Video of The Evolution Of Dental Care

Hello, it's Anthony Chadwick from the webinar vets. This is Vet Chat, the UK's number one veterinary podcast, and it's February, and of course it's veterinary Dental Month, and I'm super happy to have Norman Johnson, really one of the founding fathers of veterinary dentistry in the UK with me in the podcast today. So, Norman, welcome to Vet Chat.

Thank you, I'm very, very privileged to join you actually. Honoured. Oh, well, listen, Norman, it's very much reciprocated because I remember very, very much early on in the career hearing about you doing veterinary dentistry.

It was something that really. I qualified in 1990. It wasn't taught in in veterinary schools, and I'm not sure the situation has improved nearly as much as it should do, because.

I mean, dentistry is such a massive part of most GP's workload, isn't it? Yeah, I mean, when I, when I was in general practise, we . Obviously, I had an interest in dentistry from a really early stage, but, we were, we were looking to have about a quarter of the ops in any given day to be dentistry.

It's stuff that's there every day of the week. It's stuff that you can rely on, it's not seasonal, and it's necessary, and that's, that's the thing about it. So my, my, my feeling in the early days is it was just being ignored because we didn't either know enough about it.

Or we're worried about our skills and dealing with it. So that was really what took me into dentistry as a, as an interest in the first place. Plus the fact when you're a young graduate, you're the one that gets to do it.

All the, all the more interesting stuff gets done by the boss. Well, it was always an area that fascinated me because I think it was one of those areas that you could immediately bring relief to a patient. And it wasn't until, you know, during the pandemic, I had my own dental problems, and of course, dentistry was very basic during the pandemic.

So a tooth was yanked and I'd spent 2 or 3 nights not being able to sleep and almost that instant, relief from having that done. And, and I saw this all the time in my own practise where dentistry, in fairness was an easy diagnostic disease, because often you smelt these patients before you saw them in the consulting room. They, you could sort of get a sense of them as they walk towards you from reception.

The, the smell was often overpowering. And at that stage it was very basic dentistry because it was the Yorkie or the cat that needed 1015 teeth out. Yeah.

And the first thing was, well, the first thing was persuading people because they'd often been to another practise and it was an older dog or cat and they were told, oh no, the cat or the dog probably won't survive the anaesthetic, so therefore don't do it. And my attitude at that time was, but from a welfare perspective, the dog or cat is probably in so much pain, it's unfair to just leave it as it is and I'd rather take the risk of an anaesthetic knowing. Potentially I could lose a dog or a cat, although it happened so infrequently in my career, to lose a, you know, a, a dog or cat coming in for a dental, that this was a perceived risk rather than an actual one.

Yeah. And you'd come back and the, the, the clients would say, this dog is 5 years younger than it went in, what did you do? And I said, I just took away all of its infection and its pain.

So such an important area because, and you get such good results don't you? I specialise in dermatology and often it was more kind of managing a problem rather than ever really getting rid of the problem, whereas with dentistry. Relief and, and cure is, is almost instantaneous, isn't it?

I mean, the two, obviously the oral problems were, were an issue with these older dogs and cats, but it was really the systemic infection, the low grade chronic infection that gave them lots lots of other trouble as well. You know, so their kidneys and their heart and their liver and spleen and all the rest of it was so they they just did better when you got rid of all that burden of infection. And as you say, it was a relatively instant thing.

But it was, it's interesting when you say about the older older animal and people really being worried about putting them under an anaesthetic and Of course, even, you know, when I was a, when I suppose say, when I graduated in the 70s and certainly the anaesthetics were less sophisticated than they are now but quite, quite a margin. But even then, would they rather have their animal live on in chronic infection and discomfort than have it sorted. You're sentencing them to the the last year or so of their lives in, in, in poor health rather than dealing with it and .

The interesting thing about it was that, you know, even guys like dentists and and and and doctors were the ones that were often most reluctant to, you know, to agree to the anaesthetic astonish you were members of the public would take your, you take your advice on, on, on face value, whereas you know the, the dentist or the doctor would say, oh no, no, no, I'm not having that. But you know, also we have the same situation because there would be a lot of vets who would not put those dogs through an anaesthetic and actually all you needed to do was explain the procedure to the client and if the client trusted you as they obviously did yourself, then people would agree to it. Yeah, yeah.

