Hello, it's Anthony Chadwick from the webinar vet. I'm welcoming you to another one of our vet chat podcasts. We're very fortunate today to have Andrew Perry on the line from East Coast referrals down in Swindon.

Andrew is a diplomat of the European College of Veterinary Dentistry, and we're going to be talking about cats today. I've just come back from ISFM which was in Rhodes, and armed with some of my newfound knowledge, I'm going to, hopefully, Not sound totally out of touch here Andrew, when I ask you some questions and maybe find out how you're approaching cases, what sort of equipment you're using and some advice for us when we're out in practise, what are the, Things we should be doing and what we shouldn't be doing. Sounds great.

Thank you very much and thank you for having me today. Ah, well, great to meet you, and obviously I know you're from the Cotswold Hills originally, but I think there's always a little bit of scouse in you if you spent 5 years in Liverpool as well, isn't there? You never lose it, right?

I'm, I'm very proud of my scuse, scuse's upbringing, so yeah, I might, I might even verge on Scally intermittently. All good. Well, from a, a boy who was born in Anfield, it's, great to have an adopted scouser on the podcast.

And I was at Rhodes. I'm showing off now. I had a week in the sun and then I've come back.

I think I brought the sun back from Rhodes. We're in the middle of some really lovely weather at the moment, and there was talk at the conference about Fox feline or a facial pain syndrome. Is that a condition that you see very often in your referral practise?

So I guess the simple answer is we are lucky in many respects. We don't see fox hugely frequently. It is a horrible disease.

It really is. There's no question about that. And, you know, the patients that do come to us with true fox can be extremely challenging to manage.

I guess I say true fox because oral facial pain syndrome is probably, I think it's fair to say, as a syndromic, disease, it's, it's not probably just one single pathology. And it's a complex disease and it's definitely a disease of exclusion. So you know, to a certain extent we're giving it a sort of Gallic shrug by the time we get to that that making that diagnosis.

I'm sure, I'm sure they talked about Burmese cats at Rhode with you. I, I'm, I, you know, I'm, I'm a Burmese cat owner myself. I have a, a small troublemaker that might come and, you know, photobomb any second in, in a typical manner.

But, but sadly they're definitely hugely overrepresented in true or facial. Pain syndrome and there's presumably some form of genetic component. Some have suggested that's a nerve channel gating defect and and potentially that these nerves are, you know, overly sensitive and essentially you get All the classic symptoms of nerve pain, so you get allodynia, hypersthesia, you know, these phantom shooting pains, and patients will self-traumatize.

I have sadly seen patients self-traumatized so badly that we've ended up euthanizing them. Because they've injured their tongue so you know, so, so extraordinarily, so it is a truly disgusting thing to to to get sadly. Yeah, I think we saw a very similar condition in in dermatology called acral mutilation syndrome, and I'm pleased I only ever saw one in, my dermatology career and baffled and baffled and in the end had to.

Sadly, put the dog to sleep, it was a springer spaniel, a lovely dog as well, but these pictures and videos that I saw I ISFM of. Virtually amputating tongues is is as you say, truly horrendous, isn't it? Yeah, absolutely and .

The scary thing is that although in many of the more severe cases, you'll see some symptoms or some potential triggers earlier on in life, especially when they are rotating their deciduous to adult dentition. But in some cases, the first signs that you can see of this type of presentation, at least, is when they have either dental trauma for some reason, and a common cause of dental trauma is, is us, you know, if we, if we go and try and deal with tooth absorption, for instance, and you do everything by the textbook and you do a beautiful job and you know you are delicate with those tissues as you possibly can. If those individuals have a predisposition to the development of oral facial pain syndrome, that can be a trigger.

And, and it can be really scary because you have a cat came in for a simple, you know, periodontal therapy, and, and suddenly you've got a cat that wants to self-mutilate. And quite understandably, the client kind of points the finger at you because everything was OK until the dental, absolutely, and, and you know, we all have those feelings of guilt and what did I do wrong and all of those kind of things. And I think that that's one of my sort of, you know, top tips I guess is that if you are dealing with a patient certainly that has Burmese traits or is a Burmese cat, you are very sensible to warn owners before you undertake any dental treatment that this is an individual that has an increased risk of these problems.

