Thanks very much, Caroline. Good evening and thanks everybody for for joining us. Hopefully there are people out there listening.

. As, as Caroline said, the focus of this evening is really, it's gonna be looking at how to improve, I, I guess, outcomes for both patients, for owners, and for you as well. I know that, you know, many of us will have attended, you know, how to do extractions and. How to take X-rays, all those sort of things, very frequently.

But, the sort of, there's a lot of, a lot of bits in between those things that, that can really make a big difference. And hopefully, we're gonna just touch on a few things really just to start getting you, hopefully just to stimulate thoughts really, and, give ideas from, from my point of view, that, that might be useful and, and hopefully, helpful to you in general practise. Obviously, what we're talking about is, is dental disease.

And this is one of my, I guess one of my slight bugbears is, is what, what is dental disease? We don't have orthopaedic surgeons talking about what is orthopaedic disease. They discuss individual diseases and, and, and that's one of the things that we're gonna, I'd like to briefly touch on is, is.

From a communication point of view, that's where you can make a big impact, for you and the ease of your communication with clients is to actually don't just say it's a dental. It, it describe what the pathology is. Here we can see, you know, the classic gingivitis in the top picture and periodontitis, but that's not the only dental diseases we treat.

We've got cats here with classic tooth resorption. And on obviously on the bottom there, we've got the severe sort of gingivitis, stomatitis patient. And then we have all the way through to these sort of, you know, maleclusions and and those type problems, that, that can, you know, developing young patients like this dog at the top is obviously juvenile patient with primary teeth present and so yeah, it's a, there's a, there's a whole raft of different things that are out there and, and so.

Just lumping everything together as dental disease is, is actually doing, I think, a disservice to the skills that is required to treat these cases. And, and also just doesn't give the owner the, the information that they need, and to appreciate what, what you're doing and what you're recommending and how you've treated things. Equally, recent paper published by Summers, indicated that dental disease was one of the top 3 problems in UK based patients from a welfare point of view, along with things like titis and, and, and osteoarthritis.

But, you know, that's one. The things that I enjoy the most about what I'm doing is that I feel like I have a huge impact on my patients' welfare, often when the owners haven't necessarily appreciated there's a problem. And, you know, we've, I'm sure we've all had cases where we've done treatments and, and, and, you know, dealt with what we presume to be painful problems that the owners have not seen any clinical symptoms.

For and suddenly at the end of it all, they come back 10 days later and say, it's like having a kitten again or a puppy again. I, I can't believe the difference. And that's when they said to you beforehand, well, there's no problems.

He's not stopped eating. Well, you know, stopping eating is not normally associated with dental disease and dental discomfort. It's obviously dental, you know, oral pathologies, we get away from that term, dental disease.

Oral pathologies are, are really frequent. If we look, and, you know, there's numerous studies out there. And in some cases, you know, you'll find patients with a widespread of, of ranges of disease, from mild gingivitis, which is obviously extremely common, all the way through to severe end-stage periodontitis, which is gonna be less frequent, but nonetheless, I think that it's fairly well accepted that periodontitis is the most common infectious condition affecting cats and dogs, and that is just one small facet of, of, you know, oral pathologies.

And or pathologists definitely have a systemic effect. There's multiple studies that have indicated that you get, changes in systemic inflammatory markers and, things like compliment, induction and a whole range of other things. Equally with periodontal disease, we believe that it is a, a sort of a pro-inflammatory condition.

And so, if you have periodontal disease, you're potentially at greater risk of developing things like heart disease, diabetes, etc. And that may not be a causative link, but the same processes that, that put you at risk of periodontal disease also put you at risk of developing those other diseases. I think When I say influencing the outcome of surgery, I think that, we have sort of three key areas where we can have a positive impact on, on our, on our patients and ourselves and our owners, sort of, response to, to oral treatments, or oral oral pathological treatments.

And obviously, we've got that sort of pre-operative phase, . I think that from a lot of people's point of view, it can be really challenging is understanding why we are advocating, for our patients to have oral dental treatments, and often they are picked up as obviously as a, incidental finding. It may not be incidental to the pet, but an incidental finding nonetheless, that routine vaccinations.

And, and clients don't necessarily always understand why what the reason is for us recommending these things. And I think that's really important, trying to take time to explain, and that's why I say, you know, having a clear, discussion about what actually is occurring, not just dental diseases, but have you got peridontitis, have you got tooth resorption? Have you got a complicated crown fracture?

Is there evidence of maleclusion, etc. Etc. And, and really, you know, taking that time to, to have that conversation and that's not easy to do that.

And certainly in my practise, we routinely offer sort of free dental health checks with, the, the, some of the dental team members and we find that incredibly beneficial because it gives us the chance to have a proper conversation. Again, you know, you wouldn't necessarily try and discuss, the ins and outs of ATP, with a client that you're doing a vaccination on at the same time, it may be something that you would treat or, or, you know, want to go over and investigate and treat, at a second, a second consultation. Well, the same applies to dentistry.

And I think getting the communication, right up front has a massive impact on, on what you can do. . For your clients from a very positive point, but also reducing the stress from your point of view as well.

And we all know that there are huge limitations of, of a conscious oral examination and making that really clear to owners, you know, expressing early on that you, you know, maybe we'll need to call them during the procedure to discuss the findings and, and really what we can see. In the mouth, conscious is probably the tip of the iceberg when it comes to pathology. And so that, that's something that I always, you know, pains to communicate.

And I think we shouldn't be frightened to, to say that in some circumstances, patients might need more than one treatment. It, it is certainly not uncommon for, you know, some patients to have very extensive dental disease or dental pathology. That that really requires, you know, a long, long period of time of treatment and to do it properly, to do it well.

And so, you know, being able to say at the start, OK, well, maybe we're gonna need to separate this into two or more procedures. It gives the owners, again, understanding of the sort of severity and extent of it, but also gives you, flexibility. We can obviously influence the outcome of, of treatments intraoperatively through, you know, the, the procedures that we perform and the skills that we use, and, and certainly, That's something that hopefully we'll touch on a little bit later.

And then obviously the postoperative support. It's really distressing to think that many of our patients are in, you know, worse circumstance almost than beforehand and the, yes, there's always going to be oral discomfort and pain associated with surgical precedures. There's a huge amount that we can do to try mitigate and and and minimise that.

