Right, so kind of following on from what we've already talked about here. So what do we want to do, identify what might be painful. And why, and, and what sort of pathologies we're, we're looking at, what, you know, does this problem cause pain, which again sort of follows on from that very last question really, trying to avoid things that we make worse, which again is, is very relevant to that last question.
And how do we minimise this? How do we make our, our animals as comfy as we possibly can? Both with what we, we do in terms of technique and also with considerations for analgesic, particularly local analgesia, of course, and the fact that we might want a multimodal approach as well.
But local analgesia is such a fantastic thing to do. We can't go over all the techniques in this particular presentation because we're looking at all sorts of elements of pain. But suffice to say, this is something I would very much recommend you learn further and again, get yourself on a wet lab, because there's nothing like having a go on the real thing.
So, what sort of pathologies are we looking at that may cause discomfort? Well, there's all sorts really, and having worked in NHS emergency clinics, a lot, then and, and, and enjoyed those in that they're very rewarding. You can see a lot of people coming in in abject pain and then going out comfy, which is great, and it also gives you a good handle on what does cause what sort of level of pain.
So things like pulpitis, which is inflammation of the pulp, and that's inevitable if you get pulp exposure. Periaical disease can cause discomfort. Again, it doesn't mean that you've got this in every single case, but.
For a proportion, you do get it, and you want to treat anyway, so I would always err on the side of caution and consider that an animal may be painful rather than ignore an animal, thinking that it's fine when in fact it's not. A periodontal disease can also cause pain. I was always taught by veterinary dentists that this was not the case.
However, I know that it is, from human patients, and we've also had quite a few, well, canine and feline patients actually, where, We can see, for example, the most obvious will be a mobile tooth, stretching of periodontal ligament fibres, they have innovation that will cause discomfort. Actually they're usually easy to take out as well, so that's great. We can get our animal more comfortable, very quickly and easily.
But also actually some of the levels of gingivitis can, can be an issue, and I recently had a consultant anesthetist's cat in. With a very, very subtle lesion, actually, and I was rather hoping that, you know, the periodontal treatment would do the job, but you think, gosh, do you think that caused the signs that he was seeing in terms of pain? And the answer is yes, because the pain has not been, or at least there have been no signs of pain since then.
So, again, you know, I wouldn't have believed it once upon a time, but with human patients and the things that they say and they complain about, yes, that can certainly cause pain. We can get sensitivity from dentin because dentin contains tubules, effectively it's porous, and within those tubules we have effectively nerve endings. So yeah, that could be a very sensitive place.
Obviously bone. Where we've got, infection, inflammation of bone, we know that that could be painful and ditto with soft tissue. Obviously, if we cause injury to that, then we, we are well aware that we've got, pain as a potential issue there.
And obviously the treatment that we provide may add insult to injury. So we've already got an animal presenting with diseases or injuries, some of which may well cause pain, and then we're going to go and do our treatments, which will be basically adding on top of that. We're trying to do, it's a necessary evil to try and get things more comfortable, but in the short term, We've got an area of, say, inflammation, and we've got wind up going on with pain, and what we do is we go and make things a little bit worse.
So we've got to be careful that we don't add even more to that by, for example, getting your, your thermal injury to your bone, slippery instruments, leaving bits of roots behind. So things like Carey's, periodontitis, these are all things to consider. So Cary's dental decay, initially not painful, but as we get that lesion deepening, we end up with our pulp becoming inflamed, i.e.
Pulpis, that gives us toothache, and eventually we can get pulp death. As we can from exposed pulp, things like that, as you'll see from this rather unpleasant, and very brown necrotic portion of what was also very smelly pulp remaining in this canine here. And if we get infection, of course, then we can get pain from abscesses and things like that.
And of course, tumours, we, we can get that. Cats, for example, squamous cell carcinomas, overt signs of oral pain in an older cats, and that's always something that I, I bear in mind, and just have there as a, as a suspected issue. No, actually, scaling can be quite uncomfortable.
So I'm not saying don't do it by any means, but just be aware that you can get sensitivity while you're doing it. Our animals are anaesthetized while we do it, of course, but some individuals are more sensitive than others, and you may actually have some sensitivity that continues after the event. And if we're going to do scaling or cleaning within pockets on routes, then that can be really quite uncomfortable, so actually that's something that I would numb up for.
Extraction is an obvious one. Clearly, extraction is painful. If we assume that you can do a perfect job of either a closed extraction, that's a simple extraction, or a surgical extraction, then the surgical would be more painful, because, of course, we're going through more tissues.
With the surgical, we're into our soft tissue flaps, we're into our bone removal, . And that will be classed as severely painful in people. A closed extraction would tend to be less painful, but of course, that assumes that you do it very well.
If you struggle and you damaged tissues on route, then that can become even more painful and also more prone to infection, etc. Afterwards. So all of these things, obviously potential for pain is there.
And what is it that's going to feel all of this? Well, it's the trigeminal nerve, and that feels the face is also involved in terms of the motor aspect, to chewing, but we're bothered about that sensory elements. We've got our V1, 2 and 3, if you recall from your anatomy days, probably in the dim and distant past for some of us.
So we've got our axillary branch and our mandibular branch that we want to focus on. Those are relevant to our, our dentistry, or oral maxillofacial surgery. And we've got our maxillary branch, then splitting into infraorbital palatine incisive branches, and in the mandible we've got our mandibular canal with our mandibular neurovascular bundle branch heading through that.
And then of course we've got our lingual and also our buckle branches that are going to supply the tongue area. Tissues and also the buckle or the cheek area tissues as the names imply. So sensory, it feels the face.
And here we are heading in a rustral direction, exiting our throne. So we've got this sensory supply then branches of the trigeminal nerve. It's a major cranial nerve, obviously, and they are going to have little tiny branches off each of those major branches, and they are going to supply our pulps.
So in other words, you've got tiny little branches of nerves and obviously blood vessels heading to every apex of every tooth, entering there and supplying our pulp. And we've got different nerve fibre types in there, so the pulp is quite complex. We've got our A and our C fibres, which explains why we get both sharp pain, and also we can get a dull throbbing pain as well, depending on what stage we're at with our, our pulp.
And then, as I alluded to before, we've got this sort of nerve endings, if you will, or little nerve branches through these dentine tubules. Those are actually our odontoplasts, and the adonoblasts have these processors that go into those. Tubules and mean that we've got sensation right to the outer limit of our dentin.