And things like local anaesthesia and regional anaesthesia obviously can help reduce that sort of trauma, or surgical sort of neuro neuropathic sort of wind up essentially drugs like ketamine as part of the anaesthesia combinations, gabapentin, amantadine, those kind of products are also really helpful postoperatively for cats that we feel are at risk. And certainly if you have a case that you are highly suspicious, is developing or has developed or a facial pain syndrome, but has significant dental pathology, they can be linked. Unfortunately, you know, you've got just oversensitivity and, and most cats show relatively minimal signs of oral discomfort with, with, you know, standard periodontal diseases, but if you've got oral facial pain syndrome, it, it, it makes everything so much worse.

So, Sometimes in those circumstances we'll we'll end up actually trying to manage the pain before we manage the disease, and that seems a bit counterintuitive because most of the time we manage the disease to to to eradicate the pain. Mhm. It was really interesting at the conference again, you know, we used to talk about, again, bringing it back to dermatology.

I know this will be upsetting any dentists that are listening, but we talked about feline, psychogenic alopecia, and as you ruled everything out, you realised it was a very, Uncommon disease, but then it was really interesting at the conference we had Claire Ruxbridge, obviously neurologist, Danielle Gumbour, medic, Sarah Heath, a behaviourist, and actually in a lot of diseases that we see, especially in the cat, you know, there very much is the physical but also the mental element of disease. So, you know, feline idiopathic cystitis and so on is obviously has a huge component. As it sounds like, you know, potentially Fox does, some cats just cope with pain differently than others, don't they?

Completely. And, you know, and, and again we, we would use things like amitriptyline in the management of, of fox cases in some instances because it has both effects on neuropathic pain and, and obviously on, on, you know, your levels of anxiety or an individual's levels of anxiety. So no, I, I think that you have to look at these patients very much holistically.

but I definitely agree, as a diagnosis of exclusion, I, I wouldn't jump to this conclusion of diagnosis of fox, especially in breeds that aren't particularly at risk, so domestic short hairs, those kind of groups. Without ideally ruling out a number of other possibilities and certainly in our clinic we've had patients referred for investigation of Fox where we found meningiomas, otitis media, a couple with, with thoracic pathology. Even can sometimes present with sort of cholecystitis type symptoms.

Well, cholecystitis causing sort of that brookism and general, you know, discomfort and, you know, just trying to get all that tied together really. So I wouldn't necessarily jump to the conclusion of a FOS diagnosis in a patient that is not an at-risk breed, and this needs obviously a very thorough workup as to make that sort of diagnosis of exclusion, obviously MRI CT radiography, all those things sort of come into it then, don't they, to help with the diagnosis. They very much do, yeah.

So, you know, dental radiography is, as usual, the cornerstone of all sort of investigative steps when we're looking at dentistry and You know, sadly, I know, I'm sure many of your listeners have probably been to dentistry lectures before and will have heard, you know, the sort of mantra of X-ray, X-ray, X-ray. The truth is that that, you know, that that is undoubtedly the case. We, we probably, you know, we, we absolutely relying on dental radiography to help us in day to day cases, you know, if we're looking at cats specifically.

You know, I, I, I now in good conscience wouldn't undertake, you know, dental treatments on cats without dental radiography because I know how much I'd miss, and, and, and I mean miss as in the presence of disease. And so, yeah, I, I, you're, you're trying to operate blind, you're trying to operate without, without all the information and that's impossible and. I, I don't know what the equivalent in dermatology is, but I, I'm sure that orthopaedic surgeons, no matter how cavalier you are, you're not going to, going to try and fix a femoral fracture without a without a radiograph.

Well, sadly the same applies to us. So we're peppering this podcast with with tips. We've had the Burmese tips with fops, obviously with radiography or or with any cat dentistry.

We should do radiography first. Again, interestingly, I'm, I'm sort of now on the other side of the fence in that I don't practise, but when I was doing dentistry, we could do some sort of basic dentist basic radiography, but obviously, you know, I probably wasn't doing it at the level that I should have been. What do you think about these cats that come in?

You know, with a little bit of gingivitis, they don't seem to be in pain with it, I think you were saying before about how some cats. You know, you can look at their mouth and, and there seems to be minimal pain. I always used to say, this mouth must be painful.