And so that improves the, the outcome for our patient clearly it improves the the what the client perception is, but it also means that you don't get phoned in the middle of the night, hopefully to, to say that there's a problem. So we could touch on all of those different areas. So as I've already said, you know, oral surgery, what, what is this treatment, you know, these, what are these treatments that we might be presuming, performing, and, and I've tried to sort of put a, a rough list of a few of the sort of cases and obviously, we start off with pretty basic extraction techniques and periodontal surgery and then we start to get more interesting and complicated and endodontic surgery and fracture repair or biopsies and maxectomies, etc.

And so, again, it's really important not to play down the technical difficulties that, that an extraction or a maxillectomy has. They, they have very, very similar sort of core, disciplines and, and there's a huge amount of similarity. There's a slightly Difference in, in scale, but, but that's all.

And the, the skills that required to do a quality, effective and low traumatic extraction are just the same as those required to do, mandibuectomy or so, yeah, I, the, the, just a quick dental, is almost never just a quick dental and, and so yeah, don't, don't play down the skills that are required to do, to do what you're gonna be doing. I think patient preparation for me is a, is a really big part of, of improving the, the care for our, for our individuals and, and as I say, improving client perceptions as well. And.

Unsurprisingly, periodontal tooth resorption, and a whole range of other oral pathologies increasing frequency with increasing age. And so we often have a number of comorbidities to, to consider when we are managing patients with periodontal with, with dental pathologies. And certainly, we have owner concerns regarding, anaesthesia, and certainly, you know, there's always the concerns associated with multiple anaesthesia if that's something that maybe needs to be considered.

And pros versus cons of, of that. Now, obviously, that's something that you have to decide on yourself, but I feel very comfortable, advocating, you know, fairly significant oral surgery to patients that are pretty old, because, the vast majority are, are far better off after having that sort of treatment than before. That sort of pre-operative database acquisition and I'm, I'm sure that many of you are doing this routinely, but certainly I would definitely recommend for more mature patients thinking about getting some sort of baseline database and, and that would probably include total so.

And PCV perhaps urea creatinine, and, and some electrolytes, and then obviously an additional testing on top of that, urine analysis with specific gravity, and simple sticks is I think is really beneficial alongside those two things. And it just gives confidence to yourself and to the owners and it also informs about, the I guess potential for postoperative issues, it informs about obviously what drugs we may or may not want to use and so, yeah, you know, bear all those things in mind. The management of patient physio, physiological and, and, and potentially psychological stress is a really important thing, and I, you know, put the, the cat friendly clinic there.

And equally, this applies to dogs as well as cats and I think that again from, we're often very busy and it's very difficult for us to be able to schedule things sometimes in to make things easier. But certainly if we can manage, patients stress, we can have a significant impact on everybody's experience and obviously, we can reduce the risks of things like Cooline induced, cardiac, incidents at and around the time of, of, anaesthesia, which is obviously a pretty significant concern. I, we often spend some time discussing with owners about, if they have a particularly, anxious patient trying to arrange so that, we can have, you know, sedation with the owners waiting and, and immediately being transferred through to, treatment.

It's often difficult if you have, a pre, you know, you have cases where you are gonna be doing dentistry alongside other. Sort of more clean surgeries. And so I think there's a good rationale for considering doing dentistry, or having, a number of dental procedures on a single day, allows you to, to sort of prioritise and focus on those.

You're not obviously then having to do a spa and castrate and a number of other procedures and then trying to get this dirty dental done before, you'll have lunch or before the evening consults and that's when Something that needs a great deal of concentration and a lot of fine motor skills and starts to become a real chore. And you know, I like normal vets out there used to dislike intensely trying to perform these procedures like that and felt like I was doing a pretty awful job. And I think that we, we ought to try and, you know, adapt to that situation as much as possible.

The Van Houghton, Forsyth Silo and Bain group, obviously recently published the use of gabapentin, as a preoperative, antilytic and, and for cats, specifically, at all preoperatively, and they used the dose of 100 milligrammes per cat, and found It, it was very beneficial. I know a lot of people have, have, you know, started using that protocol. Certainly, we in my clinic, use it fairly frequently.

If it's given an hour or two, before, you know, the patients need to be, handled, then it can have really significant benefits and that might be done by the owner at home, or that can be done on admission to the clinic if they're then gonna be put into, a Qatari environment. I think that the other things that we can do from an intraoperative point of view so we've, we've done our sort of preoperative evaluation, but we're moving on to the sort of more intraoperative support stages, often anaesthesia, these procedures are fairly prolonged, and, you know, it's not uncommon for oral surgeries to require hour or 2 hours or even potentially more and And again, I think that that is something that is, is probably a little bit different from your average mass removal or castration, especially when time is, is extremely predictable or, or pretty predictable for those types of procedure. And again, we have our patients, you know, many of our patients are more mature.

So. Duration of procedure is something to bear in mind. I personally struggle to concentrate for any longer than a couple of hours.

And so, I will, again, be fairly cognizant if that, if something's gonna take me a really long time and it can be split up, and, and. Treated in more than one phase, that's probably good for me, that's probably good for the patient as well. And, and I certainly feel that two shorter anaesthetics is in general far better tolerated and and half the surgical trauma is.

Far better tolerated than trying to do everything in one go. And, and I think most owners are actually fairly understanding if that point is put appropriately. I get very, very few clients that say, oh no, I desperately want you to do everything in one go.

Obviously intraoperative intravenous fluid therapy, I think is something that is really strongly advocated from a whole range of reasons, of course, you know, reducing dehydration and blood pressure support, etc. But again, these are often Longer procedures with patients that are, have these other comorbidities. And so, I think that's something that I would very much recommend that all patients that are undergoing, evaluation and treatment for oral diseases that, that, that we should consider that to be a very sensible thing.

And we use a lot of water when it comes to dental treatments. We use, obviously water cooling for, for cutting and for performing dental treatments and dental procedures with the scaling tips and, and the, the high-speed hand pieces and the high speed burrs. And, and obviously that cools those units down to stop them from overheating and causing thermal injuries to the teeth, but it also cools the patient and, and obviously the tongue and the oral cavity is designed in dogs, especially to, as a, as a heat softener, as a heat releasing of heat, panting, etc.

And so we are at greater risk of having patients and becoming hypothermic. And equally, if we're using things like tub tables, often our patients will be suspended above, an air void again and getting, getting cooler and obviously evaporation of the water that gets into their coat, etc. Has an effect.

