That's great. Thank you very much. So this evening we're gonna talk about feline dental disease, focusing on two important aspects, firstly, periodontal disease, so gum disease, and also then tooth absorption, two very common diseases that we see in cats and diseases that often vets struggle with, particularly tooth absorption.

So just, some brief, bits about periodontal disease, periodontal disease is a, is a progressive disease and without intervention it will progress through several stages from reversible early stages, then through to irreversible stages towards the end of the disease progression. So in those early stages we have plaque deposition, cactus formation and inflammation of the gums. And then as the periodontal disease progresses, we'll start to see gingival recession, bone loss, and then ultimately loss of attachment and loss of the tooth.

Mm. So the reversible stages, what is plaque, plaque is a biofilm that builds up on the surface of the tooth. The biofilm is a, a protonnaceous material on the surface of the tooth that holds bacteria.

In a sort of mucopolysacchaide matrix. It can't be rinsed off, so, the only way that we can remove a biofilm is by physical removal and so for teeth that means toothbrushing. So just simple rinsing with antiseptic agents, mouthwashes, that sort of thing, doesn't have any effect on plaque on the surface of the tooth.

It needs to be scrubbed off with the toothbrush. Just the first important thing to remember. The biofilm attaches to the surface of the tooth via the salivary pellicle, which is a proteins made up from proteins in saliva, and then bacteria will colonise on that pellicle in a fairly predictable manner according to their species.

Gingivitis, so again the other key part of the reversible stages of the disease is the the host response to bacteria present on the surface of the tooth. So it begins as soon as bacteria and plaque start to accumulate on the surface of the tooth, so within 24 hours, and we get vasodilation of the capillaries, which causes the redness of the gingiva, we have an increase in fluid in the gingival sulcus. And information.

That the response develops over a 2 to 4 day period. At this stage, the ginger ale will appear clinically healthy. After about a week of plaque accumulation, that information will increase.

So we get that vessel dilation and more redness, and increase in white cells, and the attachment cells, the fibreglass starts to cells of signs of cell damage. We'll also get some coronal epithelium loss, and that will allow plaque to extend below the gingival margin. And that really allows the periodontal disease to progress to the irreversible stages.

So periodontitis, again, increasing fluid within the gingival sulcus, increased inflammatory infiltrates, neutrophils are going to predominate. And then we'll get loss of gingival collagen, and that allows space for infiltrating cells into the gingival. The junctional epithelium, so that the epithelium that sits adjacent to the tooth is no longer closely attached to the tooth, and we get a pocket starting to develop around the tooth, and again, clinically we'll see redness and then bleeding and swelling.

At this stage, the Periodontal disease can remain stable or it can progress. Periodontal disease is a is a disease that will wax and wane. It won't necessarily progress in a linear fashion.

Or a balancing act between the plaque on the surface of the tooth and the host response to that plaque. As paradon disease progresses, we can get more plaque extending below the gingival margin, and we start to see more chronic inflammatory cells. We get more loss of the periodontal connective tissue, so we start to see the loss of attachment of the tooth.

And then we get apical migration of that junctional epithelium is the epithelium around the gingival sulcus towards the apex of the tooth. And that's where we get the formation of our two periodontal pocket and you can see here on our slide here, a periodontal pocket, so the periodontal probe placed into the area between the tooth and the bone where we've got a periodontal pocket. And obviously this is resulting in bone loss around the outside of the tooth.

What we're seeing here really is the body responding to bacteria on the surface of the teeth that it can't deal with, so. Inflammatory cells can't access the bacteria directly. So periodontal disease really is about the body pulling the structures, the vital structures, the large structures around the tooth away from those bacteria and withdrawing them away in a way so that those bacteria can't get into the sensitive structures.

Ultimately that will lead to the tooth being shed. So the tooth is the contaminated structure within that alveolus, and with that tooth being that will remove the problem. So it's the body's way of dealing with that, those bacteria present on the surface of the tooth.

Really important to remember that the bacteria are on the surface of the tooth. They're not in the tissues of the mouth at this stage. So.

How do we go about assessing periodontal disease clinically, well, the first stage of any disease, treatment is history taking. So at the beginning of each day, I'll admit my patients in a consultation, and that obviously gives us the time to discuss with the owners, things like appetite and eating habits, water consumption, things that are gonna affect our anaesthetics, so cardiovascular health. For me though, the most important part of that initial consultation is assessing the postoperative compliance of the owner.

And in cats that's really important because brushing teeth in cats is not necessarily an easy job. There are plenty of videos available on YouTube, of people brushing their cat's teeth. So if anyone wants any pointers as to how to do it, YouTube's probably your best source of information.

But a lot of owners will struggle to brush cat's teeth. The cats are not always overly compliant, as we know, so really we need to get a, an insight as to how likely the owner is going to be able to brush the cat's teeth postoperatively because that's gonna affect our decision making process with regard to, whether we're going to think about preserving teeth or whether we're gonna think about extracting teeth. So it helps sort of figure in with our decision making process.