I, I had a tooth removed during the pandemic, which was really sore, . Helps you to understand the pain, but do cats in some ways maybe react differently to that sort of gingivitis state, or should we be really thorough with cleaning, should we be using, you know, food that helps to clean teeth and things like TD? What, what's your thoughts about maybe before they come to you, the sort of early cases, how should we be dealing with those?

Yeah, I guess the simple truth is that it depends what diseases you're talking about, and, and I guess that's one of my, my own personal little bugbears that orthopaedic surgeons, again, I rant at orthopaedic surgeons, orthopaedic surgeons don't refer to a lame dog as having an orthopaedic, and they don't say come on in, we'll we'll do an orthopaedic on you, or we'll do a dermatology on you. And dentistry, just like all the other specialists, is, has, has multiple diseases that we treat. Now if you look at If you look at gum disease and peridontitis in cats, gingivitis is probably not uncomfortable for the majority of cats.

Same goes for people, you know, most of us will have at some point some, some degree of gingivitis. You know, you're brushing your teeth, you get a little bit of blood on, on, on your teeth, or you haven't flossed for a few. Days and then you floss, you'll definitely get some bleeding when you're cleaning incidentally, and that's gingivitis.

Are you in pain? No, you're probably not, but what gingivitis is an indicator of the presence of increasing plaque levels and the likelihood of development of an associated disease. And the problem with cats is that they don't tolerate in the vast majority of cases brushing.

So you know, diets and chews and those kind of things are great and I actively would encourage them, but they may not fully, you know, limit plaque levels to the point where you can manage gum disease effectively and certainly in at-risk groups where you have, you know, let's say Maine Coons, those kind of group breeds that That are really prone to this early onset aggressive, what we call acute periodontitis. You get cats that are 2 or 3 years of age, they have gum recession, wobbly teeth, teeth that are falling out, all of those kind of, they're extremely challenging to manage in real terms. I think that there's no easy solve with, with gum disease in cats for much of the time.

Tooth resorption might be associated with gum disease, so we know that there are two sorts of tooth resorption. Type 1 definitely is associated with gum disease. Type 2 definitely isn't.

And again, genetic component. We know it's a really complex condition. You get, you know, changes in, in the sort of receptor activity at a cellular level that up regulates osteoclasts and turns them into adontoclasts, and they start eating away at teeth and again.

You know, diet, etc. Is not, not gonna necessarily help that, so it can be really difficult to to, to sort of. Yeah, palliate these, these conditions in many respects in cats.

Those cats, as you say with the Maine Coons and and others I often saw with the Siamese as well, the very red teeth are starting to come out. Do do you sort of approach that often as sort of a whole teeth removal, or do you do that in stages sometimes take some out and then come back? A year later to take others out or how do you approach those?

So I guess the simple answer is it depends on what we believe is the underlying disease process. So and we would definitely differentiate between what we would term acute periodontitis and and gingivitis stomatitis. Gingivitis stomatitis, our first line treatment recommendation is always going to be elective extractions.

Elective extractions doesn't mean full mouth extraction. That means Identifying those teeth that have normal or, you know, normal plaque levels or normal, you know, within reason plaque levels but have inappropriate, gingival inflammation. And those individuals are always going to have caudal mucositis, so they're going to have inflammation of tissues beyond the mucogingival junction.

So they might have glossitis, palatitis, but they will always have caudal mucositis. And in those individuals, yeah, elective extraction's definitely the best bang for your buck. 35% of those are going to get better like you fix them, within a month.

35-40% are gonna get better. But they might need some supportive therapy for up to 12 or 18 months because just like with nerves, if you get wound up immune system, it can take a very long time to settle down. So we wouldn't necessarily expect to see an immediate resolution, and then 20% or so are going to improve or get better but not get to the point where they can come off medication.

And they're going to need ancillary patients or a group, a percentage of that group is probably going to form true refractory cases, and they're really challenging to manage, as we know. Now if you've got acute onset periodontitis, you've got really early onset inflammation, then I'd often do a swab at that point to check and see if they've got cavichi virus. If they do have calichi virus, I'd be worried that this is going to be a case that's going to progress into gingivitis, stomatitis.

And certainly the prognosis for management of gingivitis dermatitis is more guarded than than if you've got if you've got acute periodontitis. Acute periodontitis, you might have really, you know, like really localised severe inflammation that's perhaps inappropriate to the level of the plaque on the tooth surface, but you're not going to have the stomatitis. You're not going to have the inflammation anywhere else.

