Hello, welcome to my talk on geriatric dentistry. I'll just give a little introduction about myself. So, my name's Ellie.

I'm a qualified equine vet. I qualified from the University of Liverpool in 2014. I've been working in equine ambulatory practise, and I've just moved to a dentistry specific job.

I passed the Beaver BADT exam in 2019. Because dentistry's been an interest of mine for quite a long time, and I have just this year started my postgraduate certificate. So why does dentistry matter?

The dentistry matters because there's, well, for one, there's a large economic opportunity. The UK herd last recorded in 2019 is nearly 850,000 horses. According to a study done in the last 10 years, about 80% of UK horses receive regular dentistry.

There's approximately 3000 registered equine vets in the UK and only 220 EDTs. So 220 EDTs are probably not treating 850,000 horses per year. So there's a lot of work left for equine vets.

Dentistry is also really important for welfare. If we consider the five freedoms, hunger and thirst, you can't eat if you have bad teeth. Discomfort if your teeth are painful, you're gonna be in a lot of discomfort.

Pain, injury and disease, again, by managing dental pathology, preventing dental pathology, improving dental pain, you're gonna make a big difference to that. Express normal behaviour. Horses, it's normal behaviour for horses to graze.

They graze typically for 14 hours a day. And if their teeth hurt, and they can't do that properly, potentially there's gonna be frustration involved in not being able to eat and fear and distress. Potentially that one a little bit less, but, I mean, 4 out of 5 is still under a pretty large impact on welfare.

The prevalence of dental disease is actually really quite high. And tends to be underrecognized and underreported by owners. In a study done comparing owner reported problems to vet found problems, there was a prevalence of 95% of dental problems in horses over 15 years old, but only 25% of those horses had dental problems, dental problems reported by the owners.

So 70% of horses had dental problems missed by the owners. On top of that, geriatric horses in this study were found to be less likely to receive routine care. So education is really important for owners to educate them on the importance of routine care and keeping up with it.

And also that the horse is highly likely to have a problem, even if they show no clinical signs of that. And the only way to know is to look. So what equipment do you need for your dental appointment?

I'd say the essentials are definitely your dental motor, preferably a dental motor over hand rasps. It's gonna be a lot harder work if you're only using hand grasps. Definitely a light source, a dental mirror, a pick and or a probe, sedation.

As we suggested already, pathology is a lot more likely in older horses, and particularly for subtle pathology, it's gonna be a lot easier to pick up, if the horse is sedated. On top of that, horses with dental problems, you know, their mouth is probably a lot more painful, so they might be a lot more resistant to a dental exam. So sedation might be required to make them amenable.

And personally, for me, if a sedate horse is sedated, you know, it's, your life is a lot easier if they're on a headstand. You're not going to be doing the best job if you've got a heavily sedated horse and you're having to hold it up and, or the owner's not going to be very happy if they have to hold it up. So yeah, a headstand's definitely a worthy investment.

Your ideal extras, they asked him a flush, you know, all the horses, lots of they asked them a lots of food packing. The best way to get all of that out is with a flusher, alligator forceps, again, to help remove any food packing. And I'd quite like to have a pair of, pony forceps in my dental kit.

Really useful for, you know, younger horses to remove caps, older horses, any sort of really quite loose teeth that just won't quite pop out with you grabbing them. It's really useful just to get a pair of forceps on, and a lot of loose teeth will just pop out with those. So I sedation really necessary?

In my opinion, yes, it is. It enables a full and complete oral exam, particularly as the there's higher incidence of dental disease in geriatrics. Also, of course, sedation adds analgesia, so make these horses more comfortable during and after your exam.

And I really think as vets, it's the one thing that sets us apart from EDTs. You know, we're all qualified to look at and treat teeth, us a lot more so than EDTs. We are a lot more qualified.

I think sometimes it's difficult to get owners to accept that. But, you know, if we're not using that one point of difference, then, you know, I really think we're missing a trick. It's also a lot safer for, for you, for the horse and the owner, and yet allows any painful conditions to be dealt with without sort of major resistance from the horse.

So the dental appointment, I think it's a really good opportunity, given that these horses are probably seen less often by the vet to, you know, do a full and complete exam, take a full history, try and identify any other problems, particularly their vaccination status, you know, often owners. And not competing these horses anymore, maybe not riding these horses so much anymore, so they don't think vaccinating them is important. And I think a lot of owners don't think about tetanus vaccines.

They just think the horse isn't going off the yard. It doesn't need a flu vaccine, and they completely forget about the fact that it's probably then not also having a tetanus vaccine. So if this horse has got a problem, it's not been treated for a while, I'd say there's a fair chance it's tetanus vaccines have lapsed.

And if it's got problems in its mouth, it's got sores, you're potentially extracting teeth. Tetanus vaccination is really quite important. So I'd definitely be looking to restart tetanus vaccines, asking the owners about any weight loss.

A lot of, like, progressive slow weight loss, you know, they might not have, noticed that. Like, I get a lot of owners tell me that the horse used to be a good doer, and now they're having to feed it a bit more than they used to, and they think that's just an age-related problem. Actually, you know, maybe this horse isn't masticating as well anymore, not eating as well anymore, but it's not quitting.

So the owners don't really notice that. Quitting, I find owners get really confused between the horses just sort of partially dropping food out of their mouth versus actually balling it up and spitting it out. I always think it's really useful to have a look around the stable or over the door and actually see if there's quidd material around.