We're then gonna move on to our conscious examination, so we're gonna do a full systemic examination again, pre-anesthetic assessment of body condition, there are conditions that we'll see, gingivostermatitis or neoplasia that can affect body condition. We want sort of a gross examination of the head, and then moving on to A sort of a more dental orientated assessment. So looking at the teeth, looking at the occlusion, and then the gross signs of disease, and that will allow us to discuss potential pathology there and treatment that we're likely to carry out.

Really important to explain to owners though that. Really, we don't get a very detailed examination of them out until we've got our patient under anaesthetic. So it's really important to stress that to him is that although we give a rough idea of what treatment we're going to carry out in that consultation, things will change once we got our patient under anaesthetic.

On we can do a more specific examination. So the 3 instruments I have out at the beginning of each procedure are the periodontal probe, the Sharp Explorer, and dental mirror. So these are, that's my examination pack that I have out at the beginning of every procedure.

Periodontal probe, like the instrument we're gonna look for periodontal disease. So the disease we've discussed so far. So we'll go through how we're gonna go about using that periodontal probe to assess which, which teeth we're gonna extract.

We can see the periodontal probe in action. So into that periodontal pocket around the upper left canine tube. Sharp Explorer is the middle instrument instrument that we're going to use to assess damage to the hard structure of the teeth.

So particularly we're looking at fractured teeth here we can see a fractured upper left canine tooth with pulp exposure. The pulp is bleeding there. If we were to run our sharp Explorer over that area, then we would find that the Sharp Explorer catches in that area of exposed pulp, and that would tell us that that's the tooth that needs treatment.

We can use our sharp Explorer on the crown surface above the ginger margin, and that will help us to look or in fact feel for tooth absorption. It's much easier to feel reabsorptive lesions than it is to see them sometimes, so we can use that sharp explorer around the base of the crown of the tooth on the surface of the tooth, looking for tooth absorptions. And then we've got our dental mirror which allows us to look on the palatal and the lingual aspects of the teeth.

And then we're going to record our information on our dental charts. The dental chart provides us with a structure to our examinations. That's really the most important reason for charting teeth.

I think it means that we move from tooth to tooth, making sure that we examine every tooth in a very methodical way, so that we don't miss problems, so that we don't miss treatment, and, and end up waking up our patient before the treatment has been carried out. It obviously also then provide a record for us to refer back to from future future times. These are the sort of dental charts that we use, so these charts allow us to record a lot, a lot of information, particularly in pictorial forms.

So the chart you can see we have a pictorial representation of each of the surfaces of the teeth, so the buckle surface, the lingual surface, and then the occlusal surface, so we can actually draw lesions on these pictures rather than having to describe them in words. And then on the back side of the chart we've got areas where we can record our problems, we can record our planned procedures, we can record the procedures that we've carried out and any complications, and then we can record that treatment also on the small chart at the at the bottom of the of the page. That again it provides a nice methodical way of examining the cat's mouse.

So what information are we going to put on there? The, the first thing our chart is the gingivitis index. So here we're going to use our periodontal probe into the gingival sulcus.

We're gonna assess the response of the gingival sulcus to us placing our periodontal probe into that area. So gingivitis index, 0, no inflammation, really only exists where owners are brushing their cat's teeth at least once a day. So mostly we're gonna start our index at one, so mild gingivitis, where we have mild reddening, swelling of gingiva, but no probing.

So that's sort of at that at that reversible stage of of periodontal disease. The next stage up, we've got moderate gingivitis. So again, we've got gingival inflammation, rhythming and swelling, and the difference here is that when we probe around the tooth in that gingival sulcus, we're getting bleeding in response to that probing.

And then severe gingivitis can significant swelling of the gingiva, sometimes we've got ulceration here and the difference here really is that the gingiva is bleeding before we start probing. So to move up through that index system, we have one we have where we have no bleeding. 2 where we have bleeding after we've probed around the gingival sulcus, and then 3, where we've got spontaneous bleeding before we start probing.

So that's how we move up through that index system. The next thing we're gonna measure is the periodontic probing depth. So again, we're gonna use our perioddontic probes into the gingival sulcus.

And then we're gonna measure the depth of the gingival sulcus at between 4 and 6 locations around the tooth. So the normal values for a cat really should be less than 1 millimetre. So we place that periodontal probe into the gingival sulcus and the edge of the gingival margin just comes up to that 1 millimetre marker on the .

Parental pro If we've got values that are greater than 1 millimetre, then that means there's two things. Either we've got enlargement of the gingiva, so we've got some sort of mass effect, on the ginger er that is creating a pseudo pocket around the tooth. So, ginger enlargement will create a pseudo pocket, or we've got the reverse, the irreversible stages of a peridontal disease where they're having that apical migration of the gingival attachment.

And so therefore we've got our true periodontal pocket. Either way, pockets are an awkward thing and a difficult area. Once we get a pocket that starts to develop around the tooth, that is an area between the tooth and another structure, be that soft tissue or bone.

Where plaque and then calculus can build up and deposit on the surface of the tooth, and it's an area that then an owner is going to struggle to clean off even if they're managing to brush the teeth effectively once a day. If we've got a pocket around the tooth, it means that the owner is going to struggle to get a toothbrush into that area to clean the tooth. The next aspect that we're going to assess is gingival recession.