And as soon as you take those teeth out with active infections around them, that gum is going to heal very readily and they're going to get better incredibly rapidly and so. Yeah, in short, if you've got severe acute, you know, periodontiti, yes, you may end up doing formatic or you know, extracting all of the teeth because all of the deceased have disease, but I wouldn't extract teeth that didn't have disease, but I would warn owners that in the longer term this individual's probably at risk of developing periodontitis. It may be very difficult to prevent onward progression.

And regular checkups, regular professional cleaning, and sadly further extractions are almost certainly going to be needed. With the Calici cases, would you use antivirals on those? Great question in the sense that, so there's limited evidence to suggest the benefit of antivirals for management of gingivitis stomatitis.

The sort of the one good recent study by Henne and team, . It was a relatively small cohort, but it was a nice double blinded trial and a prospective study, so it's pretty, you know, scientifically rigorous, and it, they didn't show any statistical benefit to using interferon, and it was interferon antiviral that they were using. They did in individuals, owners and, and, and sort of.

Total mouth inflammation scores did decrease, but not, not statistically significantly. So to be honest with you, when we get to the stage of of considering use of interferon, which is probably in these more refractory cases, we're not so worried about whether or not. It's going to be beneficial hugely.

It doesn't do any harm and for some individuals it seems to be beneficial, so we will often use it, but it's not not a frontline treatment, and I would not expect miraculous resolution with use of interference. If you're interested in new, new stuff, there's excellent evidence in these truly refractory cases that, that stem cell therapy could be really beneficial for at least half of those cases. And, and certainly that's a technique that we're we're working in partnership with Edinburgh University and and sort of matching some, some research work that was done in the US using allograft or, you know, fat, fat grafts essentially to generate stem cells and then return to these patients.

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Pop and say hello to a community of over 2000 veterinary professionals by searching. The webinar that community on Facebook. Fantastic, and I suppose all the work with monoclonal antibodies, you know, in, in other, inflammatory diseases like, osteoarthritis and obviously dermatology, atopic type diseases, I presume, you know, there's a potential there for, for dentistry as well, isn't there?

I think there is, and I, I have heard people, and, and manufacturers of monoclonal antibodies. Proposing that that these could be really beneficial, and, you know, if anybody wants to do a trial out if anybody, if any manufacturers out there listening, please contact me. I'm easily available, and, but, but, but in essence, as yet we, we don't have, any, any clinical data, but again, yeah, no, I, I, I would, it wouldn't be something that I'd be very interested in exploring further.

Perhaps if we can move on just talking about, because we've mentioned it about. Radiography and so on, and, and, you know, the tools that we need perhaps to do good dentistry in practise, so if we can maybe start by talking about, Imaging, what do you think as a first opinion vet, GP vets should be the setup for, for doing dentistry maybe from the imaging, and then we'll move on to the, the kit that you use to actually clean teeth and and remove them and so on. Yeah.

So, I, I think, I think it's, it's, it's not an understatement to say that that dental radiography is a critical component of doing good quality dentistry and. So I think undoubtedly it is a massive portion of it. I personally, wherever you can, would always recommend chairs side operations.

I think whenever you have to, you know, take a patient from the area that you're doing dental treatment in and take them to an area where you're going to X-ray them and then bring them back again, or you have to take an X-ray, take it somewhere else to develop it, and then bring it back again. It adds a degree of faff and, and, and I, I don't deal with you doing it, yeah, absolutely, you know, we, we all know that, you know, we're busy, super busy people, and, and, and, and, and, you know, to, to quote the internet ain't nobody got time for that and so yeah, you definitely don't, don't end up. Doing as many radiographs as you should, and, and the truth is that, you know, we, we would always do full mouth radiographs in all of our new feline patients, and anytime that I have an issue intraoperatively, I take an X-ray.

And, and you know, we might take 20 x-rays of an individual patient if you, and, and we think that that's really important. If you don't have that ability or you have to, there's something that's going to interfere with your workflow, slow the whole process up, and it suddenly it takes 20, you know, 2030 minutes to do full math series, that that's not efficient, appropriate, or going to be used enough. So yeah, and it also keeps, you know, the cats or the dog under for a lot longer with the anaesthetic, which increases risk, doesn't it?

