his initial exam. We performed a further prophylaxis at this time and advised the owners to continue with the triple combination of medications at home and the hygiene where possible. We saw him back a further 12 weeks later and as you can see, there's a dramatic improvement.
By this time, he was no longer aggressive and would now allow his face to be examined, but not his mouth to be opened. The inflammation and the ulceration had resolved, and the winner was extremely happy. The dog then continued to see us every 4 to 6 months when the owner noted the inflammation recurring or the hallow doses beginning.
This case was kept under strict control by scrupulous hygiene and the triple combination of medications, but this was mainly down to the vigilant owner who was happy to keep bringing him back to see us for regular prophylaxis, and was also very aware when the treatment was required by closely monitoring his dog at home. A year into treatment, and the dog was now allowing the owner to brush his teeth, and the inflammation and clinical signs had resolved. Now this case is an example that shows the very hard work that the owners must be prepared for in these cases properly to manage the condition effectively.
Otherwise, this dog, if the owners had not been on board, this dog might have had to have further extractions. Now this next case was a 5 year old male neuteredcoccal cocker spaniel who presented to us with severe oral pain and halitosis. He again was very aggressive and would not tolerate an oral examination.
His owners were a bit concerned, he had become aggressive at home and especially with young children. His aggression and unpredictability had got to a level that they were seeking a solution or the owners were considering euthanasia. This is a very common presentation in these cases just due to severe oral pain, and we also suspect that it was due to the young children because again, they, he didn't know if they were going to touch his mouth or pull at his mouth and what they were going to do with him due to him.
So our initial oral examination showed severe oral ulceration and inflammation, especially, especially associated with measures of the mouth. You can see it down here all around, and he had ulceration associated with the other teeth, but it was mainly right around all these measures. So you can imagine every time he opened or stretched his mouth, he had severe oral pain.
So at this point, we performed prophylaxis, but advise extraction of the chete at this point due to the severe inflammation and the apparent pain that this dog was in. However, the owners were very reluctant for extractions at this time. So we initiated pain relief and triple combination at home.
And we saw him again 4 weeks later. At this point, there was some improvement in his demeanour, but the plaque accumulation was still present, which can be seen here. And and so the owners were still not managing to brush his teeth properly, and there was a lot of plaque and still apparent.
And you can also see from here that if anything, the ulceration appeared to have gotten worse. And so we now had ulceration as well as around the measures associated with all of the teeth all the way along the mouth. So we showed the owners where they needed to concentrate on of the plaque, and again, we discussed that extractions should maybe be considered for the stock, but the owners were still very reluctant for the extractions.
So we continue to see the dog over the next 6 months, every 8 weeks for prophylaxis, and at that point, then eventually, due to the continually having to come back and lack of improvement, the owners agreed for extraction of the cheek teeth. So we surgically extracted the cheek teeth and also the right maxillary canine as it has this persistent ulceration, which was constantly associated with it. We then saw him back 4 weeks after the symptoms, and the ulceration and inflammation had resolved dramatically.
So there's still a small ulceration associated with left maxillary cane, but the owners were very happy at this point to keep on brushing the teeth. And also by that point, the demeanour in the dog had dramatically improved, so he would now allow his head to be stroked and also his mouth to be handled and examined, and his rostral teeth to actually be brushed at home. So often extraction of the teeth is the only way to resolve the severe oral symptoms with these cases.
So don't think of it as a failure when you have to move to elective tee teeth extractions, or if you want to move to the extractions early on in the teeth that you are treating. Once the inflammation and the ulceration has resolved, these dogs are much happier and healthier than they would be with their full complements of teeth. So remember, in these cases, it's always to get the dog out of pain and to be happy and comfortable at home rather than to save all of the teeth.
So the main take home messages for treating cus cases is make sure you perform a thorough workup for each case. Cuss is a diagnosis of elimination, so other conditions such as periodontal disease, autoimmune diseases, and neoplasia should be ruled out before a diagnosis can be made. Also ensure that the owners are on board with the treatment, before you start and that each every review again, discuss it and emphasise what their role in treating this case is.
Make sure a stomatized disease activity index chart is performed every time. This is the only way that you will be actually able to have a score for the oral ulceration and inflammation, and allows you and the owners to see any improvements or deterioration in the condition. Intraoral radiographs are also essential, as otherwise you will not be able to see any of pathology below the gum line.
So conditions such as tooth absorption. Per pathology developing and anything that could be causing this oral ulceration could be missed if you don't have intraoral radio. Medical management and pain relief should also be initiated from the start, as well as the oral hygiene.
And we kind of combat these cases in a multidisciplinary approach, and again remember that pain relief is vital in these, in these dogs. If you think about it, when you have a small ulcer. And on your tongue or on your lip and how painful it is.
You can just imagine if your whole mouth was affected by ulceration, and that's what these dogs are experiencing, especially when they use their mouth daily to kind of pick up toys and and eat and sniff around, and then these dogs are often very, very depressed and in severe oral pain. So also don't, don't wait to move to extraction if the symptoms are not resolving. Again, don't think of a failure on your part, because these dogs are much happier once oral inflammation has resolved and often extraction are the only way to resolve this.
So many thanks for listening today. Please, if you have any questions about anything I have spoken about, then send them to my email address, which is on the bottom of this slide. And again, I'm very sorry that I can't be with you live today, but I hope you all have a great day and and enjoy all the other lectures.
Thank you.