So again, we're gonna take our periodontal probe and we're going to, place it against the side of the teeth, and then we're gonna measure from the cemento enamel junction, so that's at the base of the crown down to the free gingival margin. So here's our cemento enamel junction here, and that's the free gingival margins. So that's gonna give us another measurement of millimetres.

So we've got two measurements now we've got our periodontal probing depth and then we've got our gingival recession, in millimetres. Using those two figures, we can then calculate the periodontal index so we can, where, where we have areas of both paradontal pocketing and a ginger rule session, we can add those two numbers together and then we can divide that measurement by the total length of the root and that's going to give us a periodontal index. And this is a useful guide as to when we should be thinking about extracting teeth.

So if we've got greater than 50% attachment loss, then we should extract the tooth. The tooth has gone beyond us being able to salvage that, so greater than 50% attachment loss, we should extract the tooth. Between 25% and 50% attachment loss, we're thinking about our discussion with the owner.

At the beginning of the day and whether the owner is going to brush the teeth or not. So the vast majority of cats where owners are going to struggle to brush their cat's teeth postoperatively, then we're going to think about extracting those teeth as well. So over a 25% attaching loss, the likelihood is in cats, we're going to think about extracting those teeth because almost certainly the periodontal disease will progress.

The other way that we can assess the periodontal index is by taking dental radiographs. So the dental radiograph is a really nice pictorial representation of the relationship between the tooth and the alveolar bones, so we can see, in a pictorial way that attachment lost from the surface of the root. So dental radiography really good for assessing periodontal index.

The next thing we're going to assess is furcation exposure. So the furcation is the area of the tooth, between the two roots or three roots, below the base of the crown of the tooth, so where the two roots meet. So here we're going to take our periodontal probe and we're going to place it into that location area.

Stage 0, notification exposure that is normal. If the probe can be placed up to 1/3 of the width across the tooth, then that is stage 1. If the probe goes more than 1/3 of the width across the tooth, then that is stage 2.

Or if we can place our periodontal probe all the way through the cation from one side of the tooth to the other, and that is stage 3. Certainly for stage 3 ocation exposure. We should be extracting a tooth with stage 3 location exposure.

When we have stage 3 location exposure, we've got a little tunnel that's developed below the crown of the tooth between those roots, and with the best will in the world, any owner is going to struggle to keep that area clean from plaque. So plaque is going to deposit in there and then the periodontal disease will progress very quickly. So once we get stage 3ification exposure, then we should be extracting those teeth.

If we've got stage 2 location exposure, we've still got quite a, a deep area below the crown of the tooth for the owner to keep clean. So again, we're thinking about that discussion at the beginning of the day. Is this an owner that's going to brush the teeth?

If they are, then we may be able to preserve those teeth, but the likelihood is that the owner is going to struggle to get a toothbrush into that area, keep the plaque away, and, and so therefore, peridontin disease is going to progress fairly quickly. So again, stage 2 and 3, the likelihood is that we're gonna think about extracting those teeth. Tooth mobility again really important, probably the most important feature of periodontal disease for our patients.

Tooth mobility is the time when periodontal disease starts to become painful. If the tooth is mobile within the alveolus, then every time the cat bites down or something, that tooth will move around, and that will stimulate the nerves in the periodontal ligaments face and then through the apex of the tooth, and that is going to cause discomfort for the patient. So tooth mobility is really important for our patients.

Really, in cats, we, we want to see no movement of any of the teeth. So again, even single rooted teeth, any movement more than a millimetre, that's certainly multi-rooted teeth, any movement at all, and we're gonna want to extract those teeth. Slightly different situation to dogs, often in dogs, particularly with their incisor teeth in small breed dogs like Yorkies will expect some degree of movement, up to about 1 millimetre is considered normal, but in cats really we don't expect to see any tooth movement.

So everybody happy with periodontal disease, we're going to move on to think more about, tooth absorption now. So, anyone who's listened to a lecture of mine on cat dentistry before, knows that really, as far as I'm concerned, a feline dentistry. It's something that we need to be carrying out with dental radiography.

It's not an optional thing. I think if we're not using dental radiography when we're carrying out dental work, then really we're not assessing cats' mouths effectively, and we're not going to be able to carry out a good job. And that really is, because of tooth absorption.

So tooth absorption is is a very radiographic condition. We're gonna assess tooth absorption using den radiographs. We're going to decide how we go about treating it based on those radiographs, and if we're not taking radiographs, then really we're not, carrying out, feline dentistry in the way that we should.

So tooth absorption, let's have a a little bit of an overview of tooth absorption. And it's been known by lots of different names over the years, neck lesions, felineodontoclastic resorted lesions or falls, but tooth absorption is, is what we should be calling it. And tooth absorption is where we're getting destruction of the dental hard tissues and then replacement with either granulation tissue or bones, so we're losing dental hard tissues.

It's a very common condition depending on which papers you read on the statistics of tooth absorption. We know that it affects 13 to 50% of all cat patients. So that's a very high number.

You know, if you think of the cats that are coming in for a vaccination, every 3 or 4th, sorry, every 2nd or 3rd cat that's coming in for a vaccination is going to have tooth absorption, so it's a very common condition. The tooth absorption is broken down into 3 types. We've got type 1, type 2, and type 3.