So that's right just under our thin layer of enamel, or in the root, of course, just under the very thin layer of cementum. So we've got sensation really of of the vast majority of the tooth. So we had a transverse section of a tooth here, in this case it's the root, and we had a look at that.
So A to B our transverse section. You'll see in the centre, of course, we've got our pulp, and this is the wall of the tooth. So in other words, the dentin.
And what I'm trying to do, it's very stylized here and simplified, but what I'm trying to draw is these tubules within the dentin. And so dinal tubules and as I say, sensation throughout there to the outer perimeter of our dentin. Now, we've got this big cranial nerve then, feeling the face.
And then we've got to think about where that signal's going to obviously in the brain. And if you recall, we've got the homunculus. Now that was where we had a diagram that was trying to illustrate what sort of area of the brain was devoted to feeling what area of the body.
And if you recall, and of course here we've got a human one, but if you recall, an awful lot was devoted to feeling the facial area. And you usually get a great big tongue and lips, and, and obviously in animals, we get the vibricity as well. So we've got big cranial nerve feeling from the face.
We've got a big area of the brain devoted to feeling that area. And to make matters worse, our pulp has got this great innovation, different nerve fibre types, and its default setting is to feel. So rather than feeling what temperature something is, what pressure something is, it just default sets the pain.
It's too hot, I feel pain, cold, I feel, I feel pain. It doesn't, you know, sort of differentiate between temperatures and things that, for example, of course, our, our skin would do. So, unfortunately, by the time you combine these elements together, there's obviously great potential for great pain from injury to the, the teeth and the facial areas.
Now, we want to prevent pain, obviously, from a welfare point of view, make sure that we care for our patient, both from that point of view and other elements like our healing, etc. And we know that if we can try and prevent the release of the the catecholamines, the cascade of factors that occurs when pain reaches the brain, if we can avoid that happening in the first place, then so much the better. Once we've got wind up, it's quite hard to rein that in and gain control again.
So this is where local becomes so important that if we try and get the area numbed up from the word go, we're blocking that pain signal in situ. We're blocking it going from where we're gonna do our surgery, etc. From getting to the brain.
Now obviously it will get there ultimately, as things wear off, but it will be much, much reduced. It also means, of course, that we don't need to have our animal deep, deep under anaesthetic, and we find that in surgery, you know, we, we, we only need a very low level just to keep our animals still basically, so I can do my job. The other thing of course is we're gonna get faster recovery, better healing if we've got an area that's nice and comfy for our animal.
And we get less complaint, we get less revisit because we've got issues and our clients are concerned. So, again, you know, all of this is, is win-win for everyone, for our patient, most importantly for our clients and also for ourselves, for our, our satisfaction in our work quality. So we've got local analgesia being a really, really useful thing.
But of course there's other things. So if for example, in this dog, if we had a jaw fracture, the movement of those relative portions of jaw is gonna clearly cause pain. So actually stabilising it might be one of our most effective ways of, of getting reduced pain.
So what we're really trying to do then is look at what our presenting problem is and whether we've got pain there. And then, you know, also once we've, so it might be that this animal is presenting as painful, or of course, it might be painful, but we don't identify that because animals, of course, tend to hide it, and we often don't see overt signs pouring, facial rubbing, going off food, changing the way they chew, that kind of thing. Our owner might not spot subtle changes, or very commonly, those changes are actually behavioural signs that we don't really Eyes are signifying oral or dental pain.
So they might become more clingy, they might sleep more because the sleep quality is poor, and they might appear to sleep less because they can't really sleep. They will often be less interactive with games and things like that because they just feel rotten. Sometimes they become a bit crankier and people might say they become snappy and, you know, they put it down to old age and things like that, when actually these poor animals got chronic pain.
So we want to try and see, have we got signs of pain? When we look in the mouth, when we're making a diagnosis and investigating, can we see anything that had that may well be causing pain? And then, of course, our treatment plan, you know, are we going to be able to do something meaningful about the plan, the pain?
What's the best thing that we can do for this animal? And when we do our treat. Well, we know that if we're cutting and things like that, we're going to add the pain.
So, again, how can we help minimise that and control things? And that all feeds into our different elements of the plan and ultimately to our analgesic plan as a whole. It's all these different elements combined.
So again, just thinking ahead, thinking around the subject. So, getting the right diagnosis, that's the first thing. Have I identified what the problem is?
Do I think it could or couldn't cause pain? And, and sometimes, it will be a lesion that could cause pain, but isn't, we think at the moment, but give it a few months, for example, it might well be doing that, that kind of thing. We want to be preemptive, that's the main thing, isn't it?
So, you know, that we're anticipating pain. Making sure our surgery is a traumatic as we possibly can, again, thinking about our holster's principles for the mouth, as well as for everywhere else and good analgesia. For all the different elements.
So, management is is all important, clearly. And we might want to think about, well, OK, once this animal wakes up, it's in recovery, then it goes home, you know, is it going to be able to eat what it once ate, or are we gonna maybe have to manipulate the diet for the next day or two, or maybe more, depending on what, what was the problem. The first place and what we've planned on doing, what we've done, and also how well it's gone, because, you know, it might go super smooth and, you know, be related to less pain.
We might have really struggled, had complications, and actually we're anticipating higher levels of pain now. So it comes down to the basics as ever, really. It's a bit like Domino's, I would say is dentistry probably applies to anything really, but if the first simple thing that you do, so assessing your animal, doing a probe and chart, is a bit sloppy, and we've missed the odd thing, then the next thing is we won't take the X-rays, we won't create the treatment plan, we won't do the best treatment, and so it goes on.
And again, you know, have we sharpened our elevator, have we sharpened our luxat, or are we struggling away with a blunt instrument? It all pairs back to the basics and from good basics we can then move forward. So we want really good charting, thorough charting, a chart that we can look at, rely upon.
We don't need to reprobe things. We can look at that, determine what we're going to X-ray, and also create a bit of a A triage, so we can go, OK, I've got 2 things that are a problem in this mouth, but I think that X, Y, and Z are the most painful. That's what I'm going to focus on today because I want a comfy animal.
That's our fundamental first professional obligation really, and certainly what we want to do. So we know that if we don't X-ray, we're going to miss 60 to 70% of our tooth. We just can't see it because it's, it's root roots are the majority of each tooth.
We also know that most pathology shows sub gingivally on and around the roots. So again, taking X-rays is fundamental to, to dentistry. And of course, we might also then think that we need a biopsy if we've got any suspicion at all, and then we want to add that to the mix.