And there's some very simple things that you can do to try and avoid that, things like inco sheets, which are, are a, obviously waterproof on one side. If you cut a hole in there and, and pop that over the muzzle and, and, you know, the dogs and cats can, or primarily dogs can have that as a waterproof barrier, and stop from water from getting soaked into their coat. That's pretty useful.

The use of things like bear huggers and heating pads and, and hot hands and warmed intravenous fluid therapy and just, you know, making sure that the, the local environment is, is warm has a really significant impact. And certainly, we know that, that hypothermia has some pretty dramatic and significant effects on our patients. Certainly will alter the way in which pharmaco Products are metabolised.

It can potentially result in organ dysfunction. Interestingly, it can increase the, the risks of infection and certainly it can reduce wound healing. So, you know, patients that have a transient hypothermic event at the time of surgery on average will have more infections and, and greater complications from wound healing.

Certainly altered coagulation and then delayed recovery. And, and I think again, you know, Certainly from my point of view, if I've got the supportive care right, most of my patients are gonna be up and about and eating and thinking about, you know, going home within 45 minutes to an hour. They're obviously gonna stay with us for longer for postoperative monitoring, but, but certainly, I, you know, we see very few patients that are sort of sat there still looking pretty miserable after, an hour period, and, and most of my patients will eat on the day of treatment.

And so I think that's the sort of expectation that we should have. And antibiotic use intraoperatively can be, important. I've put intraoperatively and I've referenced the, the ABDC, which is American Veterinary Dental College, and that's, something that the ABDC and the European Veterin Dental College work very closely together, and they have this, co-supported and position statement.

And essentially it says that antibiotics are not used as a monotherapy when it comes to oral treating diseases. In other words, they, they are ineffective on their own for management of, of bacterially driven, problems. And the reason for that is that bacteria that are in a biofilm, in other words, they're in plaque, are hugely protected from antibiotics and planktonic bacteria in saliva and in the soft tissues are pretty easy to kill, but those bacteria, they're in a biofilm.

Really difficult to kill and, and certainly nowhere, you know, we're not going to get rid of them just by antibiotics alone. It says that we would only recommend antibiotics postoperatively with severe infection. So that's severe periodontal disease, apical, you know, severe infections, abscesses, osteomyelitis.

And so for a vast majority of our patients, they're not going to need postoperative antibiotics. But certainly if we have patients with comorbidities such as heart disease, kidney disease, etc. Perhaps some form of immunosuppressive condition or have some form of orthopaedic implant like a hip replacement or an elbow replacement.

Then, intravenous antibiotics, should be definitely used. And, and certainly, we use antibiotics intravenously, primarily, potentiating amoxicillin, but sometimes the, one of the cephalosporins, at the time of surgery, and that would be repeated every 90 to 120 minutes during anaesthesia and, and, and, but then discontinued at the time of recovery. And for most patients, that's all that's needed.

If we're going to use antibiotics, postoperatively and in very rare circumstances, preoperatively to try and improve the health of the, the gingival tissues and the periodontal tissues, before they get operated upon, then I would primarily use potentiating m. It's the antibiotic that has the greatest, or the most appropriate spectrum of action for oral pathogens. If you've got osteomyelitis, then I might consider using clindamycin, but in truth, we use very few other antibiotics and it's not just because we don't have a good imagination.

Again, lots of our patients will have, you know, kidney dysfunction, and a number of other problems, and I think that one of the things that we often, perceive or I perceive as, as having some issues with, with. Hypertension. And, and I, again, really strongly, especially with cats, feel that, blood pressure monitoring, it is really important for patients that are anaesthetized for longer periods of time.

And I definitely, would, would strongly recommend. I'm, I'm obviously not anaesthetist. I'm very ably supported in my current position by an anaesthetic team and, and I'm very grateful and I've learned a huge amount from them.

But, I think that, having a sort of an idea of your response to hypertension is, is probably quite useful. Again, I'm sure many of you already have a fairly well organised, protocol. Certainly wherever possible, try to.

Minimise the use of inhaled anaesthetics, so the, isofluorine, tevaflurane. They tend to have the greatest effect on, on blood pressure and, certainly drive a hypotensive state and so the more that we can spare those, the, the better on the whole. Certainly using additional anaesthetics, additional pain relief is gonna be hugely beneficial for sparing out inhaled anaesthesia.

And in rare circumstances, we might even consider total intravenous anaesthesia again to, to try and aid with that side of things. That'd be pretty rare though. .

Certainly if we're concerned that we have a hypertension associated with, blood loss or dehydration, then we would often use a dose of intravenous fluids. So, 5 to 10 mL per kilo delivered over a 10 minute period. .

And I think that was historically, that's how I would have treated most hypotensive, but I, I think certainly we're moving away from that now, and trying to, again, not an anaesthetist, but trying to use things like glycopyineium, or ephedrine potentially, for patients that are hypertensive through other reasons and that tends to be through drug effects or, you know, phase dilation, etc. And certainly if we've got a patient that has a relative bradycardia, then, glycopyronium or glycopyrelate is, is, is very effective, just picking up the blood pressure. Equally, things like ketamine can also be useful and ketamine, has a, has a positive idotrope, so it can have a, a beneficial effect on, on both pain and, and, and inhaled anaesthesia smearing and also on, on blood pressure.

Ephedrine is an excellent product as well. And then you've got the sort of the, the fallback big guns if necessary, dopamine, dobutamine, but again, we use those sort of things very, very infrequently. But, but yes, if you're not using things like glyco and ephedrine, then that's something definitely to explore.

And I guess that takes on to analgesia. And we've spoken about things like ketamine, and as you can see, that's very much on, on this list and ketamine works through as an MDA inhibitor. And, it's very useful from the point of view of pain management and at relatively low doses.

we use ketamine very frequently in both cats and dogs, for, for specifically for pain. And we're using that at 0.25 to 0.5 milligrammes per kilogramme.

So it's a very small dose, but that's the dose that's effective as a pain relieving and And, and has, yeah, very good response. We don't see dysphoria and, and, and, you know, problems on recovery. in fact, mostly it helps significantly with that side of things.

So I think ketamine is often an unused drug. Then you have Amantadine, which is another NMDA inhibitor but tends to be used more chronically. It's primarily used in people.