So type 1 is associated with inflammation. So where we've got cats that have got inflammation of the gingiva, because of periodontal disease, gingivitis, or because of conditions like feline chronic gingivar dermatitis, where we're getting inflammation of the, of the gingiva. That gingivitis will stimulate it ontoclast at the cemento cemento enamel junction, and they will essentially eat into the surface of the tooth.

And if you look at a radiograph, it looks like, sort of the typical apple core lesion where someone has taken a bite out of the side of the tooth. But the important thing with type one absorption is that the root is unaffected. We've then got type 2 resorptions.

This is replacement resorption, where we're getting adontoclas sitting on the surface of the roots that are being inappropriately activated, and those adontoclasts are then, firing their way into the tooth, and they're changing the tooth, from tooth structure into what looks like a bone material. So it's a very different condition to type 1 resorption. Type 1, we know roughly what causes that, we know it's associated with inflammation, but type 2, we really don't know the cause of.

And we're gonna treat those very differently. We've also then got type 3 tooth absorption, so that's where we've got a combination of both type 1 and type 2 resorption affecting the same tooth. And how we go about treating that tooth absorption is based entirely on the radiographs that that that we take.

So let's look at some examples. We've got here a tooth affected by type one tooth absorption. So here we can see this lower right first moulded tooth has got periodontal disease.

We can see that we've got horizontal bone loss, . Around the tooth that indicates this tooth has got a periodontal disease. The gingivitis associated with that is then stimulatingodontoclasts at the cemento enamel junction.

Those odontoclasts have eaten into the surface of the tooth, and we've got that. Lucent area, that hole that's developed in the side of the tooth at the cemento enamel junction, and that hole is then gonna be filled with the pink granulation tissue that we're all familiar with when we look in cat's mouths at their teeth. The important thing here though is that you can see that the roots of this tooth are completely intact, so we've got a periodontal ligament space all the way around both of the roots of that tooth.

So I know that that is type 1 absorption, and from that radiograph I know that the root structures are there and that's the tooth that we're going to need to extract. This is a tooth with type 2 resorption, and the nice thing about this radiographs here we're looking at the mandibular canine teeth, is that we've got one relatively normal canine tooth that's the, the right tooth that's on the left of your screen, where we've got our periodontal ligament, the dentin and the pulp, so we can see nice banana-like structure of that lower canine tooth. If we compare to the canine teeth on the other side, we can see all of those root structures have disappeared, so we don't have a periodontal ligament space.

We don't have, recognisable dentin, there's no pulps there, and the material that we can see there looks pretty much like bone. So if we take a radiograph like that, we know that that is type 2 resorption, and we know that, that's the tooth that we're gonna have to treat. You can see we've got polluccent areas again around the base of the crown, so you can, those areas are going to be filled with that, pink granulation tissue.

So clinically it's gonna appear exactly the same as type one absorption. We're going to get the lesions around the base of the crown, but you can see radiographically very different. And we're going to treat that tooth very differently.

So, this is a, a tooth where we've got no root structures to extract. So this is a tooth that we can treat with the crown amputation. Then we've got type 3 resorption.

So this is, the middle tooth there is our lower 4th, pre-molar tooth, so we can see our, our red arrow is pointing at our type 1 lesion. So that's a sort of Apple core lesion where it looks like someone's taking a bite out to the side of the tooth. And then the blue arrow you can see pointing at the medial root there where we've got complete sort of loss of definition of that periodontal ligament space.

The dentin has lost its structure, and we're starting to see sort of type 2 resorption, affecting that route. Interesting though if we look at the distal route, so the, the more caudal roots of those two, we can see paraon ligaments face, we can see denting and we can see pulp, so that tooth root is yet to become affected by tooth absorption. So here in this tooth, we've got, type 1 lesion, we've got type 2, root that's affected by type 2 resorption, but then also we've got a, a normal root.

And we're going to treat that tooth differently, different parts of the tooth differently, so the, the medial root with the blue arrow pointing at it, we can treat that with a crown amputation, but the distal root is a route that we really need to extract. If we just amputate the crown of that root, then we're going to leave the paradontal ligament, we're going to leave the pulp. So that is potentially going to cause discomfort to that cat, and we don't.

Truly know whether that route is gonna continue to resolve. We expect it to, but expecting it is gonna be much more preferable than doing the row amputation. So let's look at some case examples.

What sort of tooth absorption is affecting this lower left canine tooth. Well, we can see we've got the pink fleshy granulation tissue around the base of the crown of that tooth. But that's not really telling us anything.

That's just telling us that the tooth has got tooth absorption. It doesn't tell us what sort of tooth absorption that is. The only way that we can assess that is by taking a radiograph of that tooth.

Here is the radiographs. So the tooth that we're looking at here is the one on the right of the picture, the right canine tooth, and we can see, that actually both of these mandibular canine tooth have gone through, type 2 tooth resource. We've got no root structures there discernible.

We've got no periodontal ligament space, we've got no dentin or pulp. So this is type 2 resorption. And how are we gonna go about treating that?

Well, there's nothing to extract. There's no root structures left to extract. So this is a tooth that we're gonna treat with a crown amputation.