So, for example, this cat did not have mobile teeth because of periodontitis, which is what the vet had thought. Take a radiograph, dead obvious, we've got something very aggressive going on, so of course it's neoplastic. Something like this, you'd think it's obvious to take a biopsy, but often people don't, they just think, oh, it's a lumpy gum, let's burn it off, and then it can be too late to do anything meaningful.
So what sort of things cause pain? We've already mentioned a couple here, but cause trauma. So, whether we're exposing dentin, then we can have our sensitivity, or more obviously we expose our pulp.
And that could be through rapid trauma. So we fracture our canine tooth trying to catch a stone that some Foolishly through for us, clearly we've got an exposed pulp and, and then we're going to get pulpitus. It's not, well, we'll wait.
No, we, we definitely will, we'll have inflammation, pulpitus, and eventually we'll get pulp death. And of course necrotic tissue is a great place for for bacteria to grow, and then we can end up with our abscesses, etc. So we've got trauma that's rapid because it was kind of almost instantaneous with a thrown rock or whatever it might have been, or we can have rather more slow trauma.
So if you think about your animals with worn teeth, of course that can ultimately cause pulp exposure, or even if not exposed, then our pulps can become inflamed and infected. And we know that if that happens, then we can end up with our, our abscess and that anyone that's had a tooth abscess, and has felt the pain that's possible from that will know that it's extremely high. So typically you ask someone that's had one, what was your pain score out of 10, and they say 11 or something like that.
And that actually, unfortunately, analgesics do very, very little for abscesses. And in fact, we would find that, antibiotics are more effective in those cases. Now, I'm not advocating antibiotics as a treatment for an abscess.
I'm just trying to make the point that the pain there from the pressure, from the, the infection is the issue and therefore, antibiotics in some cases are used if you can't treat immediately from a, a, a pain point of view. But that antibiotics alone would be regarded as negligent in terms of treatment of abscesses in people. It needs to be in combination with the required often for first opinion practise, it would be extraction.
We might also think of alternatives like root canal, for example, but that antibiotics alone are not appropriate as a treatment per se for these infections. Then we've already mentioned periodontal diseases, so typically periodontitis and most obviously mobile teeth, but that this is inflamed tissue and it can be really, really sensitive, so don't ignore that. Tooth dysplasia carries, basically things that affect the the or compromise the outer wall of our tooth to our enamel and then our dentine and we can get sensitivity and then inflammation of pulp and then infection and so forth.
Trauma can, of course, not only be two tooth, it can be a bones. So as we've said, fractured jaws, pretty obvious that that's likely to be painful. Symphoceal separation, generally speaking, far less so.
So if you've got a symphoeal separation and a very painful animal, then certainly look for other injuries, and that, that will be quite classic, that actually it's the broken tooth that's causing the issue. But so often if you've got maxillofacial trauma, whatever you spot is the injury, there's going to be quite a lot of others that perhaps go under the radar. So, keep a very close eye on those X-rays and of course ultimately CTs help an awful lot.
Injury, laceration, soft tissues like tonnes, you only need to have had an ulcer in your mouth yourself, to know that these can be painful. And of course, if we get large areas that that are constantly being traumatised, then that could be really, really unpleasant. So it could be dermatitis in a cat, could be in this case, a dog with a fractured canine.
No one's spotted the fractured canine, very sharp edges of enamel, and we've ended up with laceration and alteration under the tongue. Pretty unpleasant. This er animal had a fracture.
Of a, a, a tooth, and we've got our on aquatic pulp. It can be, An uncomplicated fracture, in other words, a fracture where we've not opened out into pulp. We can still get unfortunately, our pulp affected.
So don't think that the only way of getting an infected and inflamed pulp is by exposing the pulp. If we expose dentin, it can follow suit as well, and it has in this particular animal, we've ended up with very long term chronic infection and inflammation, and it's broken down both all of the bone that once covered the root of this canine. And also the soft tissues are pretty nasty in there.
That's not me having caught some sort of bizarre flap. It would be a pretty odd one. No, that unfortunately is the the infection has done it for us.
Pretty nasty, poor, poor dog. And of course, as we've said, neoplasia can also cause pain as well. So we need to select appropriate treatment.
That is, is obvious, isn't it? And if we've not done our planning right, we might well be off beam with our treatment choice. So selecting that appropriately is is obviously important.
And here I'm showing in both cases, a fractured canine in the one case, I'm extracting it, that get rid, gets rid of the pulp, and the pulp, of course, is often what causes the pain because it's what becomes inflamed and infected. And in this case, I'm getting rid of the pulp. Only I'm doing it by root canal.
Now actually I would normally have this all sort of draped up if you will, so it's what we call dam placed on it. But here I'm just trying to show that we've got a hole in the tooth there, we've got something going down there. We're trying to get rid of the pulp, so we get rid of the bit that causes the pain.
So there are different treatment modalities out there for, for injured teeth. So we want to make sure our technique is good. Actually, a root canal is a classic.
This is definitely not something to give a whirl out. You either do it very, very well or not at all, because again, if they go wrong, they need monitoring to make sure that's not the case, and they can be very painful. So, they need really good training.
I mean that's, that's why I did further of that, on the, human training side, the endoontology, that's what it refers to things like root canal treatment. So you want to do things, if you're going to do it, you want to do it very, very well. We also want to make sure that we're going to apply the correct analgesia.
And, you know, the same goes for if we're going to do extraction. We want to do that very well as well, we don't half do it or do it and cause lots of trauma to the surrounding bone or neighbouring teeth. So for example here.
You never ever loosen a tooth by working it off its neighbour, unless, of course, you also want to extract the neighbouring tooth. You'll damage the crown of the neighbouring tooth. You will damage and bruise the periodontal tissues, and we clearly don't want to do that.
We only want to work on the tooth or teeth that we're interested in instructing. So never ever working a tooth loose off an adjacent tooth, unless you are extracting both. So how painful do you think it would be if it was your own mouth?
Well, I've had extraction, surgical of a wisdom tooth, and I can tell you it was pretty painful. I had some excellent consultant maxillofacial surgeon I knew who did the operation for me. I know what an absolutely awesome surgeon he is, and yet, and he used very gentle technique, and I was numbed, and yet it was painful afterwards.
So again, don't underestimate it. Just have a little think. How do you think you would feel if it was yourself?
Our Prophet dental school used to do what he called the daughter test, where he would say, don't do something to a patient unless you would also do it to your daughter. I think that applies to perhaps also your son, your spouse, your animal, etc. In our case.