Absolutely. And, and most of these patients, you know, dental diseases. Are, are more common in older patients, and you get more comorbidities.

And so, of course, you know, anaesthesia time and anaesthesia stuff is, is critically important to many patients with, with dental disease. So I really like, I, I, I don't have a problem or a difference in, you know, I think that any of the chair side systems are, are, are absolutely great, but I do think it's really useful having the ability to take X-rays where you're working. And I would always, if you have the ability to have a fixed area, then have a wall mounted X-ray generator, it just gets in the way far, far less and allows you to work around the patient really efficiently.

I think that the CR systems, so these are the indirect digital systems, are probably, easier and more amenable and perhaps even. And more have greater crossover in general practise than the direct digital systems. The downside with the direct digital systems is that the screens, the sensor size is relatively small.

You're only going to get one. They're really expensive if you damage it. It's like 50 to replace, whereas the indirect system, although it's a little bit slower initially because the screen sizes are bigger, you can often take more teeth on one image.

So actually it all evens out. I think the quality of the DR systems is excellent, but the CR is, is very, very good, and so, yeah, for most people in general practise, I would recommend the CR systems and the CR 7's an excellent, you know, workhorse basically. What about some of the handheld machines that do you, have you seen them being used?

Again, I guess we've got to separate the two things. So you've got an X-ray generator and then some form of, of, you know, capturing those that X-ray data, and then, then, you know, extrapolating that to, to a digital format. And, and so X-ray generators essentially they're all much of a muchness.

They, they just, you know, you're either going to have wall mounted, floor mounted, or handheld unit. I've used the handhelds actually doing wildlife dentistry. I've used them on lions and so, you know, they've got plenty of punch and they work just fine.

And, and they are really very safe. I think the downside is that the massive benefit is if you've got a multi-center site or multi, you know, centre set up, and you're going to be wanting to do dentistry at multiple sites and you're going to only have one system per site or per, you know, hospital, you can move that around. They're super portable, very, very easy.

If you're a peripatetic dentist and you're going into practises, you know, lugging around a full size X-ray generator might be just too much hassle. So again, I know some people that have used track, but the truth is that that the learning curve is, is probably much steeper initially with the the handheld units. You know, we, we end up doing these weird bisecting angle views and and it's all about calculating different, you know, angles of beams, etc.

And when you're able to step back and somebody else is taking the load, you know, the, the arm of the machine, it's much, much easier than when you're trying to eyeball it from behind. And so that's the downside of those units. Brilliant.

And then if we move on, I, I suppose obviously with your work you're obviously also doing. Not just dentistry, but you're obviously investigating, as you said, for tumours, etc. So presumably on any sort of bone type work, CT is probably the best, but MRI you obviously need to use for neurology work.

So you, I know you've got both, scanners in, in practise, in a sense, some GP practises are going there cos they're becoming more affordable, but this is probably where. The specialist really comes into their own with this advanced imaging, isn't it? I think so, yeah, so.

So dental radiography is amazing for anything within the alveolar bone essentially. So anything within the alveolar crest, you can probably identify with dental radiographs, and that's both the upper and lower jaw. But as soon as you move out of the alveolar bone into the sort of true mandible magzilla and beyond, sadly dental radiographs are not much better than standard plain radiography.

And, and CT is our probably our go to modality. We, we do have, as you say, MR as well, and certainly for sort of neuropathic origin problems we may end up using that technology, but the vast majority will tend to use CT first. It's obviously, it tends to be cheaper.

It's definitely much quicker and mainly I'm interested in bones and the soft tissues that I can see on a, on a CT. The, in, in veterinary medicine, in veterinary dentistry at least, for specialism side of things, there's a big drive towards, or there's a lot of people now using the sort of the cone beam CT technology, which, which is a little less costly and a lot lot smaller than than the conventional CT and and. Some of its its benefits, you know, it has a greater sort of slice.

The slices that you can generate are definitely thinner and therefore image quality is pretty fantastic. It's not so good for looking at contrast agents and those kind of things and lungs, etc. And it's a relatively small field of view, so very good for just the head.

So if you have a lot of pure dentistry or trauma patients, then it might be great, but if you do quite a lot of oncologic surgery, then perhaps more conventional CT. But yeah, we, we use CT every day in our department, and, and obviously we, we do a fair bit of, of maxillofacial surgery. We, that's, that's kind of my area of special interest, pure, you know, that's sort of beyond pure dentistry really, but, but, but yeah, CT is, is wonderful.