OK, here we can see this cat has got two visible, resorptive lesions. So we've got our maxillary 3rd premolar tooth and we've got our mandibular 4th premolar tooth. So we're gonna look at those two teeth separately.

Again, the maxillary third premolysis we can see around the base of that crown, we've got our pink fleshy granulation tissue. When we take a radiograph of that tooth, we can see that this is what the tooth looks like. So the root structures of that tooth are turning into bone material.

We've lost the parallel ligament, we've lost the dent team, we can really see the pulp. So this is a tooth that's going through type 2 absorption. So how are we gonna go about treating this tooth?

Well, this is a tooth that we can treat with our crown amputation. There's no root structures left to extract, so this tooth can be treated with a crown amputation. So same cat, same mouth, mandibular 4th pre-molar tooth now, here we can see that pink fleshy lesion again at the furcation area when we take our radiograph, this is what the tooth looks like.

So we can see in the centre of the crown there is our loose interior where we've got our resorptive lesion. but you can see that the root structures of that tooth are completely intact. So we've got our periodontal ligament space, we've got dentin, we've got pulp.

So this is our type one lesion, and, this is the tooth that we know that we need to extract. So this is extraction of that tooth. So that's the same cat.

Two different teeth affected by different types of tooth absorption. So just because we've got one. Absorptive lesion and we identified that it doesn't mean that all of the teeth are going to be affected by the same type of tooth absorption or in the same way.

So we need to assess all of the teeth in the cat's mouth when they're being presented for dental treatment, take each tooth on its merits, assess each tooth individually, and then treat that tooth accordingly. OK, so here we've got our left axillary 4th preroll too. And here again we can see that we're missing probably 50 to 60% of the crown structure on this tooth now and that's been replaced with granulation tissue.

This is what the radiograph of that tooth looks like. So again, we can see you've got a large area of the crown missing as a result of the tooth absorption. If we look closely, actually, we can see here that we still have all three roots of this maxillary fourthre motor we've got the 2 metre roots sat superimposed over each other, and then if we look slightly cooler to that, then we've got the sort of triangular structure of the distal root and then behind that a fragment of the first molar tooth.

So this is type 1 tooth absorption. It's extensive type 1 absorption. We've got a lot of loss of the crown, but actually we've got 3 roots still there that needs to be extracted.

So really important they'll be getting radiographs of this tooth so that we can assess it and make sure that we've got all the, the fragments of that tooth out. Just to give you an idea of how tooth absorption progresses, this is a cat that we had treated with root cloud treatment, so you can see that the lower right canine tooth has had a root cloud treatment. The owner then contacted us about 3 years later to say that the tooth had fractured again, so we saw the cat and re X-rayed it, and you can see this is the same.

Tooth. You can see our root and our treatment still sat there so you can see our alteration, but very different structures around the tooth. So we've lost the structures of the root and that root has been replaced with bony material.

So that tooth has gone through type 2 resorption. And you can see actually the canine tooth on the other side has also gone through the same process, so both teeth have been affected by type 2 resorption. That's the cells sitting on the outer surface of the tooth, so it's nothing to do with the pulp or the, the tooth itself actually, it's the, it's the cells sitting on the outside of the tooth that cause all the damage.

OK, and then just a little case just so that we can highlight the need for us to take them to radiograss to assess cats with tooth extortion. This is a cat that, . Was presented at a vets for dental treatment, and the vet could see that the lower right canine tooth had tooth absorption had a lesion around the base of the crown.

So attempted extraction of that tooth and you can see we've got a loose interior where the luxator has slipped down through the mandible and then down through the synthesis, and that's caused a fracture of that jaw. And hopefully by now you can see why that's happened. So if we look at the tooth there, you can see that that lower right canine tooth is going through type 2 resorption.

So we lost the periodontal ligament space, and so really there's nothing actually left for us to extract, and that's most certainly why the fractures occurred because there's no way that that route could be taken out and actually that didn't need to be taken out. And that's why the vets pushed too hard because there's no ligament space to get the instrument into, so pushed too hard and ended up, fracturing the cat's jaw. So what do we do with this?

We know that actually the, root doesn't need to be extracted. So all I did was smooth the sharp edges around the, bone in that area and then close the soft tissues over that. The fracture was well opposed.

There was minimal mobility there, so just a soft tissue repair. Sufficient in this case to stabilise the jaw. You can see how if we take depth of radiographs before that procedure had been carried out, what's the treatment option that we should have been carried out on, on that tooth roll that's a type 2 resorption.

So that's the tooth that should have been treated with just a crown amputation. And as we see in a second, the crown amputation really is just a 5 to 10 minute procedure, so a very straightforward thing to do. So, in all cats that are having dental work, I would advocate full mouth dental radiographs.

Generally, we carry out dental radiographs in general practise, you could probably do that in 7 you see, we can see we've got our axillary canine incisors on one view. We've got the maxillary cheek teeth. We've got the mandibular cheek teeth, and then we've got the mandibular canines and incisors in the centre, and then obviously those are repeated on the other sides.