But the, the message is there, isn't it? You know, if you think this might be a bad treatment for yourself or your loved ones or whatever, then don't do it to your patients. So this is good treatment and I'm doing a surgical extraction and I'm using the right technique, but even then it's gonna be painful, severely painful.
Done badly, it, it will be really excruciating. So again, nice gentle technique. So our considerations for analgesia then, yeah, we always want it to be preemptive.
I'm sure you'll have heard this from anaesthetists as well, of course. So preemptive before we even start doing things, we want to make sure we've got it on board before we start. We also want to think about what we're doing during the operation and then afterwards as well.
We want it to be multi-modal, so we're thinking about our, for example, our pre-medication. So typically I might use something like methadone. So I'm doing extractions, say, I know that that's a painful procedure, so I'm gonna use it in my pre-med my methadone.
I may think about using non-steroidals, provided it's safe to do so. My blood pressure's good in my animal while I'm monitoring. I might in a dog start thinking about things like paracetamol, and I'm definitely gonna be thinking about my local analgesic, my local anaesthetic.
Where's the pain coming from? We need to be aware of that. Is it the soft tissue, the bone?
Is it the tooth itself? And also, yes, sometimes antibiotics are, are warranted, for various reasons. For example, our local works poorly, and we might get tracking infection if we've got a roaring, infection in the area that we want to numb up.
So if we can't treat our animal immediately, for example, with this abscess. Then we might consider antibiotics. If this hadn't burst and was draining, we don't want burst draining abscesses, but the good news about the point at which they burst and drain is the pressure reduces, and therefore, our pain is generally speaking greatly reduced.
If we've got that swelling building and building, and particularly if we've got signs of malaise, if we've got pyrexia, we need antibiotics in that animal because it's, it's now, dangerous and of course we can get our systemic effects, . And sepsis and things like that. So, you know, there are times and places for antibiotics, but it is quite rare and you need to make sure you can truly justify their use.
And this draining tract onto the cheek here was from this tooth. So we've got a fractured tooth, and you can see that we've got a pulp exposed, in other words, a complicated fracture there. Now, most of the time, it bursts through the tissues in the point of least resistance, which is commonly, this is our muco gingival line here, so tough caratinized gingiva, pretty tricky to to burst through that.
It's pretty tough. So very often when you see things, and a draining track there will be just beyond this muco gingival line in this delicate sensitive mucosa. More rare that we get it on the cheek, and that's kind of waving a flag saying, Help, I've got an abscess.
But the others go under the radar because people often don't. Check soft tissues in the mouth carefully enough. So always be very careful, look along that line and everywhere around teeth, look for those draining tracts or evidence that they have been there, because most of the time they don't go through all those tissues to burst out here.
They're actually draining into the mouth, and all that people notice is perhaps a bit of halitosis. And again, classic radiograph showing us this halo around the root, around the apex there, and that tells us we've got infection of our pulp. So, thinking about what pain level from the presenting pathology, what pain level we might cause by our treatments of choice.
So butorphanol, not very good at all. So I don't use that whatsoever. Buprenorphine, pretty good in cats, we, we do use that, and sometimes that's something we'll send them home with.
Methadone is probably what I use most of all. We've got our systemic, we've got, as I say, non-steroidals, where it's safe to do so, paracetamol only in dogs, of course, and then our local. So here I'm just cleaning the, the mouth a little so I'm just, just prepping the mucosa with a little bit of cloxidine, gluconate 0.12 to 0.2%.
And then, so I'm, I'm trying to have a clean field for surgery, of course, but I'm trying to have a little bit of a clean field for placing my local, so I don't go through all sorts of gunk, as I place this, and I'm using, in this case, it's a human setup, but using local in practise is very effective, quick, cheap, easy, relatively speaking thing to do, but there are things that can go wrong, so we've got to be a bit careful. And again, a wet lab is always the best way to, to pursue that. So we've removed renol, er sorry burophrenol because it's, it's very, very poor in terms of its analgesic effect.
And local we're highlighting because it's fantastic. So cheap, quick, effective, and to some degree, what more do you want? It's win-win every way.
We spare our anaesthetic. That's great. We're preventing wind up, so we're blocking that signal before it gets the brain.
Perfect. And we're going to reduce the need for other analgesia and, and drugs, going on into the future once this animal is going into recovery and and going home. Now, as I say, it's relatively safe, but you can do things wrong, so you can cause nerve damage, you can Injecting vessels, that kind of thing.
You can unfortunately end up injecting into the eye instead of, where you want. And so it's something to, to have caution with and to treat with respect, but not to be scared of that you don't learn about it more and, and, and as I say, try and do a sort of practical wet lab because it is so, so effective. When are we going to use it?
Well, all the time, basically, everything I do that might cause any sort of discomfort, I'm going to use local. So cutting into the tooth, we're going to cut therefore into pulp. Yeah, we need it then.
So, of course, if we're doing an extraction, we're also going to be impinging on soft tissue and bone as well as our tooth. So clearly it would be a good idea. If I'm doing the deep cleaning with pockets and things like that.
Now for biopsies, yeah, but you've got to be a bit cautious here. If we think we've got neoplasia, you want to make sure that we're not going to have potentially, neoplastic cells tracking along a local analgesia line. So, and, and withdrawing them as we move our, our needles.
So you need to be well away from the area, but try to make sure that it's And all sorts of other surgeries as well. Clearly it's got all sorts of applications. Various things that we can use.
The most common in practise is going to be like the canine. So rapid onset, you know, we're going to find that it's on board and doing something within around sort of 5 minutes on on average, and then we'll find that it lasts variably. So on the pulp, not so long actually, probably about half an hour, but we get several hours with the Soft tissues, which for us, extractions is really good for people while we're doing fillings, really, we just want the tooth numb.
So actually it's a bit of a pain when we end up numbing up lips and things like that as part and parcel, because, you know, people end up dribbling their soup and and and feeling funny. And all we wanted to do was cherry pick and numb up that that pulp. But in first opinion, we're talking about extractions primarily, and so it's a great advantage that we get those soft tissues and the bone numbed up, and for some time after our pulp is starting to potentially revive.
Of course it's not going to revive because we've extracted the tooth. But we, we want that to be the case, once we've numbed all those tissues we're good to go into. Buppivacaine, so a bit slower onset, so maybe we're talking sort of 15 minutes or so, but it's going to last longer.