I think certainly once they, once, once there's somebody in the practise that actually builds up skills, that's, that's, even if somebody else in the practise doesn't want to do dentistry, in my case, my two partners were really completely disinterested in dentistry because they did other things and they built up skills in other ways, but for me it was a niche that I would, I, I started early on and . Once the high speed drills and things like that came in in the mid mid to late 80s, that completely changed the way we did dentistry because, and I don't know about you, but certainly we had we had a class of extracting teeth and cadaver cadaver German shepherd dogs or something like that with things like gli wire and hacksaws. And this mediaeval mediaeval instrumentation was still being taught in the 70s.

So once the high speed drills came in, different. Well, I certainly removed a lot of teeth using a hacksaw, you know, to, to obviously split them, and that was, you know, in the 90s as well, so. Yeah, it took time for the drills and and so on to come in, but they were obviously revolutionary, although I suppose it didn't build your arm muscles quite as much as the hacksaw did.

No, I didn't actually. There's no doubt about that. But that was the thing that your dentistry, dentistry is supposed to be a something that's done with finesse.

And you know, people worry that they don't have the strength or that kind of stuff. You don't need strength actually you just need technique. Sees golf, you know, you don't wha the ball a long way by being, you know, really hard.

You stroke it, don't you? It's it's just what I've never got into, but yeah, I can understand it. And, and of course the problem with the hacksaw was it would take me a long time to do all the instructions and at some point you'd also go.

Oh, do you know what, I'm gonna leave that tooth in, you know, I just can't, you know, because obviously older dogs again, you don't want to have them under a or cats. You don't want them catch you didn't quite need to use the hacksaw as much, but you, you didn't want a dog under for 2 or 3 hours doing a dental because that was a, you know, a long, long anaesthetic, wasn't it? Well, there's another aspect to that really where Your own welfare when you're, when you're doing a dental procedure like that is quite important because your dentists recognise, you know, very clearly that their own dexterity and skill drops markedly after an hour.

So they rarely will do a procedure that takes more than 45 minutes to an hour. You know, they'll do something that takes that time frame, and then that would allow them to stand up, walk about, focus into the distance. See another patient with another problem.

So, from their point of view, really, they were, they were keen not to spend a long term, and yet for us, we were still spending hours and hours and hours, you know, on these, these, difficult extractions. So I think it was quite easy to then, once the anaesthetics got better, then to schedule a second procedure for maybe 2 or 3 weeks when the original part is healed and you've got another, another fresh look at it. Well, particularly also, you know, full cat mouth extractions.

Again, that could be a long process and of course then roots would be left in. I'm sorry, Norman, but I used to go in then when we did have the bear and and drill them out. I love, one of our speakers on Webinar bets, and I always mention him because he, I, there is a bit of a bromance, probably only on my side, Professor Mike Willard.

Who was a professor at Texas A&M on gastroenterology and he used to say everything I taught you 10 years ago was a lie. I just didn't realise. So there's definitely a fashion side as well, isn't there about can you, you know, you, .

Roots out should you leave them. I had my own wisdom tooth taken out by an expert who obviously didn't look at the history before I went there because I had a hooked root. And this was why the the ordinary dentist wasn't doing it.

And he managed to leave part of the root in. And he said, oh, it will just resolve, don't worry about it. So it's, it's interesting when you, you know, there are two veterinary dentists in the room and they both agree with each other.

The one of them is probably not a veterinary dentist. It's kind of, there's always opinions on these things. Where would you be now, on kind of roots and things, particularly in cats?

Well, I would take it as a general, as a general, principle, you, if you leave a root in, you should go back and get it. Yeah, you shouldn't leave a root in, but there are certain circumstances where you might, for example, the root might be very close to, an artery, a nerve, you know something like that, sinus, nasal cavity, these kind of things. So there may be features about that particular case that you might not want to to go back at, but in general terms, the thing that is your friend is the radiograph.

So, If you do leave a route in, obviously, you should log the fact that it's there on a chart or on a history, and then Offer the owner a review radiograph at some point, because the radiograph will tell you whether or not it's an issue or not. It'll tell you, for example, whether it's resorbed, and they rarely do. It'll tell you whether it's causing pathology because say that that route may not have much organic tissue left in it.