We can add in these additional views, so we've got a separate view of the maxillary incisors, and then we've got natural views of the canine and third premolar teeth, but certainly 10 views is is all we need to be able to, image all of the teeth in the cat's mouth with a with a DR sensor. And once we get good at that, actually, that's a procedure that we should be able to carry out very quickly. Dental radiography in cats is a, is a, a nice thing to do because the nice thing about cats skull is that it's very anatomically similar from cat to cat.

So actually, we can go through a nice routine when we're taking our dental radiographs, in order to speed the process up. So the first view that we do is our bisecting a review.s moved on too quickly there, bisecting a review of the maxillary canines and incisor teeth.

And that, is coming straight down onto the occusal surfaces of the teeth. Then we're going to keep, so you can see here we've got the sensor post in the mouth, resting on the two maxillary canine teeth. We're going to leave the sensor in the same place, and then we're just going to elevate the cone of the X-ray beam up to about 30 degrees now.

So that's going to give us our, a bisecting angle view and a bleak view of the maxillary canine tooth. So again, using our bisecting angle technique. And that's gonna give us this, nice view of the maxillary canine tooth.

Then the sensor is gonna stay largely in the same position. We're just gonna elevate the, the, edge up adjacent to the pre-molar teeth so that it's covering the premolar teeth, but largely staying in a similar position, and then we're going to elevate the cone of the X-ray, the cone of the X-ray head up to about 50 to 60 degrees now, and that's going to give us that cheek teeth view of the, of the axillary pre-molars. This is a view that often vets will struggle with the structure here that complicates life is the zygomatic arch the zygomatic arch will sit over the root structures.

So if we angle in a slightly, from rosal to caudal as we're aiming towards the sensor, then often actually that will move that diagrammatic arch out of the way and give us a better view of those roots. The next view that we're going to do is the parallel view of the mandibular premolars and molar. So we're going to place the sens between the tongue and the bone of the mandible, and then we bring our X-ray beam down so that it's coming in perpendicular to that X-ray sensor, and that's going to give us the mandibular premolars and molar.

And then we're gonna do a view of our mandibular canine teeth again, this is a bisecting angle view, replace the sensor balanced on the two lower canine teeth in the centre of the mouth. Usually I'll have the tongue between the sensor and the teeth, and that will just, allow us some cushioning there. It just stops the sensor from moving around so much, and then a bice review of our mandibular canine teeth.

That's gonna give us that view. And then for the next view, the sensor is going to stay in the same place, and all we're going to do is elevate the cone of the X-ray machine up to about 15 to 20 degrees now. And that is going to give us a bisecting angle view of the lower canine tooth, so a lateral view of the lower canine tooth, and that gives us often a slightly better view of that third premolar tooth.

Sometimes the apical area of the meal root of that third premolar tooth is, is missing from our, parallel views. So that lateral view gives us, that, mandibular third premolar tooth right in the centre of the radiograph. So you can see that by and large we're not moving the sensor around too much.

The sensor is staying in a very similar position for all of the maxillary teeth, and we're only gonna move it twice more to do the mandible mandibular teeth so. That allows us really to, to move through those X-rays very quickly in order to take those 10 views. I just hope certainly with a lot of practise, you know, you could have those radiographs down to a few minutes.

OK, how are we gonna treat tooth absorption? So, the first we're gonna take our radiogras so this is a very, typical case. Presentation is just doing its own thing at the moment.

So It right again. How are we gonna treat tooth absorption? So if we've got type one tooth absorption, and as we discussed, we've still got our root structures, so we know that this is a tooth that's gonna need to be extracted.

So this is a very typical presentation. We've got teeth here that are covered in calculus, and when we remove that calculus, we can see these are type one lesions at the cemento enamel junction. So to extract cat's teeth, 90% of cat extractions we're going to do via a surgical approach.

So we're going to lift a mucop periosteal flap. So we're going to make an incision along the gingival sulcus around those teeth and then a releasing incision to create a triangular shape flap like this. We're then going to resect.

Retract the mucop perusteal flap out of the way and expose the bone, and then we're going to use our, our b to remove bone on the buckle aspect of the tooth roots like that. So we're aiming to really expose about 50% of the root structure, removing the buckle aspect of the of the bone. Then we're gonna section the teeth, so the maxillary 4th premo tooth are section from the fircation area at about 45 degrees like that, and that creates a little lip and allows us to extract that distal route using an active leverage which I shall show you in a second.

So the other pre-molar teeth, I tend to take a V out. So rather than cutting down to the centre of the tooth, you can see there we've made two cuts in that maxillary third premolar tooth, to take a V out, and that allows me to get my instrument into periodontal ligament space without the crown of the tooth being sat in the way. So take a V out like that makes, getting your instruments in the right place much more, straightforward.

So this is our oops. This is our wheel and axle leverage, which again I'll show you the video in a second. And then for the, remaining roots in, in the cat's mouth, and, and most cat roots, to be honest, we're gonna extract using luxation.

So luxation is where we get the instrument into the periodontal ligament space, and then we're going to advance the instrument down the periodontal ligament space, cutting the periodontal ligament, and acting as a wedge between the tooth and the bone, just compressing the bone slightly in order for the tooth for us to get the tooth loose. This is a fluxation how we go about it, the instrument into the periodontal ligament space and then we tend to rock the instruments around in that periodontal ligament space in order to cut the periodontal ligaments. As we advance towards the apex of the tooth, so they're cutting the periodontal ligament all the way around the tooth, and then gently compressing the bone in order to make the, the tooth root loose.