So on soft tissues, for example, we might get up to 6 hours with this, less so on the bone and even less so on the pulp, but again, typically speaking, the pulp will be long gone. It will be in the bin, so, you know, that, that's not so much of an issue. Most of the time for dentists you really lgate is what you want.
Typically without adrenaline, but of course you can buy it with as well, if you're going for these pure dentistry type amules. The bivocaine, very similar to igniccaine really, tends to be free of adrenaline and it tends to be a little bit better in areas of inflammation, because again, inflammation infection is going to alter the pH of your tissue, and that can make the the, the local work less well, can make it less efficient. So sometimes per the cane is a good choice.
We can do different things, nerve blocks, splash box, infiltration, then you've got intraligamentary, intraosseous. Really, I think we'll ignore everything apart from nerve blocks and infiltrations because splash block is after the event. So that is, not, having the same preventive effect as, as our nerve blocks infiltration, and the others really tend to require specialist equipment.
But nerve blocks and infiltrations, we would use a combination of the two. So here's an example. We've got an upper canine, and we've got pulp exposure, as you can see the pulp necrotic.
We want to remove that tooth or we want to restore it. We've got the choice of either. Now, if we just wanted to do something restorative, in this case, it would be a root canal.
So here you'll see there's an upper canine tooth that has got a filling here, and it's because it's had root canal treatment we've taken out the pulp. So that would be appropriate for this tooth, and all we'd have to numb up will be the pulp. So actually doing something like Intraorbital nerve block.
Well, that would be more than adequate because that's actually gonna numb up the soft tissues as well as the bone on this outer, so buckle or, or labial aspect of the tooth, as well as the pulp. So that's kind of over the top, really. It's more than we need for a root canal.
We're only bothered about the pulp. If, however, we were doing a surgical extraction of this tooth, we know we're going to be using our scalpel, our elevators, looks, etc. Go to involve soft tissue, bone, the pulp, and we're going to be affecting tissues both on the outer or buckle labial side, as well as the inner, the palatal aspect of this teeth.
We're going to be insulting both when we do our extraction. So therefore, we can't just rely on our infraorbital because that is only going to be tackling the pulp and these outer buckle labial tissues. We want also then to add to that.
Palatal infiltration. So, of course, with the nerve block, we're aiming to place a lab of solution of our local analgesic near to our nerve. Shouldn't be in it, it should be near to it and wash over that nerve and therefore have its effect.
So we're trying to aim specifically, to, to the nerve. Whereas with infiltration, what we're saying is, well, I want to numb things in front of here, for example, in a sort of a simplistic way. And what we're going to do is put a lab.
So we just put a blab in the tissue that soak into the soft. Issues soak into the bone and and and give us the the the numbing effect there. So then we've blocked both the outer and the inner side, if you will, actually, as you'll see in this particular example, it could have been a fractured tooth like this one, or in this case, it was an unerrupted, impacted canine that I needed to get out.
And I'm doing the same thing. I'm numbing up the soft and the hard tissues on either side. So here for example, we're on a lower canine, so I would do the same approach.
I want to know soft tissue, bone, pulp. Pulp here is dead, so actually that itself is unlikely to cause an issue. It's very invasive, it can be very, very painful this one to make sure that our analgesia is good, and I want to make my technique really gentle so that I don't make matters worse.
So, we follow it through. We're trying to make sure that we're not leaving, you know, splintered bone and bits of root and all sorts of things like that, nice and neat. And I'm avoiding using much tension and pressure here.
I'm letting a nice sharp, slim blade do the work, trying to sneak down, as delicately as possible. But it takes good technique and it does take time. So, again, we need to think about what we're doing and, and, and how we do it.
And what we might need to think about is repeating things. So in some cases, we might even repeat our local, but again, you also need to bear in the back of your mind what the toxic limit is for this patient. So you need to know its weight and work that out.
We also can then think about our opiates. So do we repeat our methadone? So typically we, for example, would have the animal hospital.
Liz after recovery, we'll be thinking, when's our next dose of methadone due? And then we might see how dysphoric our animal is on that. And then we would alter our dose and our timing 3 to 4 hours every year, every time.
And then we might think, OK, well, actually, now we're going to go from our methadone in 3 to 4 hours after we've given that dose, what we're going to do is now start it on buprenorphine instead. We're getting our 6 to 8 hours provided our dosage is correct. We might send our animals home, so particularly with cats, with trans mucos and squirts and buprenorphine.
With dogs, of course, paracetamol, we can give that postoperatively, but also intraoperatively. We can give our intravenous solutions, so that again, we're being preemptive with our on our analgesia. And then our non-steroidals depends if it's safe, depends on whether we've got good blood pressure, obviously, but, you know, there's a variety of non-steroidals out there.
And then other things I've put here and again just a photo of, we've stabilised the jaw. So again, you, you've you've got that instantly, and more, more comfortable avoiding that movement. So we're thinking about what we can combine, making sure that we're safe, making sure that we're thinking about the different levels of pain that we anticipate and whether our patient is perhaps the sort of sensitive type or the stoic type.
Now that doesn't mean to say that you give a stoic type less, but you're also kind of trying to judge how this animal might behave. So just because it doesn't show overt signs of pain, that we're anticipating it. But always I would say, benefit of the doubt, and this brings us back to things like the daughter test or just our own empathy.
How would we feel if this was ourselves, or again, you know, our pets, our loved one. Would we want more analgesia, more gentle technique, more care, or would we be happy doing it quickly, not quite as nicely as we would like, and, you know, short changing on the analgesia. Clearly, we wouldn't want that.
And what tends to happen, unfortunately in practise is you're under pressure and people very commonly will underdo the analgesia and use an antibiotics where they really, really aren't required. Pain scoring's a nice thing to do, so we want to make sure the comfort that we've not got a radio blaring, dogs barking away in the background. I know it's hard in general practise, but try and do your best for that.
Cats that are a bit scared, you know, provide them with a cardboard box or even their own carrier inside the cage. Let them make sure that you can observe them, of course, but that they can hide away and feel more secure that way. But pain scoring is a really nice thing to do.
Check that they're eating, so I like to give them some food in the hospital and see how they're doing with that, how are they coping, or they're managing. Do we need antibiotics or not? Well, we want to avoid it, but on occasion we do need it.
And if you think that things have gone very badly, that you're going to get wound infection, then, you know, sometimes unfortunately, that, that, that is required. But we're trying to avoid it. So in summary, again, the same thing first cause no harm.
We really, really don't want to make our animals feel worse after we've treated than they did before. And we want to try and, and have the best for animals, so we're trying to make them feel better, identifying things, treating appropriately, making sure that our analgesic is adequate and preemptive. And, and not doing things that would harm them.