There may be virtually no pulp in it, and it might just sit there quite happily, giving no problem. But you know, two things about it. If you don't look later, you won't know.

And secondly, you can't ask the, you can't ask the patient. So the patient's not going to come back and say, you know, you're going to go back and say, listen, that route you left in is giving me trouble now, whereas we can't ask that. So the radiograph is our friend when it comes to that.

And interestingly enough, you know, the radiographs have been sort of part of a dental procedure from our point of view, certainly since the 90s onwards. Now it's cone beam CTs, you know, a lot of, a lot of practises that do this, certainly specialists will have cone beam CTs or access to a CT scan and CT scans tell you a whole lot more about the pathology that's there than a radiograph ever did. Radiographs do underdiagnose quite a bit in certain circumstances.

And I know you're going to slap my wrists for using a bear to just nuke that that roof. Yeah, I apologise. This is the this is the confessional box we're moving into now.

I had a a couple of radiographs that were given to me by a friend of mine who I was mentoring through one of the diploma programmes, and it was a before and an after. The before, well, before actually it was, it was, it was, it was following an extraction but a route left. And then The, the cat was sent to him, and he took an after radiograph and the person who'd originally tried to drill the root out had missed it completely.

So they've actually gone down the side of the route, not touch the root whatsoever, and gone into the canal, which has got, of course, the sensory and nerve to the whole of the jaw on that side. So, and that cat was in quite a lot of trouble. Now that's.

It's difficult actually to drill up because of the fact that really you've got water on in the go, you don't necessarily know what path that route follows. So it's, you might be lucky and get most of or all of the root out, but in general terms you don't, you know, they'll leave bits behind walls of the tooth and so on. So it's not generally a good thing to do.

Everybody, everybody that does dentistry likes to actually physically see the root in their hands when they've done that. Yeah, yeah. I think with dogs it was a lot easier, but often with cats you, you felt they do resorb roots more, don't they?

So one of the great advances has been around veterinary radiology, hasn't it, because we, we just. Didn't have that, and now we've got super machines like the Clark machine and so on that are handheld. When did that kind of start coming in, you were obviously one of the first to start using it.

When were you starting to use radiography as a kind of normal part of your dental procedures? Well, when I did the, the, the academy exam, which was in in in 1990, I had to have radiographs for that. The credentials that went in for that.

Involve radiographs, and once you start doing root canal treatment, of course, then you take multiple radiographs throughout the procedure. So I, I had a, there was a dentist, locally in Edinburgh where I was practising at the time. They had retired and they had a garage full of stuff they just wanted to get rid of and a job lot for about 100 pounds, seats, tables, reading, you know, the dental X-ray machine, the whole lot, and .

We had that on the wall for, I mean, it was an absolute workhorse that he'd worked for, he used his whole career with this, this unit, and I used it for about another 12 years. So, it was only just when it became, it had a little clockwork timer on it. And that health and safety eventually got to the stage where the clockwork timer just wasn't good enough.

So that that's why it didn't, it didn't, it didn't have to go because it stopped taking good radiographs. It's just because it couldn't have a digital timer. So, from really from the early stages on, but they, as you see, the, the little handheld, machines, they're a little bit controversial in some places because I think certainly, you know, for example, in Canada, I don't think they're they're legal.

But they they certainly made a difference to practises that wanted to take a unit from place to place. If you were doing dentistry and say your main, your main practise, but also maybe in a branch practise, it was great to be able to take this little thing with you in this case and have radiographs at the other end as well, because it, it meant your, your clients were getting a basically a second class option if they were having dentistry done at a branch practise without radiographic facilities. So it was nice to have that, but they were expensive and they were less good than the, you know, is that in Canada a health and safety perspective that you worry about the radi radiation, yeah, yeah, yeah, although I think in Europe there was never, never any issue with it as far as I'm aware, you know, they had the, the CE mark for safeties without any difficulty, I think, yeah.

It's in, I was speaking to a colleague recently and he said, you know, they have somebody who's specialising in dentistry in the practise. They're in a first opinion practise. And they ended up where people were not doing dentals because the price was becoming so prohibitively expensive because the person wanted to do that dental absolutely correctly, but then with that, you know, outside of the budget.