What we want to avoid doing is applying any leverage forces, any rotational forces, so that that's elevation. If we do that in cat's teeth, a cat's tooth is a very fragile structure. So if we apply too much leverage force to that, then often we'll find that the tooth root will fracture.

Once we've extracted our teeth, then we're gonna smooth the bone, so we use a diamond ber for that to smooth the bone so we've got a nice, smooth area so that we've got no sharp areas of the bone, sticking out through the, the the flap when we suture it closed. Then just a few simple interrupted 50 monocle sutures to close that over. And really important that we're taking post-extraction radiographs as well.

That gives us peace of mind to know that we have taken all of the root structures out. It also gives us a good record to refer back to. So if we have any complications postoperatively, we can refer back to those radiographs and we know that we haven't left any, root material behind.

So this is a little video just to show you how . To extract that maxillary force remote using the wheel and axle leverage. Mm, I can make you book.

So OK, here you can see the sectioning from the furcation here at about 45 degrees. Really important to create that angle that's gonna give us a little lip to hook against our instrument in order to extract the tooth. So sectioning down through the furcation at 45 degrees like that.

And then we're taking our . Elevator in between the two parts of the tooth. I'm just using my fingertips just to rotate the instrument around gently.

You can see as we rotate the instrument around, the root just peels away from the alveolar. So we're taking advantage of the fact that this tooth is a triangular shaped tooth with a triangular shaped root. So if we apply rotational force in the correct direction, then, the tooth is going to come loose very, very quickly.

And we can see that root extracted, so very little force applied to that tooth just using our fingertips, getting the instrument used in the, in the correct way in order to take advantage of the, of the mechanical properties of that instrument. OK, how are we going to treat type 2 resorption? So type 2 resorption again all based on those radiographs that we've taken at at the outset, if we still have vital structures, so if we've still got pulp or periodontal ligament, then our aim is still to extract the roots of that tooth.

But if we've got no vital structures, so if we've got no periodontal ligaments, and we've got no pulp, then it is acceptable to treat the tooth using a crown amputation. We shouldn't be carrying out crown amputation unless we've got radiographs with that tooth demonstrating that this is a tooth that's got type 2 resorption. So here is our radiograph.

We can see that this is a tooth that's got type 2 resorption. We've got no root structures left. So to do our crown amputation, what we're going to do is lift in this case the mandibular canine tooth a little, try and get a shape mop periosteal flap, and the aim here is to expose the tooth, at the alveolar margin.

That's where we want to carry out our, crown amputation. So we're gonna expose that alveolar margin there, and then I'm gonna take my burr and work at 90 degrees to the surface of the tooth there, so we're sectioning the tooth across that the alveolar margin. When I'm using the bur, I tend to go about 80% of the way across the tooth, and then I'll use my thumb actually to break the last part of the tooth off and that avoids me putting my burr into the soft tissues on the, lingual aspects of the crown of the tooth.

And then if you've got any sharp spiky bits of the tooth, then we can just smooth those off with a diamond burr, and then just a few sutures just to close over our, our crown amputation site. So crown amputation, if we've got those radiographs, it's a really nice procedure to do, it's very quick, so 5 minutes only really to do that crown amputation, which is a big difference to trying to extract, certainly man can on tooth like that with no root. OK, just looking at some conclusions for that.

Paradon disease has our reversible and irreversible stages. If we can treat the tooth during those reversible stages, then we may be able to avoid tooth loss or extraction. Once it's progressed to the irreversible stages, then salvage of the teeth becomes much more challenging and certainly we can catch for thinking much more about extracting the teeth.

Assessment of the periodontal disease requires a nice methodical approach, using our dental examination and also dental radiography. And treat option often seen along with periodontal disease, needs to be assessed in all patients being presented for dental treatment using our full mouth dental radiography as we've discussed. Matthew, that was, that was excellent.

I, I really, really enjoyed your, dental X-ray positioning techniques. I, I'm sure I speak for a large percentage of vets to say that it's a nightmare positioning, cats, dental, X-rays and everything else. But, those techniques you showed us now were absolutely fabulous and, and looked very, very simple.

It's just, as you said, a little bit of practise and we should be able to whiz through them. Absolutely, it's all about practise with cats. The nice thing about cats is that is that they're anatomically very similar.

So once you get a good technique, a good system to take your own grafts, actually it's, it's, it's very quick to take the radiographs. So it doesn't really add anything onto your anaesthetic time. That's something the vets always bring up is that it adds a lot on anaesthetic timer certainly when you start doing it, it does, but once you've got, got the technique, it's, it's a very quick procedure to do.

Yeah, yeah, no, it is, and, and, . I, I know I'm going to go back and watch those X-ray techniques a number of times. I'm sure most people will do the same thing because there's just, there's always little nuances to them.

But yeah, it's great. One of the comments that's come up in the, in the chat box is amazing webinar and adding the video of the extraction was a really nice touch. Thank you.