You can identify in cats, you know, if they've had road traffic accidents, we know that you'll find twice as many, fractures in cats than you, if you're using CT than conventional. You're looking at the temporomandibular joint, I don't know if you, if you remember taking X-rays of temporomandibular joints and trying to, it's just impossible and we used to dogmatically say that if, if you have a fracture of the temporomandibular joint that almost certainly those patients were going to get ankylosis and they needed some treatment. And since the advent of CT, what we probably should have said is if it's bad enough that we can see it on an X-ray, it's probably going to get ankylosis and probably needs further treatment because we missed just huge numbers of, of much less severe fractures of the temporomandibular joint apparatus.

In, in, in cats because you just can't see them on conventional radiographs, or it's really hard. When you're dealing with cats, is it more catmatically than dogmatically, or do you, can you still use the word dogmatic when you're talking about cats? You say catmatically?

I just think you've got to be fair to cats here. I, I don't think so. I think I, I'm comfortable with dogmatic in reference.

OK, OK, fair enough. Just to, just to sort of to finish off the imaging part, obviously I suspect you also get sort of pulled in for throat type things as well. Is there ever a need for ultrasound of of throat or nose perhaps to look for foreign bodies, or would, would a MRI or a CT pick that up?

So is, is ultrasound a tool that you don't really need to use very much. So yeah, we use ultra and. Relatively commonly and certainly as an adjunct it's, you know, we'll often get called in for patients with pain or mouth opening.

So a lot of those will have issues in the retropoal space and certainly that that's part and parcel of the investigations that we do and we also When we're doing oncologic staging, we use ultrasound guided lymph node aspirates, and obviously lymph node aspirates of the mandibular lymph nodes are relatively easy, but one of the challenges is that it's a lympho centrum, so you've got maybe between 3 and 5 lymph nodes per side, and then you've got the media retropharyngeal, which is the sort of the big daddy of the of the lymph nodes in the head and drains the entirety of that area. And we always like to take an aspirate or a biopsy from, from that as well when we're we're doing oncologic staging and that's really. It's quite an invasive surgery, it's quite straightforward, but you know, you're, you're right next to the, the internal carotid artery, you can kind of wave at it and and and some other pretty significant, what you want to.

No, you know, it's definitely it's got a name, you don't want to cut it. So so so yeah, you know, it's . If you can use aspirates and and ultrasound guidance, then, then it's fabulously useful and, and yeah, absolutely our, our amazing imaging team at Eastcot are, are pretty good.

They've done a lot of those in the, over the years. So it's, as you say, it's a whole spectrum of imaging then, really, isn't it? Yeah, absolutely, and the head is it's quite a complex area is the simple truth.

And as soon as you move outside of the immediate, as I say, immediate jaws, then it gets pretty complicated pretty quickly with a whole range of different tissues and therefore you've got to bring all these different imaging modalities to bear. Depending on what you're looking for, finally, it's I've really enjoyed it, I suppose we're moving on to an area that is. It's really important.

I'm not sure it's as topical as it should be, but it's an area that I, that really interests me. You know, the use of antibiosis, particularly with tooth extractions, gingivitis. What is your thoughts around that?

What do you do, you know, within your practise and what would you recommend a general practitioner to be doing? Do you swab at all and and things like that, maybe just talk us through. Yeah, so, we do do swabbing but not routinely, .

Swabs from oral cavities are probably not hugely beneficial for the general, sort of oral pathogens, and we actually know that quite a lot of the bacteria in the oral cavity aren't actually culturable. You know, we, we've used now DNA markers, RNA markers, huge amount of works done by Waltham, and, and, and thank you to them looking at the microbiome of the oral cavity in cats and dogs. And, and, and the vast majority of them aren't, you're not going to pick up our culture.

So no, we don't use culture very frequently. Where we would use culture is if we have some form of chronic infection. We've got osteomyelitis, those kind of things, and tend to what we would tend to do would be to take tissue samples and send for tissue maceration and culture.

So we don't really use swabs very much at all is the simple answer. From an antibiotic point of view, we definitely do use antibiotics, but we use them pretty infrequently. I would say that the vast majority of patients are going to not receive antibiotics.