It's off licence just like gabapentin is, for our patients, . But, it's used, I believe in Parkinson's medications, but as an NMDA inhibitor, it can be used alongside some of these drugs, for sort of more neuropathically driven pain. And I think neuropathic pains something we really need to consider for oral diseases.

And the reason I say that is because, a lot of our patients will have been painful for quite a long time. And, and, and even if they're not exhibiting significant symptoms, if you've had long Standing chronic discomfort, there's going to potentially a risk of having a neuropathic component to that pain. And obviously, that regulation of, of, you know, into, connections between neurons and, and physical changes in white matter occur with neuropathic pain, you're gonna get increased sensitivity to normal symptoms.

You're gonna get allodynia, which is obviously the sort of phantom pains. And so certainly when I see patients that are showing significant discomfort, those would be in my mind about about it for oral pain and and how I might look to manage them. Intraoperatively, we would use quite a lot of, opiates.

We have a pretty big range here, obviously, and certainly, most commonly used, opiates for, dental procedures is going to be methadone, and, and we use some buprenorphine for what we would consider to be less painful procedures. We would use butrophenol almost never, other than if we were just planning on sedation, . From a sedation and pure new agonist, point of view, I think pethidine works very well.

It's, it's, it's pretty, pretty good from a sedation point of view. So if you have a very anxious cat, for instance, pethidine works quite well. The only downside is a bit, it, it, there is some stinging when you inject it.

And, and certainly from again a managing intraoperative pain, I think that fentanyl works extremely well, especially in, in dogs, and, and so something that we use very frequently. Gabapentin, we've already mentioned from the point of view of controlling anxiety, but we also use it quite frequently for pain, both, primarily postoperatively, in conjunction with non-steroidal anti-inflammatories, . And, perhaps in some cases, so, cats with, chronic gingivitis, stomatitis that are really very painful, or even for patients with, cats, again, with, sort of oral facial pain syndrome, we might use non-steroidals, Amantadine, gabapentin, and, potentially buprenorphine orally, and use all four of those together.

And, we would often end up in those circumstances using them for a fairly prolonged period of time. We try and wean out the buprenorphine fairly early and then try and wean down on those other drugs and, and taper them out, basically. But in some cases, with significant long-standing discomfort, you may need to manage discomfort, so manage symptoms of pain and Especially in neuropathic pain for a number of months, even once the, the disease process that's caused that pain has been eliminated.

Obviously something that, again, we use a huge amount, is, is regional anaesthesia. And it has a huge number of benefits and, and, it gives you a pain-free surgical field if, if it's successful. And the, one of the major.

Benefits is that it persists after recovery from general anaesthesia. It's obviously sparing of of the general anaesthetic as well. So you often find that you, you can use a lower dose of the of the inhaled anaesthesia and we've already said that that's a a big factor in the development of hypertension.

And there's a relatively low rate of complications, and most of the complications associated, with the regional anaesthesia techniques are going to be based on, poor technique rather than anything else. And then we've got this sort of regional anaesthesia versus local anaesthesia, local anaesthesia, that's gonna be things like, what we call splash blocks. So just local infiltration blocks, or, or potentially even just, you know, lavaging tissues with, with local anaesthetic.

Now, how effective that is, is, is probably, difficult. To ascertain in people. local infusion is used fairly frequently and you will certainly get some, local anaesthetic diffusing through the, the alveolar bone and potentially anaesthetizing, dental structures.

It's not clear whether that's the case and, and in our patients. And so we primarily use a regional anaesthesia. From a materials and methods point of view, it's pretty simple, and you don't need very much.

I would definitely recommend using a very fine needle. And the smaller the needle, the less likely you are to cause neuropraxia. You are looking ideally at 27 gauge needle, and in our practise, we have both 13 and 19 millimetre length ones and 13 millimetre obviously for cats and very small dogs, and 19 millimetres for, for bigger dogs, basically.

I personally like to use a 1 mil syringe, because I find that it's, it's very easily manipulable, and you obviously using fairly small doses. And, I'm mainly going to use lidocaine or bupivvicaine. Probably in most circumstances, we will use bivvocaine.

The only times that we tend to use lidocaine is going to be when we have a, a situation where we need it to work more rapidly. Lidocaine's going to start working within a couple of minutes. Buppica's gonna take maybe 10 minutes or so to become effective.

And so obviously that does require you to plan in your when you're going to be operating and when you're going to be operating and so normally we will be placing locals as we go through our initial charting phase and identifying. Dental disease that we're going to treat, and perhaps then turning the patient over, doing the same on the other side and then turning them back again and by the time we've turned them back again, we would expect our, our anaesthetic agent to have worked. From a maximal dose point of view, we wouldn't want to exceed either 4 milligrammes for lidocaine and 2 milligrammes per kilogramme for bivvicaine.

But normally I would, I would half that dose and, and in most circumstances use significantly less. For, cats, I would often use 0.2 to 0.3 mL per block, of bivvicaine and for dogs, maybe 0.4 to 0.8, depending on which block we're looking at.

Obviously, if you're going to be doing multiple blocks, and it's not uncommon for us to do that, where we might choose to use, regional anaesthesia to anaesthetize, you know, potentially the whole oral cavity, then, obviously you need to pre-calculate your doses and make sure you're not going to exceed total dose as you, you, you know, all caught that out. And regional anaesthesia has also recently been proven or shown to be beneficial for things like rhinoscopy. And so if you're doing rhinoscopy or examination of noses, and we've all seen patients that try and wake up as soon as we start sticking things up their nose, again, things like, maxillary nerve blocks can potentially reduce that problem.

Lido king's obviously gonna last between somewhere between 60 and 120 minutes. Pupilating potentially last between 6 and 8 hours. In some circumstances, we might try or might wish to have a, an increased duration of, of action of our local anaesthetic.

And, in those circumstances, we might use, an admixture. And, one that we use probably most frequently would be to add meatomidine to, our local anaesthetic. And 1 mcg of meatomidine added to 1 mL buppivocaine.

that, that sort of concentration. And potentially has the ability to increase the duration of buppivacaine action up to about 18 hours or even potentially more. And so for some of the more painful procedures such as maxillectomy and mandibullectomy, then, then we would certainly consider using that.

From a technique point of view, you want to obviously in most circumstances stay relatively close to the bony structures, but you don't want to do is, is traumatise the tip of the, the, the needle by putting it against the bone or digging it in. That will cause a micro burr to develop on the tip. And obviously, if you're insert.