So that's, that's great. These are, sorry. So so that that technique is a really useful one.

It's, it's almost foolproof. You can never say anything is foolproof, but certainly sectioning the tooth like that and using that with an actual leverage on the distal route to that broad premolar tooth, it almost always works. It's such an easy technique to use.

Yeah, I, I, I. I didn't particularly like your, your comment to use your fingertips because I use that technique. And if you're in a bit of a hurry or if you've, you've got that, that elevator in your full fist, man, you get that horrible crack sound every now and again and then you realise, 00, I'm going too fast.

Yeah, absolutely, patience, definitely the virtue of dentists. Yeah, yeah. Lisa wants to know, could you please give us access to those feline dental charts?

They are so much better than the ones that they currently have in their practise. Yeah, absolutely. I mean, if anyone wants the dental charts, then they can certainly email me and I can email those back out.

Dental charts were developed by, Davis, University in California, and they're happy for those to be shared, so. I can certainly send those out for, or if you, if you email it into one of them at the webinar it out to all the participants as well. Yeah.

You're only sending one out and that can be distributed that way. Emma, thank you. Emma was asked a question.

She said, can you perform adequate radiography without a specific dental radiograph machine and intraoral films as we have neither in our practise. The simple answer is, is no. I think it's very difficult to take skull radiographs and be able to interpret them from a dentistry perspective.

Always when you take a radiograph of a skull, even if you're doing oblique views, open mouth views, and that sort of thing, always. It's, it's difficult to interpret the teeth specifically because always you have something superimposed from one side to the other, dorsal to ventional left to right, that makes, you know, even assessing the tooth difficult and never mind sort of assessing the pathology affecting that tooth. The other thing is that you have to be really careful with dental radiograph systems and, and using standard X-ray systems they, they don't really have the resolution for us to be able to assess cat's teeth properly.

The dental radiography systems are much higher resolution, which means that you can assess in particular that periodontal ligament space which in cats is of absolute importance when we're looking for, for tooth absorption. So I think really practises should be. Investing in dental radiography equipment, you know, even if it's just the cats, you know, there's a reason enough for doing that, and it will pay for itself very quickly.

You take lots of radiographs, you see lots of cats for dental treatment, and, it's not a, it's not a big expense in, in setting that up. Yeah, we, we've just put a, a really good system into one of our practises and it costs us about 16,000 pounds to put the whole thing in. And it, it's changed the way the vets look at dentistry and And instead of everybody hiding in the nearest cupboard when there's a cat dental, everybody's kind of now getting to the point of saying, no, actually we can do this, we can do this.

And I'm sure I should these techniques of taking the X-rays, they're gonna be even keener to do them. You know, I think, dental radiography moves dentistry from something that it can be quite unsatisfactory, you know, we, I've been frustrated when I first started out as a vet, carrying out dental work because you never really feel that satisfaction that you're doing a good job where you start to. Take dental radiographs firstly you're assessing what pathology is there, then you know that your treatment that you've carried out is, is, is good stuff.

So dental radiography for me is where the satisfaction in dentistry comes in and more people are doing it, and the better as far as I'm concerned. Yeah, and, and we've, we've added it as a, a standard feature to cat dentals. It's not a, an optional add-on kind of thing like you, you might offer people or discuss with dogs' mouths, with cats, it's a question of, listen, this is, it, it's just got to be done.

It's one of those things. You know, you would never think of a cat dental without an anaesthetic. So, you know, just discuss it in those same lines with the owners.

Exactly the same. I mean, if you're fixing a fractured leg, you wouldn't attempt to fix that without a radiograph to start with or a radiograph to finish to see what the fractured repair was like exactly the same situation with with dental radiography, you're just in the dark otherwise. So I, you know, if you've got it, I don't think it should be optional.

It should just be, you know, built in with the way that you charge for your procedures. Yeah, yeah, absolutely. Rob has just posted an interesting question.

What is your opinion on handheld dental machines? Bentley radio coffee machines, well, I, I use one, there is, the, the, the nomad, as far as I'm aware, is the only one that is, health and safety approved in this country, so as far as I'm aware that's the only one that. That we should be using, from a health and safety perspective, but as long as you take sensible precautions and certainly speak to your RPA, about how to go about that, handheld radiography should be, should be safe.

Yeah, and, I mean, again, in one of my practises, we've got a, a nomad, and the only frustration I find with it is, if you take an X-ray and it's just slightly off and you want to change the position ever so slightly on a wall mount or one that's on a stand, it's easy to tweak, whereas the, the nomad, you got to kind of try and remember which angle you had it at. Yeah, absolutely, it's the same with CR and DR systems, you know, the DR systems for me are, are much better because everything stays in the same place when you're taking your radiographs. It makes it very easy to make little adjustments with the CR.

You're taking the film out of the mouth to process it, and you've got to have that in your mind if you want to reposition. Yeah, yeah. Well, that was absolutely fascinating, Matthew, and thank you so much for your time tonight.

I, I'm very pleased that you persevered through all the technical issues before we came on air. And it's really, it's so, so great to have a webinar that passes over relatively simple tricks and techniques to make our lives better and thereby improving the, the care and the life of our patients as well. So thank you for your time.