So that includes, for example. Not using atomization as a technique, not pushing root portions down into mandibular canals. We know that complications happen.
We know that things go wrong with the best will in the world, and you know, that, that's accepted. But we, we want to try and get you to think before you act. Try and minimise those indications and those those situations where you would need some some help.
At the end of the day, people like myself, we're there to help you, you know, that, that's what it's for. But of course, we can also guide you to minimise your stress and everything when this happens, then so much the better, far, far better for you and your patients. So again, you know, learning on wet lamps is a fantastic thing to do as well.
OK, and if there's any questions I'll be very happy to answer. That's great, Alex, perhaps while we're just waiting to come in, Luke, if you put the full screen up and that allows people to have a little look, it's coming up to one, you know, I'm more than happy to stick around for a little bit if people want to ask questions, so just give people a chance to do that. That again, I think it's.
You know, again, my memory, when Rimodil came out, we started talking about, you know, post-operative care with spaces and, and everything, . Which of course wasn't really happening before because you know you, you wanted to leave the dog in a degree of pain so it wouldn't move around so much, you know, injure it's it's wound and things, and thank goodness things have moved on quite a lot. Yes, yes, yeah, it's true, it has moved on a lot.
I mean it's still not where we'd dearly like is it, but yes, goodness, they were the . Well, we thought it was OK at the time, but it was the Dark Ages really wasn't it. Yeah, no, but things have moved on so much.
I mean with methadone, paracetamol, our own brands and things, it's all . It's all useful, isn't it? Yeah, yeah, the more, the more you can think about it, the, the better really, and you know, there's so much we can learn from the anaesthetists as well about you know, how to, to monitor these these things and and keep them as comfy as possible.
Yeah, I think it's . Yeah, it's, you know, it is so important that there is so many things we can do, and, and borrowing from the dentists with things like the local anaesthetic blocks, I think they do work so work very well on ourselves, so, and balanced anaesthesia, don't just rely on, you know, a bit of remady. If you can do two or three things, it'll probably also, as you say, help you to use less anaesthetic and often bs.
I mean, one of the ones that always used to tickle me a little bit was. People Coming to me and saying, you know, the dog, you, you knew what the diagnosis was before the dog walked in the door because the smell sort of, preceded it. You know, you're taking 1012, 15 teeth, whatever you're taking out.
And it was, well, you know, we all felt the dog was too old, maybe another. Even sometimes under the vets was too old to go through this and you think it's too old not to go, it's, you know, it's not fair to not go through, that's right, let's put it to sleep if we're not gonna. You know, we we're not gonna do the dental almost absolutely yeah, quality of life rather than being elderly and in abject pain for the rest of your days, yeah, yeah, for sure.
And then yeah, of course it's the considerations in terms of the anaesthetic and things and and and and taking those extra. I mean she'd always be very careful, obviously, but you're just bearing in mind that all those facts, compromise and the geriatrics and. And also in terms of the treatment, so I will often, you know, look at it and I'll, I'll be bearing in mind all sorts of different factors.
I suppose it's the sort of the art of, you know, our, our, our medical, surgical, life, isn't it? You know, where you're, you're, you're bearing in mind, comorbidities and all these kind of different things to think about what is most sensible to tackle first, and, you know, obviously the painful part of it is the, is the thing to eliminate, as a, an absolute priority. No, that's, that's really important.
Luke, I'm noticing that we haven't got the PowerPoint on, so I don't know if you can hear me, Luke. Do you want to do that? I can probably find it somewhere, but if you can put it up, that would be great.
So yeah, we've got some questions, which is good. Melanie's asked a really interesting question. I went to the dentist, and, and just to reiterate this question.
A month or so ago, for the first time I saw a brand new dentist, waiting to have my scale and polished. She scaled the teeth, she said, no, we don't need to polish them. And this is Melanie's question, is there any value in polishing after scaling?
Well, the short answer is yes, there is value, but not in every case. So really the, the, the polishing, the way I tend to describe it, is, is, is the cherry on the cake. So, really what your.
Your, your scaling and your polishing, the primary aim really, when you boil down to it, is actually to remove the biofilm. And both will do that. Clearly, the scaling has got that additional benefit of, of removing the, the, the calculus, which the polishing won't really do.
When you do the scaling, so this is probably, this probably reflects that Melanie does a good job with a toothbrush. Well, well, hopefully that's the case, that. If you do a lot of scaling, you will leave microscopic bits of tiny little bits of calculus behind on the tooth.
And the polishing, as well as removing biofilm, which in theory you've already done, because you've already done your scale, we kind of just whisk those off the surface of the tooth. But we tend to do it less, and there's two sort of scenarios. One is you might not need it because you, you might have virtually no calculus and, you know, you ultimately, that biofilm removal, so we can do it in, in surgery or whatever with that scale of polish, but ultimately, that's what is happening on and with people, hopefully, several times a day with a toothbrush.
So you're not going to sort of get really great benefit from polishing areas, . With it functioning the same way as a toothbrush, in that that will remove a biofilm, your toothbrush removes the biofilm if you've got rid of the calculus, well, you know, you're just gonna rely on your toothbrush, . So there's minimal value to it in in many, many ways.
You can smooth the surface from the point of view of whisking off these little tiny microscopic bits of calculus. It's not going to smooth the enamel surface itself, because people used to say, oh well, you scratch the enamel when you do your scaling, and then you smooth it off with the polishing, and that, that's not actually true. You, you add to it, unfortunately.
So you're doing this sort of benefit, cost benefit analysis really. So it sounds like the, the dentist, which would be very common, felt that it wasn't of of benefit to . To Melanie.
I don't do it in my patients where I've removed calculus, and I think it's doubtful that I'm going to get the brushing, because it takes extra time and, and, and it can well be a waste of time and therefore a client's funds to, to do it. If I. If I have an animal where they're not yet brushing, they've made, maybe they've got this animal, maybe they, no one told them to do it before, or maybe they've got it from a rescue centre, it's covered in calculus.
We get rid of that, but they're really keen and motivated to at least try brushing and hopefully do it properly, then I would do because I'm trying to get it as clean as possible and as smooth as possible for them to hit the ground running and keep it clean. But if that's not the case, then removing the calculus to see the teeth, to be able to probe and chart properly, that's obviously got value. Removing the biofilm, well, that's got temporary value, but not an awful like someone then doesn't pick up a brush.