It near a neurovascular bundle, you have the potential to cause injury. And so, yes, you want not to obviously cause damage to the tip of the needle, and you want a fresh needle for each time and you don't want to put the needle into a bottle or inject it or, or use that for, for, for multiple blocks. You need to to apply negative pressure once you've inserted the needle into the appropriate place to make sure that you're actually not in a vessel.

And obviously if you get blood flush in the, the syringe, you need to replace or move and and reposition basically. Intraneural injection, does happen, and it, it's very, very unusual, or very unusually reported to cause neuropraxia through intraneural injection. In fact, in, in humans, it's often associated with a more profound and longer lasting local anaesthetic effect, which obviously may be beneficial.

But you do need to stabilise the syringe and needle. You don't want them moving laterally or vertically, because that's when you can potentially again see injury to the neurovascular structures. Once you have injected and deposited your local anaesthetic as you withdraw, I would tend to place a finger over the site of injection, and that will help to concentrate the the material there.

And obviously, if you have had any contact with vessels that will reduce the likelihood of development of hematoma, we would leave our finger there for maybe half a minute or so. There are essentially two, main tech or 3 main techniques that we use, and, and the first one is a mandibular nerve block, and, we can anaesthetize the inferior alveolar nerve at the entrance to the mandibular canal. And it's a pretty simple block to perform.

It's performed intraorally. You can use an extraoral approach, but that's been shown to be less effective than the intraoral approach. And essentially what you're doing is you palpate the angular process of the mandible, and, you draw a line, between the angular process of the mandible and the caudal or distal aspect of the last molar, and that's both in cats and dogs.

And so you end up with this imaginary line. And then quite handily halfway along that line and you can pre-measure that distance and that's where the the, the, the canal is going to enter basically. And so you, if you put your finger on the angular process and insert your needle adjacent to the the back aspect of the last molar and then basically advance to the pre-measured distance, aiming at your finger, then you will be in the right spot.

And, and it's a very easy one to do. As you can see here, we've done exactly that. As I say, you want to stay close to the mandibular body, but try not to hit it.

If you stray away from the mandibular body, you can potentially anaesthetize the lingual nerve, the hypoglossal nerve. And, and equally, if you go a long way past the, the, the, the target destination, and again, that's where you might potentially see some involvement of the lingual tissues from an anaesthetic point of view. And theoretically, tongue injuries have been reported.

I've done this block, probably thousands, maybe tens of thousands of times now. And as yet, touch wood, I've never had a case that has self-mutilated their tongue, and I would consider it an extremely safe procedure. The other, commonly performed, block is going to be, of the Magzilla, and we've got two blocks essentially available to us, either the first one being the infraorbital.

Again, this is an intraoral. Approach and you just simply palpate the infraorbital frame and that has a fairly consistent position. It's normally palpate palpable above the last root of the third premolar.

So the distal root of the 3 premolar. In brachycephalic dogs, it tends to be a little bit, closer to the arcade, and then in sort of normal phallic and do phallic breeds. You do need to enter the frameen and advance a very short distance.

If you just install it at the site of the framemen, you will only anaesthetize the soft tissues of the, of the, the, the gingiva, not, not the actual teeth themselves. You want to infiltrate slowly, and obviously you don't want to advance the needle so far, but you come out of the other end of the, the infraorbital canal and, and come near potentially to, to traumatising the eye. And so certainly in brachycephalic breeds and definitely in cats, I would have some.

Precautions about using this technique because often their infraorbital canal is very short. But slow infiltration is important. What we don't want to do is inject rapidly and set up a pressure wave that, that, because we're inside a canal, we could potentially cause, injury to the, the, the nerve and cause more discomfort.

And then the last technique that we use is the maxillary nerve block, and then this can be performed either intraorally or extra-orally. And essentially you're palpating your landmark is the most rostral and ventral limit of the zygoma. And the zygomatic arch obviously attaches onto the, the caudal maxilla, and there's a little notch just at the base of that, and that normally sits immediately above the, the last molar tooth and is fairly clearly palpable.

And you insert your needle at right angles to the side of the face, into that subterygoid fossa, or into the the subterragoid tissues. You need to make sure that you insert your needle parallel to the hard palate, and it's when you wipe wander, on certainly if the needle tip goes dorsally that you might potentially cause injury to the eye. And glow penetration has been reported in one cat, but again, if sensible precautions are taken, then it should be a very safe procedure to do.

You need to direct your needle slightly rotally, as you can see from looking from behind though, we can see that the needle is going to be, essentially pointing at the back of the infraorbital canal. It also should block the maxillary teeth, so it should do the whole arcade. And in this case, you'll see that you can potentially block the palatine.

Artery, the palatine nerve as well, and also some of the nasal nerves. And that's why this block has been useful for patients with, having undergoing investigation of the, the sort of nasal disease. But probably, you need a slightly larger volume than the other blocks because you're going into this sort of fairly large space.

I want to talk about applied radiology. And when I say applied radiology, it really means using the X-rays that we're given, not just for, identification of disease, but, but also for implementation of technique and also selection of technique. And, I think.

It's, yeah, probably well documented that that dentists believe that radiography, radiology is a cornerstone of good quality, dental treatments. And I know that some of you sadly won't have access to, to dental radiographs. And, and I can honestly say that it's the thing that, that made the unquestionably be the biggest difference to my, my career.

My practise invested in dental radiographs, and I was forced to use it. And essentially, I didn't like dentistry beforehand. And after having dental X-rays, I realised that I could be a surgeon and not a butcher, and, and, and it really fueled my, my, my passion for, for dentistry, essentially.

So I think my advice is, you know, use X-rays as much as you can and if you're not sure about what's going on, take an X-ray. Use things like needles to act as radiographic markers so that you can identify certain structures. And then I put this phrase to use the topography to guide alveolectomy, and really that that refers to one of these slides that I'm gonna show you, but.

This is a situation that is common. In cats, the maxillary, the pre-mole is normally a two-rooted tooth. But in 10% of cats, you're going to have an accessory root and, that is obviously a fairly significant proportion.

If you're only expecting two roots, then you will continually find these extractions difficult. You know, 1 in 10 patients, you'll either leave a root behind, it may cause problems for postoperatively, or you're gonna find. It much more difficult to extract and wonder why.