So, obviously we understand, you know, there are specialists like yourself and and and other certificates and diploma holders that often get referred, you know, as I did with dermatology. Insurance, etc. Etc.

But how do we make it? Applicable in first opinion practise. What what are the areas that we can That we can do, you know, perhaps without using radiography or some of those other things that make it expensive.

I mean, my dentistry was very basic. It was tended to be scale and polish and an extraction of it needed to come out. And you knew that you'd done a good job or you hadn't because a week later.

The dog came back from being quite hangdog and miserable to being, as I said earlier, you know, 5 or 6 years younger than when they've walked in or appearing to be. So how does that work, you know, obviously, webinar vet is about making that good GP better and more confident. Where do you see that sort of friction and, and frission between the specialist and the generalist in dentistry?

Well, I think it's exactly the same as for human dentistry. I mean, you go to your high street dentist and you go for basic dentistry, and they may or may not do other things down there, and if they're not happy, they'll send you on to, you know, an endodontist or a periodontologist or something like that. But it's really, really important that that first opinion practises across the land are comfortable doing good dentistry.

I would always say that, you know, good dentistry doesn't need to, it shouldn't be expensive. It should be something that the average client can afford because they're going to have to have it done several times during their animal's lifetime. And it might just be a scale and a polish and the odd extraction, but it, price should not put them off.

You know, it's not necessary to send, you know, a routine dental case to, to a specialist. Because the specialist's business model, I mean, if you take just me, for example, I would be, I would be OK doing, say, 2 cases in the morning, 2 cases in the afternoon, and that was my specialist day. Now, if I was to take a routine case into that, I would still have to make enough money to cover half a half a morning, or half an afternoon.

So it wouldn't be for me to do that stuff. It would be much better if the first opinion practises were totally comfortable with it. But that doesn't mean to say that they wouldn't use charts, because charts are critical to the to the ongoing history of a case that you might see throughout its lifetime.

And radiographs, and a full mouth, once you've learned to take radiographs, and it's not difficult. I mean, I've done loads and loads and loads of teaching and my practise I left still does, but you should be able to take easy radiographs of an animal's mouth in minutes. It doesn't take any, you know, they're digital now.

They don't have to be digital, but you know, virtually everything is these days. So just perhaps maybe investing a couple of 200 in a machine that takes them and will give you digital results and a few 100 pounds in how to do it. And it's a fantastic investment.

So it doesn't need to be expensive. There's absolutely no way that, you know, that dentistry should be out of the reach of the normal customer. It's important that it isn't.

No, that's a really, really, really good point. Obviously, you know, previously we were talking about when I went to that school, there was very little dentistry taught. It's such a massive area.

I remember when we did one of our first series, with Hill's pet nutrition and we did a whole feline series and we had dermatologists, we had a dentist, I think we also had, . An orthopaedic surgeon, and of course we were all vying for which was the most common problem, and I think in the end it was decided that it probably was osteoarthritis. If you get a cat to a certain age, pretty much all of them have arthritis.

But obviously dentistry is massively important in most vets. Daily lives. And yet I think I'm not sure that the universities have still really embraced it and taught it, you know, a big, big, load of material to learn when you're there for the 5 years, but dentistry is such a massive area.

I'm not aware that there's any specialists in any of the vet schools who are in there teaching dentistry on a regular basis. So how do young vets get good at dentistry? Yeah, well, I think most of the, most of the, the vet schools will actually have somebody come in as a guest lecturer.

I mean, over the, I did Edinburgh, Glasgow and London, simultaneously, really for, for quite a while, and but it was only, I mean. I think maybe at one stage 5 lectures in whatever year it was 3rd or 4th year, and then a practical. Glasgow did a practical.

London tried to do a practical, but it's just not possible to put big numbers these days through once your numbers got into 3 figures, it's very difficult to put them through a practical class, unless you've got somebody in-house. I think it is important that that it's taught in-house because If you're not on the faculty, if you're not a member of the staff, it's very difficult to actually lever a bit of time, but any of the schools that they're looking for, maybe, American accreditation, AVMA accreditation, they, they have to show that they facilitate dental teaching, and for many of them, it's a box ticking exercise that they don't tick the box properly. So I think it's, it's been like this, Anthony for 30 years.