So if we have our sort of general guidance really would be we would use intraoperative intravenous antibiotics more frequently than antibiotics that we would prescribe for postoperative or pre-operative therapy. So a good broad spectrum cephalosporin, cephalexin type product or or potentially t amoxicillin tends to be our go to, and we tend to use that in individuals that have potential for comorbidities that will cause immunosuppression. So you know, any of the sort of diabetes, immune, those kind of issues, anything that is going to put you at greater risk of developing an infection.

And people often worry about sort of bacteremia that is associated with with toothbrushing with toothbrushing with, with, you know, having periodontal therapy. The truth is that you get a bacteremia if you've got gum disease, you get a bacteremia every time you eat something, let alone every time, you know, someone does a scaling and polishing. Your immune system is really, really good at picking those bacteria up and has been seeing those daily for months and months in most circumstances.

And we don't give antibiotics every time we, we, you know, eat something. So the truth is it's unnecessary for the vast majority unless there's this immunocompromised condition or you've got comorbidity such as, you know, renal disease, heart, heart problems, etc. Etc.

And we would use IV antibiotics then. If I've got a patient that has really terrible periodontitis, it's got deep pocketing, I've extracted teeth, there's been a lot of extractions, I might consider a relatively short course of antibiotics, but that would be in conjunction with other therapies and, and, and so just like anywhere, you know, that that guy Halsted with his principles, he knew what he was talking about and it applies in the mouth as it applies everywhere else. You debride necrotic tissue and infected tissue.

You close dead space without tension, and, and that's what allows tissues to heal rapidly. If you, you apply that, you don't need long courses of antibiotics, you know, you lavage out infected tissue, etc. Etc.

So. You know, those principles should be applied. So again, I don't use things like clindamycin very often and if I've got, if I've got an osteomyelitis, as I say, those are the circumstances where I would take culture and send off or take tissue, send that for culture and and and then use antibiotics depending exactly, yeah, yeah, yeah.

So. So the simple truth is we don't use them very much. We definitely don't use long courses very often.

We almost never give preoperative antibiotics and we tend to use a relatively small grouping of, of, of drugs and certainly amoxicillin or a potentiated amoxicillin, it is probably perfectly acceptable for the vast majority. And if you've got a really nasty osteomyelitis or some sort of more aggressive process, then you know, we would use metronidazole most commonly in adjunct with, with, you know, that, that potential tamoxicillin basically, but I really have, I've I've not dispensed and ref I guess I'm talking to a dermatologist and I've not, I've not dispensed the fluoquinolone for 10 years, . Yeah, never had the need to, and, and intermittently we've seen patients with MRSP, cultured from the oral cavity.

And quite often we'll stop all antibiotics at that stage, and we'll just use chlorhexidine oral rinses because MRSP's super sensitive to, to chlorhexidine, and, and then you just let the normal bacteria recolonize the oral cavity and they'll outcompete the MRSP and and in the vast majority of cases it's much less scary than you think. And I presume with, with cats that might. Almost come from them licking their skin where the where the MRSP was rather than them getting it, you know, in their mouth per se.

Yeah, you know, it's not going to be a natural, it's gonna be not be a common pathogen of the oral cavity and, and yeah, I think you're absolutely right. Mike Willard, who's a famous gastroenterologist who's done several lectures for us. I love Mike.

He, he says what. I told you 10 years ago was a lie. I just didn't realise.

And it is very true, isn't it? You know, I, I spent a lot of time doing dentals, and they were dentals, you know what I mean? Yeah, no, no, don't worry, it's common, it's common nomenclature, it's fine.

I know, I know, and it's terrible. I absolutely agree with you, dental procedures, and they were really satisfying cases because often you would at that stage have. People who'd go, they'd come to me and they'd say, but I've been to another practise and because the dog is old or the cat is old, they've said not to bother and you looked at the mouth and you thought.

This has to be in pain, this dog or cat. And you actually did the procedure, obviously gave antibiotics, and a week later the cat or dog came back and they said he's 5 years younger, so there were such satisfying cases, but of course it was very much the procedure rather than the antibiotics that were doing that was doing the, the good work, so to speak. In truth, .

A lot of people ask me with that sort of quizzical. I go back to reunions and people look at me and go, are you a dentist? Why?