And so things like dental X-rays can cue you to this. Equally, if you've got a dilaceration, so a tip, the tip of the root is bent, that again, is gonna be very useful information if you're planning on taking that tooth out. And sometimes teeth can be quite wobbly.

You think that's gonna be a very simple extraction. You take an X-ray and you can be surprised by what is going on there, and it really does affect how you perform an extraction or further treatment. This is a good case in point.

These are the mandibular first molar of dogs. And in large breed dogs, we often see this sort of almost double line essentially, of the periodontal ligament space. And the reason that we get this double line on the inner aspects of the roots is because there's an imagination of the, the distal aspect of the root to increase the surface area.

And that means you get a corresponding piece of bone that that locks into that region. Now, if we wanted to take this tooth out, we would section it obviously into 22 root components. We use elevators and then potentially extraction forceps.

So a lot of our, our, our work to extract that tooth is going to be by applying rotational forces to the, the long axis of the tooth root. But because there's this wedge of bone that's sitting there, it prevents that rotational force. And so if you see this type of of, of appearance radiographically, you think, OK, how do I get around that?

Well, when you section the tooth, if you use around burr and, and literally run that down the back of the, the roots or the the interproximal surface of the root. You can remove that bony, wedge and, and that was gonna make your life much easier when it comes to extraction. Here we've got a cat with tooth resorption, classic tooth resorption, this is type one tooth resorption, inflammatory in origin.

But the main thing to appreciate here is that you've got an incredibly fragile distal route. And if you try and extract that in a, in a, in a closed manner, that is definitely going to fracture. And if I see this, I'm immediately going to assume and know that I'm going to need to do a surgical extraction.

Also, the angle at which that distal route is too in comparison to the arcade changes quite significantly. You might find sometimes there's a fairly acute or oblique angle, and in some cases a more upright position and that, that knowledge of, of the, that sort of angle is really useful when it comes to which direction do I insert my, my elevator, my luxator, when I'm extracting that root and having the elevator pointing directly towards the, the apex of the tooth, is gonna minimise the likelihood of fracture of that root. So again, use the information that's available to you to make an appropriate decision about how you treat that.

And then obviously we have things like this where you've got retained tooth roots and and this is where dental radiographically it makes a huge difference and we can see certainly here we've got the distal root and the mesio buckle root of the maxillary 4th premolar in this cat. And you can see that there are sort of areas within the top of these roots, that, that appear black and, and that is where, this patient, had some dental treatment previously, and they tried to drill the roots out. And obviously, we can see that was really unsuccessful.

Dental radiography just gives enormous amount of, benefit when you're trying to extract these types of diseases. And of course, we've got this sort of situation where we've got extensive tooth resorption and we are going to look to remove and probably perform crown amputation of both the molar and the third premolar. But we've got the 4th premolar that that has evidence of, of a periodontal ligament space and endodontic system.

So that tooth needs extraction. And I go ahead and do that, or indeed, sadly, I fail. And, and I've broken the, the root off.

And this is why I think then for radiographs can be really beneficial. Essentially, if I break a root and I can't, or I can't immediately see where that root fragment is, or I can't picture exactly where it might be, then using an X-ray, and I can look at the sort of the, as I say, the topography of the X-ray. They look at the contours of the X-ray.

And I can then use those contours and apply that to what I'm seeing in the patient, and I can use the contours to guide where I might do my, my alveolectomy, where I might use a burr to remove some bone so that I can then have access to the root itself. And by doing that, I can be much more accurate about identifying where that root fragment is, and then obviously I can confirm that I have extracted that route. We're coming now on to the sort of more practical bit of this presentation, which is sort of, the, the sort of surgery side of things.

And, when we're looking at surgery, oral surgery in general, we're talking about surgical extractions or closing all nasal fistulas or a nucleating dented cysts and maxillectomies, mandibulectomies at their heart, all of these procedures have, the creation, design, implementation, use of muco periosteal flaps, and that's really, again, the cornerstone of oral surgery. And so, Deciding which ones to use and knowing which ones are available is really important. Essentially, the type of a flap is going to be dependent on, on what we're intending to use that for.

We have 4 main types and I'll show you. Of these, but essentially we have a simple envelope flap. We have an extended flap, and that can be an extended envelope or an extended triangle, or even an extended pedicle flap, and that extended just means, going around more than one tooth.

We have a triangle flap, which is a 3, which has 22 sort of incisions and then a pedicle flap, which is the classic 3 incisions, and we'll, again, as I said, we'll show you those in a sec. The most important thing when it comes to designing mucoperioste flaps is that you need to expose the full structures that you're interested in. And so normally, if we're doing a surgical tooth extraction, for instance, a maxillary canine, we're going to look at removing 50 to 75% of the buckle alveola wall, .

But I think worst case scenario, we fracture the tooth, we might have to remove 100% of it if there's a very small root fragment retained. And so we need to be able to create a flat that allows us to do that. So having an idea of that, the structures and where they run and where they are anatomically is really important.

The wonderful Americanism, go big or go home definitely applies to flaps and, and too often we see small flaps, created that, that then fail and break down, and that's purely just because they are, are, have insufficient blood supply, they should. You know, as wide as possible, to allow a good blood supply to the, to the tip of the flap, and, and the wider they are, the bigger they are, normally the better things go. So yes, don't, don't be shy when it comes to, making these sort of flaps.

And I guess how big and what if it goes wrong, I've got some photos in a second that sort of demonstrate what, what we can do if our flaps get damaged or, or worst case scenario, we have a very big defect to close. . So this is a classic, this sort of green outline is the is the sort of outline of the incision that we would use for an envelope flap.

An envelope flap is the, is a, a flap is a essentially just a circumferential incision around the tooth. We're using a scalpel blade and we're cutting firmly down onto the alveolar ridge, and cutting through the floor of the gingival sulcus. And, and I would recommend doing that for all extractions.

And the reason that I do that is because if you don't, you have to drive your elevator or luxator through the epithelial attachment before you insert it into the periodontal ligament space. That's obviously fairly traumatic and it, it, you have to use quite a lot of force to do that. And it also means that it.

You've got a, an interface between your blade and the, the fibrous tissue, and quite often you'll then get slipping. And that's where you might sort of skim off the side and, and end up potentially causing trauma to the soft tissues around the, the tooth that you're trying to extract. So yes, always make this circumvential incision, and that tends to be the, the starting point for all of our flaps, basically.