I'm not sure whether it's getting any better. In fact, I do feel it's getting worse because my, my 5 block of lectures gradually shrank down to 1. You know, so that, that just shows you how what sort of importance that particular school put on dentistry over the years.

You have to have somebody, you know, as the head of the department who actually values that. And if they don't, then you're levered out for somebody else to get these things out. I remember going to a course that Bob Partridge was running just on doing cadaver extractions and learning the techniques and actually once you learn those techniques, dentistry becomes a lot easier, particularly if you're not having to use hacksaws, but you have a, you have a proper dental, I think a dental machine is kind of essential.

So it, I, and it was a really satisfying part of my workload because these animals, as we said before, used to come in. You know, not, not necessarily in distress because of course cats and dogs hide pain, don't they? But you saw the difference a week later once you'd actually remove that source of pain and discomfort.

Yeah, yeah. I mean, it really, really, really important. I mean, and, and over a, over a course of an animal's life, it's an absolute certainty that they're going to need 3 or 4 dental procedures.

One thing that's quite interesting actually, I, I have a black Labrador who's now 9. And when I was working. I hold my hand up and I wasn't brushing his teeth every day and all that kind of stuff and Labradors kind of, they're, they're at the good end of the spectrum when it comes to periodontal disease, unlike, you know, say for example, a Yorkie or a chihuahua, but I would just do when I, when I had a day where somebody had cancelled on me, I would clean his teeth, you know, when, when it was necessary, and it was the the last thing I did as a clinician was clean my own dog's teeth and And then decided really I wasn't going to put him through this every year or pay for it as it would have been after that and I started to brush his teeth every day and That'd be just coming up 5 years since that guy had his teeth cleaned, and it was only a few months ago that he had to have them cleaned again.

And that shows the difference between bothering with cleaning his teeth and not cleaning his teeth, huge difference. Dogs are easier than cats, of course, no cat likes to have a toothbrush rammed down its throats and I was adopted and I wouldn't do mine. Well, well, I'll tell the story.

I was adopted by a cat during the pandemic because as you know, Norman, you never own a cat. A cat is adoption, but I'm now his chief butler. A feisty little devil, a, a ginger cat, and we knew who the family were who had the cat.

It was a mile away. I think, Buddy as his name is, because we know who, you know, what his name was and everything, was a bit of a snob because the family lived, believe it or not, this was during the pandemic that he adopted us, you know, he started turning up. I was obviously at home a lot more so I could see him.

And the family lived on the worst road in Liverpool. It was called Corona Road. I mean, you know, house prices everywhere went up house prices.

If you lived on Corona Road, I don't think the prices did so well. But anyway, in the end, I think he just basically was a 14 year old cat. He wanted a quieter life because there were kids, there were other cats, there were dogs in the household, and it's just me and my wife at home, we've got a little garden at the front.

So he used to stay in the garden and then gradually he sort of made his way into the house. My wife's allergic to cats. She wasn't really a cat person, but Purina had brought out a diet called Live Clear that makes the cat hypoallergenic to the human.

She knew that I kind of wanted a cat, so she kind of said, well, he can come in a bit more. She, 34 years down the line is now a mad catwoman, she loves cats. She loves him, she loves all cats, so he's been transformational.

But when he first came in. He, you know, if I tried to look at him or touch him, he'd snarl at you and try and bite you. And I'm pretty quick, so you know, I wasn't getting bitten, but obviously I was, I'm, I'll hold my hands up and say I was a bit afraid of him.

Finally, with all the love and attention, he's he's worked his way around and. You know, we were able to look in his mouth and of course he's lost most of his teeth. So in fact, when he does give you a little bite, which he still does, it's not a bite, it's just a nasty suck.

So this is often what happens with cats. The teeth just fall out, you know, without the, without the attention, but we are needing to get him in. But of course now the waiting list.

To get into vets is difficult. So we're both in the same situation of having to pay for it. He's on Calencia for his arthritis, but I have to say he does need some dental work as well.

Might not be much left to do. Well, I don't think there's a lot of people because the other one is that that kind of broken canine that you saw a lot in in and provided dentin's not showing, I don't know how painful. Are they?

Well, cats, they, the older cats, they, they often have a problem where the canines super erupt and they look as if they're they're much longer than they should be. But they're really being, they're they're really being pushed out of the socket by a pathology within the socket. And sometimes they resorb internally, what's called an external resorption.