Just because, you know, most, most of us sensible vets don't enjoy dentistry necessarily. And, and one of the big reasons that I became a dentist was actually just, just exactly what you've said is I felt that I could have an impact on my patients' welfare probably more than than almost any other thing that I did on a day to day basis and and, and I'm not really great with delayed gratification, so I'm no orthopaedic surgeon. and, and, yeah, I, I, I 100% agree with you.

There's so many patients out there that are, you know, they're suffering in silence essentially, and, and because it's a slow onset disease, it's a bit like obesity, you know, slow onset disease, you see, you don't see big changes and it's really only after you've done something about it that. You get that sort of pay off basically, so yeah, really challenging. Final very quick one again with my experience of having my own tooth taken out, I was very much, you know, I would remove a lot of teeth in these Yorkshire terriers or or cats that came in, you know, with really bad mouths, and I tended never to stitch those holes because I almost felt that the stuff needed to drain out of them.

And then new newer younger vets came in and were very keen on stitching gums. I went to my own dentist, you know, they took quite a big tooth out. Obviously they were worried about dry sockets and they, they packed it for a day or two, but actually, They didn't stitch either, so again, as, as the fashion for stitching, is that still a big thing in in dentistry or maybe a two minutes, what, what should a a GP vet be doing with regard to stitching, gums and sockets?

I'll do my best to keep it short. I appreciate, you know, like evidence to date probably indicates that I'm not going to, but I'll try. So in short, we, we use quite a lot of, you know, we stitched the vast majority of our, of our oral wounds.

And in your, when you had your tooth extracted, you were probably given a cotton pledget, and they stuck it in the hole and they said bite on this for the next half an hour, and you, I'm sure complied brilliantly. And then they said, OK, well, tonight and tomorrow, you do nothing, you don't chew on that side, you don't eat on that side. If that, if that clot comes out, I need to know.

You need to come back and tell me. And then they said, you're going to rinse your mouth twice daily with a salty water solution and if you have any, you know, excess pain and discomfort, you come straight back. My patients are rubbish at doing all of those things.

And so in humans they tend to find that human patients find oral sutures very irritating. If you look at our homunculus, our tongue is massive. We're really good at, oh God, that feels weird, and essentially they get more complaints because they put sutures in.

They use silk, so mostly commonly they'll have to take those sutures out. Because my patients are really terrible at looking after their extraction sites, I would prefer to suture because I think it increases the speed of healing, decreases postoperative pain, reduces the likelihood of haemorrhage, definitely, I think reduces the risk of development of dry socket or osteitis. And in the vast majority of I don't like being woken up in the middle of the night, and so, you know, if you've got a dog that starts bleeding, that that's difficult, and, and then you're in that difficult scenario.

So, so no, I'm a big fan of, of closing oral wounds. There are a couple of instances where I might choose not to, and I might place just some simple cruciate sutures over the defect just to pull, pull the wound edges together, but I wouldn't raise a flap necessarily to try and close that. So the classic would be as if I've extracted the maxillary first molar, but not the maxillary second molar, and I've got a maxillary 4th premolar.

That's quite a big defect, and you have to create quite a large flap, and in doing so you can infect the gingival attachment of the 4th premolar, predispose it to gum disease. So in those cases I might not choose to close it definitively, but, but yeah, just, just place a couple of sutures just to hold the clot in a bit better. Hm.

Brilliant. Was that Andrew, that's been fantastic. Yeah, that was good, that was good.

It's been great. Charlie's probably shouting at us because we have gone on. But it has been so interesting.

I hope people listen to it find it as equally interesting as I did, because of course dentistry, particularly in cats, I think they now say I remember us doing a series on cats and everybody vied, they were. Experts, each on caps and everybody vied for what was the most important disease. Obviously the dermatologist thought theirs was then the orthopod thought theirs was, but dentistry is, Is right up there, I think the orthopod brought out some evidence based medicine that suggested that they were the most important, but The these orthopaedic surgeons always think that anyway.

What's the difference between God and an orthopaedic surgeon? There isn't much of a one, is there? Well, God doesn't think he's an orthopaedic surgeon.

Very good. To finish off, we all know God loves dentists as well and dermatologists. But Andrew, it's been great to speak to you.

I know how busy you are, so thank you so much. Thank you very much time to do it. Take care, bye bye.