We, when we are, performing, this sort of flapped design, for anything other than, a simple envelope flap, and I would do an envelope flap for I say most of my procedures because I want to surgically close, even closed extractions. I will. Incise around those, extract the tooth, and then, and then maybe pop a little suture in just to either close the mucosal wound or to hold the flap close to each other so there's less distance for the, the tissues to heal.

And it also retains the blood clot and less likely to get a dry socket developing. So, It also by raising a little envelope flap in multi-rooted teeth allows you to identify the exact position of the furcation so that when you're sectioning through the furcation to divide the tooth into the appropriate components for extraction. Then you can do so far more accurately.

But for other flaps, we, we need to think about how we design them. And the most important thing to remember to think about is that when your, when your flap is closed, when you're suturing up, that you should have support of the margins of the flap. In other words, under the incisions, there should be bone.

And so it needs to be, if you're doing, bone removal alveolectomy, you must make your incision, of your flap wider than the intended alveolectomy. Incisions should be made at the line angle of adjacent teeth, and we must avoid the furcations of adjacent teeth. And, and obviously if we incise through a furcation, we're much more likely to see furcation involvement in periodontal disease and any trauma to the margin and that includes incisions and periodontal flaps and those kind of things is going to lead to some degree of alveolar ridge loss and probably 1 to 1.5 millimetres in most circumstances.

And so if you've made an incision through a furcation, the likelihood is that you will predispose that tooth to developing periodontitis. What is this term line angle of adjacent teeth though? Basically this refers to the fact that we consider teeth to have four surfaces, a buckle surface, a lingual or palatal surfaces, and then a front and a back surface or median and distal surfaces.

And the lying angle is where Essentially two surfaces meet, and so it's not right at the front of the tooth and it's right right at the side, but it's kind of halfway between them. And I, I will show you what I mean by that in a second. Gingival incisions must be perpendicular to the gingival margin.

We don't want to do is when we're cutting through the gingiva, that, we are, cutting at an angle and that will lead to, a poor vascularity of one of the edges of the margin because you'll have a, a portion that doesn't have as much blood supply and therefore likely to have decent at that site. So, yeah, cutting at right angles to, to the gingival margin is important. And if you're creating a flap that you want to mobilise, you must extend your incision beyond the mucogingival junction.

The muco gingival junction is this sort of junction between the fixed gingiva that's attached to the underlying bone and the freely mobile mucosa. And in this photo, it's that line there. So, essentially speaking, You have to extend your flat beyond that.

And as soon as you get in, so you're gonna go parallel, sorry, perpendicular to the gingival margin up to that line. And then as soon as you hit that line, you want to then diverge away from the, the perpendicular line to increase the footprint, the, the basic, the width of your flap to increase again, blood supply to the flap. And this is the kind of flap that we might use here for extraction of a 4 premolar.

And you can see, this is what we call a triangle flap. So again, there has a, there's a, a rostral releasing incision, but I haven't done a releasing incision distally. And in most 4th premolars, that's not necessary.

You could extend this flap and turn it into an extended triangle flap by going around the molar if you had to extract the molar tooth. You can see that we've got this sort of very perpendicular line as we've incised through the ginger and then as soon as we've hit the mucogingival junction, we've diverged away. So nice wide base flap.

And again, we can use that same design very commonly for mandibular molar teeth. In cats, again, we need to make sure that we obey those sort of strict rules. But the lessons, you know, if we don't have to create a pedicle flap, then we, we shouldn't do because again, that reduces the vascularity to the flap.

And then we have the classic design of a pedicle flap, and again this is in a a a maxillary canine tooth and again we've applied all the same rules, but you can see how large a flap this would generate. And, and once we've elevated that, you can appreciate the juga of the tooth, I think probably just under my finger, and that's where the root is going to end up. You'll be able to expose all of that root, but if you removed all of the bone from overlying the root, if you follow these lines from your incision, you'd have bone support underneath that flap as well.

If it goes wrong and you've in and, and you traumatise your flat margin and you need to excise some necro some injured tissue, we don't want to suture injured tissue because that will lead to necrosis and then potentially to dehissance. You can, in worst case scenarios, A full thickness flap across the gingival to the sort of soft tissues. And then you can extend your, mucosal incision as a partial thickness flap out onto the, the, the labial mucosa or the vestibular mucosa.

And you can potentially go all the way up to the gingival margin. And so, worst case scenario, if you lost a portion of the, the flap, you can extend and then dissect carefully with nets and balms scissors underneath the The, the mucosa and create a very large flap that you can use as an advancement flap. This is what we would do routinely for or an ageal fistula repair, for maxillectomy repair, those kind of situations.

When I'm elevating my mucop periosteal flap, I'll often focus on areas first that I know are more likely to tear. And that tends to be where there's an area of tension or where we've got a significant change of direction. And the blue arrows, it would highlight those sort of areas where I'm gonna work on first, and I'm going to.

Those up. And I would often, obviously, we use a perios elevator primarily, but we very commonly use, what we call a beaver blade. And some of you may, may say, I've got a photo later, I think.

These are very small blades. They're very useful from, because they're delicate, but they're also very rigid and they can be used as a very sharp periosteal elevator. Essentially, when we're using a periosteal elevator, we want to keep our elbow up and pressure on the tip so that we don't skid and slip.

And when we're cutting using a blade, we want to have what we call this internal bevel. So instead of being parallel to the surface of the tooth, we want a, a, about a 20 or 30 degree angle in towards the root itself, so that, we're cutting back towards the root. So again, we're not gonna slip.

And a useful technique if you're struggling to lift up the ginger vene and get it started, get that flap started to lift, and that's where they tend to tear, is if you've done your incision, if you go to the mucosal portion of the flap, not the gingival, but the mucosal portion, and that's where the big arrow, red arrow is, if you insert your periosteal elevator there and then work back towards the ginger from back towards the oral cavity, you see often easier to get it started at that point. And the good thing about that is if you do lose control of the tip and slip slightly, then you're slipping into the oral cavity into space rather than slipping into the soft tissues above the tooth and and causing trauma. This is a beaver blade, and you can see the design that we most commonly use is this SM64 shape.

And as I say, I think they're really, really useful, and I would definitely recommend if you've not had a go with them when it comes to doing oral surgery, then, then have a go. They are really, really handy. And then good quality periosteity elevators really, really useful.