It's not from the pulp outwards, it's from the, the cementum inwards. So you get this a lot in canine teeth, and eventually these these these go and some of them need extracted the stumps and some of them don't. But when you're looking at the end of a tooth, if it, for example, if the end of a canine is fractured.

In an older dog, you maybe take away a 23 millimetre chunk of tooth and not enter the pulp. In which case it's called an uncomplicated crown fracture. It's not complicated by an infection of the pulp, but in a cat, the pulp goes almost to the end, all of its life.

So you may find even a millimetre of of a of a of a canine tooth can open the pulp, and then at that point, you know, of course, there's a whole different kind of worms to deal with with pulpitis, pulp necrosis eventually that may leak out through the, the, the apical delta in the route where the blood vessels enter. So it's a, it's an odd one. If you can, if you have them under an anaesthetic, you can often use a very fine probe or a very fine root canal file to see if you can enter the pulp.

And if you do, generally at that stage, it's an extraction or a root canal. Canal can be quite quick and easy actually in these older cats, but, radiograph will tell you whether he's got a proper route to do it because often if the roots are resorbing too. There's no point in doing anything that, like a root canal because there might be no root canal to fill.

Yeah, but yeah, the difficult ones is, but they're hard to often hard to spot because it's not much off. You often find them incidentally. Yeah, and it's interesting, you know, again, a 17 year old cat, I did blood work recently just to see how he was doing and, and liver, kidneys, thyroid, everything was just spot on, so he's, he's obviously doing well and there's a.

Physically fit cat even for 17, so I think he hopefully he'll be around for a bit longer. He's actually our CFO in the company. I was over in America and he was displayed on the, the, on our flyers that we took over there.

Of course CFO stands for Chief feline Officer, and he was actually just before in a previous meeting sitting on the computer almost refusing to let me go into the meeting, so I had to remove him gently from, he was sitting on the laptop, so he often does come in, but he's outside at the moment. Yeah, yeah, great companions. They, they, they, they brighten our lives, don't they, and, they deserve the same dental care that, that, we hope to get as well from our dentists.

Hopefully, hopefully, yeah, yeah, I agree with that very much. Norman, it's been fascinating and fantastic, listening to you. It's been a while since we last chatted.

You were always a big inspiration for me as a first opinion vet trying to do dentistry better and and thanks for the fantastic legacy that you've left I know with all the people that you've trained over the years as well and it's a good time to practise the golf. I think so. Just by the way, the, the headphones that I'm wearing, you gave me them in 2011.

We when we started this webinar. So they've lasted all that time just with a quick change in the earmuffs over the pandemic when they were used a lot. So I have to thank you for that as well.

Yeah, well, you know, thank you because we've been so fortunate to be able to use experts like you across the world. To just hopefully, improve the quality of postgrad training, which in areas like dentistry is so important because when we come out of that school, unfortunately we haven't had a lot of training and I think this is an area that, you know, as much as we can teach in webinars, I would encourage vets who are listening and nurses who obviously get really involved in it to go on some of the courses that are available because I, I think with. Not a huge amount of time you can get to a really decent GP level at dentistry, can't you?

I think if the commonest and most useful courses would be ones where they teach extractions and they teach radiography. And if you get these two fundamentals, just find the the principles of them, and then begin to use these, that's, that's a day and a half well spent. You know, a good cadaver, a good cadaver course that gives you extractions on cats and dogs.

I think that's, that's really, really the best way you can spend some of your CPD budget for dentistry anyway. And, and actually trying to take out a healthy tooth is a bit more difficult than trying to take a rotten one out, isn't it? Well, go back to 1975 and these German Shepherd cadavers and.

Bits of chisels and hacksaw it's another carpentry tools that were used at the time. It's, it's come a far way and you know, thank you obviously for all the stuff that you've done to to further veterinary dentistry for the profession both here and internationally. Oh well, it's been a good, it's been a great career actually.

Yeah. Yeah, brilliant. Norman, thanks again.

Thanks everyone for listening. This has been Vet Chat, UK's number one veterinary podcast. Hope to see you on another episode or one of our one of our webinars very soon.

Take care, bye bye.