So am I going to add to the time and cost by doing the polishing? Well, no, I, I, I, I, I wouldn't go beyond that. So, no, we, we, we do a lot less polishing.
For, for patients, both human and animal, than, than we once did. And actually, in people, we're tending to say, right, OK, well, we're not gonna do either until you start brushing your teeth. And I can see that you're brushing your teeth.
And then you've got that carrot, as a lure, really, to try and get them into a good habit, which hopefully they'll then keep. They're sing. That's right, yeah, we.
Sometimes would, would not do that, particularly the, the paidontologists would go, right, you know, you, you do, you show me you'll do the brushing and we'll remove the calculus. Because otherwise, you know, the minute you've done it, they think, oh I've got clean white teeth now, I can ignore my teeth again for another however many weeks or months or years as they do. People just putting across brush their teeth at least once a day.
You would be surprised at how few it is. I can tell you where I have worked, we gave up, we gave up asking whether they brushed twice a day. We just said, do you brush your teeth in the end?
And you'd be amazed at the answers of, oh, if I remember, or, once a week, or, yes, it's it's a dentist. It's not the most glamorous. Yeah, it's, it, it is quite frightening, yeah.
And just while we're speaking . Ivan's plate has come up, Bonnova's virtual Congress offer. So thank you, Ivan, obviously for sponsoring it.
Thanks for all the other sponsors who are coming through now, on, on the plate as well, . Ivan, do you want to come in? Are you, are you, have, have you coped OK with that?
Have you enjoyed that dental, session or? Yes, that's a bit too gory for you, are you OK? No, that's, that's fine.
I have a shopping list of stuff for practise. Yeah, very good, very useful for a GP. It's all extremely irrelevant and with my, with my rabbit vet head on.
Local anaesthesia is so, so, so important. So you get some other, other views on that. I'm a bit cross with myself because usually we put a poll in here, and I know we've we've obviously done dental sessions before, you know, with webinar bet on the platinum membership, Thursday night webinars and obviously now as well.
I think the last time we did it, I think we had 20 to 30%, 25 to 30% who had. Dental radiography available in their practise. We've obviously got, you know, some keen people on today.
I think again, we can't do the poll because we've not set it up, but perhaps can you just answer yes or no, if you have dental radiography in your practise, it's available, you know, you can use it if you so wish, because it would just be interesting to do a very quick. Straw poll of yes to no's, if that's possible, and then we'll, there are a few more questions. I think we'll go for another 10 minutes, are you OK with that, Alex?
Yeah, yeah. I know we're, we're sort of biting a little bit into the lunch. We're, we're back again at 2 for those who are, you know, wanting to come back on that.
I mean, I think this is actually a session going on at 1, but it's on marketing, so if you. Want to go to that, obviously you could go across. Right, so .
Lisa's saying yes, she does. Katrina's saying she's got dental plates but not a proper dental tube, tricky. Eileen, no, Jane, yes, Alexi yes.
Marslade yes. Marcel yes. Katrina, yes.
So an anonymous attendee says, I use our normal machine and do quite well with this to a point, looking to get a separate dental machine. Fair comment. Can we do a tiny bit with, a normal machine?
. It it's, it's better than nothing, but yeah, it's, it, apart from anything else, it tends to be in the wrong room and certainly you won't get the same quality as with a dedicated, you know. The other thing is you have to move the head around a lot, head of the animal and obviously that, that's, you know, it's, it's unwieldy, it takes more time and so forth, but you've also got more danger of, you know, tube kinking, tube traumas, things like that. So, great that they're having a go and yeah, let, let's hope that they are successful in getting the the dedicated.
Equipment in because I think if you're already having a go with the other, then you'll just find it so much nicer to use the other, yeah, yeah, and it just opens up a whole new world in terms of doing the radiography at all. But yeah, I mean, well done for having a crack at it, but yeah, let's let's hope you get the equipment to, to make your dentistry faster and better as well. That's great, and we've got diagnostic imaging, but no dentistry, so maybe, Alex, we need to.
To get you in and do some, we, we do this diagnostic imaging with Mike most years, which is really popular, but actually, you know, we probably need to start throwing a dental session in there which is just on and you know some of those nice little, I, I, I love Mike because he shows you an X-ray and you just think it's, or, or even more so an ultrasound that I am slightly better at radiography than I am at ultrasound. And you just think it's a snowstorm, whereas actually he finds very significant specific lesions. If you want to feel inadequate, about your veterinary skills, Mike has about 8 diplomas.
I've said to him that I'd quite happily just have one of them. I could just borrow it, but he didn't seem too keen on that, so, but really good, and there we go, there's also Matt talking about anaesthesia. So we've got Astrid saying no.
Claire saying no, Mia saying no, Inga saying no. So there's probably, you know, we've obviously got keen dentists in here, but, probably fifty-fifty. So, massive change from what it once was.
It used to be, you know, you'd ask the question, I would say. 10 years ago, but you know, no one would have one, and then I would say most of the courses that I'm, I'm doing, say, wet labs and things like that, then we're probably, probably about 20%, I would say. You know, and then, I mean you might get 20 to 25% and then if you start asking more, you, quite a lot of places have it because it's part of the, you know, the, the, the hospital requirements and things like that.
How many are using it as much or at all sometimes, then, then often those numbers go down, but yeah, quite a lot have got it, yeah, which is great. And then you do have pieces of machinery that sit in cupboards and gate. Well, this is on the wall.
Yes, it is, it is. I mean, I think one of the things is people often get it and then haven't quite realised that you've got the bisecting angle technique that's, that's used all the time. And then that often starts to cause frustration, at which point, you know, they, it gets abandoned, which is a great shame and waste, but all you need is, you know, people.
To, to, to teach you exactly how to do it properly, which does take about a day, you know, to be able to really hit the ground running the next day with it. But, you know, that's, that's relatively speaking, easily done. So, you know, once you've got it, you want to just make sure that you've invested in knowing how to do it.
But again, you know, just expect that it's like riding a bike. You first get it, and you think, oh my goodness, how am I ever going to do it? And then, as long as you you doing properly and practise it, you'll work faster and faster and better and better.
Claire's asking a question, slightly off topic, have you ever seen severe hypoalbuminemia? Following an osteomyelitis, we have a current cases post-op following a removal of tooth 108 with carries who had severe swelling of face. A hypoalbuinema found after dental.
We do not have dental X-rays. My colleague is currently awaiting. Further blood results.