Don't use your perioste elevator for retraction of your flap when you are doing alveolectomy and using burrs. Invest in some simple mixing spatulas or even use the sort of the, you know, coffee stirrers if you have to, just to retract the mucosal soft tissues. There are essentially 3 rules to oral wound closure, and it's a bad pun, I'm afraid.

There are 3 rules are no tension, no tension, and no tension. And oral tissues, unlike skin, really don't tolerate oral, oral, you know, any sort of tension on the wound margin. To achieve, a, a good tension-free closure in most circumstances, we need to incise or separate the, the periosteum, from the, mucosal component of the flap, because these are two layer flaps.

So you can do that using medicine balm, scissors, or you can do that using a blade. But essentially, if you grasp the edge of the, the, or the underside of the flap, don't grasp the margin of the flap because that's where you'll crush and cause damage. But grab the underside and turn it over.

You'll be able to see the sort of white sheen essentially associated with the periosteum and you can, as I say, dissect very easily with some Mets and balm scissors in bluntly dissect between the mucosa and the periosteum, and then use those scissors or use a calpel blade to cut the periosteum. And suddenly your, your muco your then mucop periostealyte will become very much more elastic. You'll be able to close it much more effectively.

Halstead, surgical principles. He was a clever chap, was Halstead, and he definitely knew best. He talked about closure of soft tissues, minimising, wound, you know, damage, increasing healing, preventing infections, debridement, and, and those, sort of core principles.

Those principles apply to all soft tissue surgery, and that includes oral surgery. I'm very keen on oral wound closure, and if there is infected granulation tissue, that should be debrided, and then the tissues lavaged, and then the soft tissue capsule closed. And so, I think that that applies to almost all extractions that I do.

Maxillary incisors and the maxillary first molar, and perhaps that is one of the exceptions. Again, if you try and make a flap, a significant advancement flap for the maxi in sizes, there's a relatively high risk of dehissance. And so I would advise caution, but I'd still probably put a suture across the alveolar margin, that way, as I say, I can pull the gingiva slightly closer together, but it also retains a blood clot more easily.

And lastly we're gonna talk about dental bus, and this is my sort of top tips bit, . Dental bars are something that is inherently important in oral surgery. We use them for a whole range of different things, but wine size does not fit all, and they do not last forever.

And you probably get one, maybe two uses out of a. A tungsten carbide burr. And in some cases that will need to be thrown away halfway through the procedure.

If it's starting to get inefficient cutting, you'd like to get more tissue damage. And so, yes, have a range of burrs. Different sizes are very useful and equally different shaft lengths are very useful.

Here in the photo, we've got round birds and we use those for alveolectomy, and for cavity preparation for restorations, those sort of things. On the left, the furthest left, we've got a standard length. Burr.

And then we've got some, what we call surgical length burrs with this extra long shaft, and they can be really useful, when you are doing things down a little hole, or where you need better visualisation. So if you don't have those in your practise, they can be very beneficial. We've got the taper fiss cutting burrs and these are used for sectioning primarily of the crown, and that includes coronectomy, and so amputation of the crown for tooth resorption, but also coronoplasty as well.

If we have a tooth that we're extracting, . And it is very closely associated with the tooth either rostrally or distally, then sometimes removing a portion of the crown will give you a little bit more space to be able to insert your elevator and can make a world of difference and make it much easier. And you've got a taper fish at burr on the right hand side there.

On the left hand side, we have what we call Lindeman burr, and that's a, a very much more aggressive, taper burr. And that's used for cutting bone, in surgical procedures. And then in the centre there is a really helpful burr.

This is an incredibly long and very, very fine tipped burr, and this is something that we would use. For root tip extraction. And essentially, if we have a very small root fragment that we can identify and visualise, we can use this to gently remove the essentially cutting the periodontal ligaments, and cutting and sort of cutting around the tooth root, so that we can then get our elevator in and around it.

Because it's such a long and fine, but, it can be incredibly useful. And then last but not least, we have diamond burrs and we use these primarily for alveoplasty. In other words, when we've done an extraction, it's really important to go back to those hard tissues, those bony tissues, and with a digital pack, you know, that digit, run your fingers over them, and I see a number of patients that come to us on a regular basis that have had extractions elsewhere.

That have quite significant bony spurs are essentially associated with surgical extractions, very sharp points that are gonna be underneath your mucosal flap causing quite significant irritation. So use a diamond b at the end of each extraction just to go around the hard tissues and smooth them down. They're also really useful for gingivaplasty.

So if you've got gingival hyperplasia, you can use this sort of more sort of tapered shape rather than the round shape, and you can use that to remodel the gingiva itself. And it also encourages so hemostasis. And so if you're doing extensive gingivectomy, gingivoplasty, then using a diamond book can be really helpful when it comes to reducing haemorrhage.

And that, ladies and gentlemen, is, this is the end of my presentation. I hope that that's given you some things to think about. I'm sure, that there will be as many questions as answers given there, and if there's any questions that you have that are burning right now, I'm very happy to stay online and try and answer some of them.

OK, thank you very much, Andrew, that was a really, really interesting talk. So we've got one question so far. So if anyone else has got any questions that they would like to ask Andrew, there's a question and answer box at the on the screen.

So you can just type your type your question and I can get that put across for you. So the question that we have is from Greg, and he's asking about gabapentin, and he's saying, what is the definition of neuropathic pain and how does gabapentin work? All good questions, Greg, and I, I'm probably repeated myself and saying, I'm not an anaesthetist, but essentially, neuropathic pain is, is pain that is derived from, a, a nerve origin rather than a, and, and is either amplified or purely out of nerve origin rather than being associated with a noxious stimulus.

And so, essentially, gabapentin works through, GABA and, an MDA, inhibition, so receptor inhibition to downregulate those inappropriate neural signals, basically. OK, thank you. We've got no more questions, coming through, Andrew, so I, I think we, I think what you got everything that you discussed in the presentation probably answered everyone's questions.

So hopefully there's plenty of things that they can take away. Absolutely not. No, I found this absolutely fascinating, really, really interesting.

So hopefully there's lots that they can take away to. Using practise. And, yes, so thank you very, very much, Andrew, for a really, really interesting talk.

So yeah, thank you, everyone, for joining us this evening, and we hope to see you, well, talk to all you all again soon on our next webinar. So thank you very much, Andrew, and good evening. Thank you for having me.

OK, thank you. Bye.