Right, no, I haven't, I haven't is the case. I've seen quite a lot of osteomyelitis cases, but not with the the blood abnormality. So I would suggest probably that the abnormality is not a consequence of the .
Osteomyelitis, it's a separate problem going on that they maybe need to look at as well. Yeah, they have problems, don't they? Yeah, I mean, there may well be some form of relation, of course, but not one that would be found in every case.
Yeah. Beth is saying, can you put lignnicaine and bubivacaine in the same needle to give extended cover but quick onset? I would go for one or the other, generally speaking, I think, yeah, I, I what we quite often do in people is, we, we use one, One solution and, and then we find perhaps that hasn't quite worked, and then sometimes we'll go right, well, we'll use another one.
So quite often you do end up with a mixture of solutions in, in the area, which effectively is what you're doing automatically by mixing in the, the, the syringe. There is a downside because you can. You can end up with slight pH differences and things like that.
And so, you, you, you can almost end up sort of diluting it and, and making it less effective. But yeah, we, we, you can combine, you know, it's not a wrong thing to do. But I would probably try and select, well, you know, which, which of it is I really want.
And the way I tend to do it, of course, you've got this, how long does it take to get on board, . But what I would typically do is I, I do my probing charts, I do my X-rays. I've now can, can make my diagnosis and work out my treatment plan.
And then I local the side, so it's usually lying in lateral recumbency. So let's say I'm going to treat the right hand side. First, I do my local in the teeth on the right that I want to do, and then I do my scaling, plus all my polishing if I could to do it.
So that automatically gives you, you know, a few minutes. For everything to get on board, before you start actually cutting. So, generally speaking, actually, that, that period of time of onset is not too much of an issue.
But if you're doing dentistry, typically, the li the cane's gonna be fine, because, as I say, you're gonna get a few hours of the soft tissue with that. So, yeah, you can do if you want, but, you know, there, there, there are potential downsides to getting a big old volume and a big old mix in, in one area. That's all great, thank you so much for that.
We've got an anonymous attendee asking what dose of local per site. I've been to a wet lab and do use but sometimes does not seem to work. Could this be because wet lab did not advise blocking the Palatine?
Yeah, yeah, that's right. So, quite often a nerve block would be advised for a particular tooth, for example. But, but yeah, what happens is, of course, you're numbing one area, but not all areas that you're going to go into.
So that is one thing. The other, you know, very, very common reason for local not working is it's not in the right place. And say mandibular block, not always that easy to get your, your location right.
It could be that the volumes you're using are too small. So on the one hand, we've got our, you know, our toxic limits, and we need to upgrade our animal and so forth. On the other hand, it's, you know, how big a blab.
So let's say, And an average sized dog, then a lab that I would place for a nerve block, I'd probably be looking at around 0.5 mil to a mil. If I was doing infiltration under loose mucosa, so buckle labial area, sometimes lingual, then I'd probably be placing.
Somewhere between, well, generally 0.2 to 0.5 of a of a mil, which is the same as for people.
If, however, I was doing it under taut tissue like pallaly, then I'd probably be using 0.1 to 0.2 mLs.
It's only enough to see a little bit of blanching in the area or a little tiny little raised area develop, . But I would be very, very cautious that you do not work out or, you know, do, do your blabs without working out what volume is safe overall. And I wouldn't numb up the whole mouth altogether, because then you're applying that total dose in a one.
At least if we're doing, for example, let's treat our right first and finish all of that, and then move on to our left. Then A, it hasn't worn off by the time you move on to the left, and B, you've got some of that local is being metabolised. Before you give the second, so you've got a little bit more of a safety margin there.
I'm not saying you use a higher dose as a result of that, but you're just, again, just giving a little safe second safety element as well as that calculation of total. . That it's not all going on board in, in a one, in effect.
It's being staggered. Great. In a cat, I wouldn't probably give more than about 0.2, probably 0.25 mLs for a nerve block, and about 0.1 for an infiltration.
And again being very, very cautious of my totals, and I tend to use it in a little insulin syringe that's only 0.5 mL, so I, I haven't already got sort of a limiter on my, my volume that I can possibly give. That's great.
There were a few other questions, I think we should call it to a halt. Do have a little look through the, the presentations that we're letting run over. We'll let that run for another 5 or 10 minutes before we close it down.
So if you do want to look at that, a couple of things, this, . Health and wellbeing is coming up, in February. We've had huge interest in all the mindfulness stuff that we've done.
We had a great, seminar yesterday with the Royal College of Mind Matters, which if you haven't, seen, do go and, look at that because that was really brilliant, and I think you'll enjoy it, but . You know, we've always had the, the mindfulness training, but this now we're moving on to mood and happiness improvement. So, so look out for that as well.
So Alex, just thank you so much for, for the 2 hours. They've been really, really good. I mean, dentistry is such a huge area, but I think you've covered some really great content there.
Thank you to Ivan. You're very welcome to Bon of E for sponsoring this session, making it possible for us to, to make the tickets as cheap as possible. And a great new tool there, looks interesting and I hope that goes well, for the company, Ivan.
And this afternoon, we're gonna be starting up again at 2. We've got, John Berg, who is a fantastic soft tissue surgeon from America, gonna be talking about upper airway surgery, then keeping intestinal surgery simple, and then finally success factors in urinary tract surgery. On the other channel, we've got, how to make the most of your radiographic equipment by improving your radiological interpretation, that's Mike Herage, and then we've got Robert Cruz talking about ultrasound and Ed Hall about endoscopy.
So some really interesting sessions coming up. There's Mike up on the screen again with his diagnostic imaging. That begins in February.
So do, hopefully enjoy either or of those. And if it is late in the night where you're listening to and you're about to go to bed, then, good night, and we'll perhaps see you in the morning, or obviously do come back and watch the, the recordings. And if you can send us a little photograph of your lunch, I've put a little Facebook post up.
I had a beautiful tray, Alex, that was brought up to me by my wife full of goodies, which I've managed to. Demolished, you'll be pleased, it was mainly fruit. I will brush my teeth, afterwards, so I should keep everything in, in good order.
But if people can put pictures on there, if you've got any questions, I'm sure, you know, Alex would be happy to answer those if they're put on in the next few minutes on Facebook. Alex, if you go over to the webinar vet maybe in the next day or so, and if there's anything you think you could contribute, that would be fantastic. OK.
Thanks Alex, thanks, thanks to Ivan, thanks everyone for listening and hopefully see you back again at 2 o'clock for surgery or diagnostic imaging. Thanks very much, bye bye. Thanks a lot, bye bye.