Eating more slowly, you know, that's definitely a more subtle sign of dental disease or, you know, progressive dental pain that they're not eating as quickly, you know, they have taking a lot longer to chew food. And not finishing their hay net, that is a big one, particularly for incisor pain. And sometimes the only indication that they have incisor pain, because they're struggling to grab and pull food out, particularly when the hay net becomes less full and they're relying more on their teeth to grab at the hay.

Like I say, a full health check, you know, check them for any murmurs. Definitely, Cushing's is a big one. In these older horses, if they have a lot of dental pathology, you know, potentially they have a lot of wounds that might need to heal in their mouth, and, out of control, Cushing's is obviously gonna slow that down or prevent that.

So the dental exam. I always start with an external exam once the horse is sedated. Examine its external head, so you want to palpate the pole, the TMJs, look for any pain or effusions.

Look at the masseter symmetry on their forehead, you know, potentially, like this is a really good example of asymmetry, quite marked asymmetry. Probably in this horse that was secondary to pain. I believe I saw this horse a while ago.

I believe it had quite a painful problem and quite a bad sheer mouth, so it had basically stopped chewing on one side, which is why the muscle had atrophied over a period of time. Potentially this can happen probably to a lesser degree than this, secondary to Cushing's. Potentially as well, secondary to, TMJ osteoarthritis.

They might find it a lot more difficult to move one side than the other, and any other painful condition, whether that's intra or extraorally. And then palpate the mandibular and sublingual lymph nodes, looking for any effusions, any indications of inflammation or infection, palpate down their cheeks. Particularly for maxillary teeth.

Some lesions can be quite subtle, looking at facial symmetry. So, this horse, this horse was only 15. And there is a subtle asymmetry there, which was difficult to fully appreciate until the head collar was removed.

This horse had a quite a wide noseband on its head collar. So when I took the head collar off, and I found this lump, which was actually just some edoema, asked the owner how long it had been there, and she had only just noticed it when I pointed it out to her. This horse had a, I think it was a 209 infection with edoema overlying it.

Which was quite painful to palpate, and there was no sign of that in the mouth. It was only because of this subtle lump that we found that. So, external exam is always really important to do before putting the gag on.

As well, you know, look for any nasal discharge, any foul smell, not just of the nasal discharge, but also from. The mouth in general can give you a good indication if there's any food packed in there. So before placing the gag, you've done your external exam, always do an incisor exam as well and look at the canines.

For the incisors, you're looking if they're all there, any excessive or abnormal wear, are they loose? Is there any pain on palpation, and is there any tartar accumulation either on the incisors or the canines? An assessed movement of the jaw before you do your, your dental.

It can give you an indication as to whether there's anything more going on in its mouth. And also, it's really good to have an idea of what you're starting with, to have an idea of if you've changed it. It's a place that like flush the mouse.

I've seen a lot of EDTs working on horses where they haven't flushed the mouth. And, you know, realistically, you can't do a proper oral exam if there's food everywhere, because if you can't see the teeth, you just can't examine them. Palpate the teeth.

I always do this before I have a look in the mouth, just to get an idea of what's going on, how much I've got to do. And I always find, as soon as you've opened the gag, owners ask if there's anything wrong before you've even looked. So I think palpating the teeth is a really good way just to get an initial idea as to what's going on.

And then a mirror exam, you know, get your horse on your headstand, have a look. You know, you really need to be examining all surface, all surfaces of the teeth, you know, particularly looking at the occlusal surfaces, looking for any, infenddibrar lesions, any pulp lesions. And then looking for, you know, the incidental spaces, looking at any peripheral caries, you know, all of that.

So anatomic changes with ageing. Horses obviously have hips that aren't teeth. They continually erupt throughout their life, which means that there is a finite length to the tooth.

So eventually, if they live long enough, they will run out of tooth, which, you know, for these really older horses can be to their detriment. The teeth taper from the occlusal surface to the apex. So, as they're getting older, the cross-sectional area of the teeth does get smaller, which can lead to secondary problems like diastoma.

And, you know, then secondary to diastoma, they can get food inactions, periodontal disease, all of that, which we'll go through in more detail. So normal anatomical changes. The normal occlusal surface of equine teeth are made up of enamel, cementum, and dentin.

These, three things wear at different rates. They have different durability, and this normally causes the formation of transverse ridges, which is normal. Transverse ridges increase the surface area of the teeth, they aid with grinding.

As the tooth ages and the enamel unfolding becomes less, there's less enamel in the centre of the tooth, so these transverse ridges tend to disappear in older horses, and this leads to senile excavation or cutting out. This is a normal change, but it can be confused with pathology, particularly with infandibular caries. You know, the infantandibula don't last the entire length of the reserve crown.

Eventually they will wear out. And particularly where referrals are concerned, this can lead to a source of confusion that, you know, people get confused that normal senile excavation or cutting out is actually infindibular caries. The main way is to tell the difference, whether it's normal or not.

Is, to get your pick on it, like, normal, senile excavation is probably gonna be quite smooth and glassy, even if it's quite discoloured. Whereas Carey's lesions are probably, you know, like more gritty and pitted. So the, your probe will sort of grip into them a lot more, whereas you can just sort of glaze it across a normal senile excavation.

You know, also, as you get to the end of the teeth, you get pulp amalgamation, which again can make the tooth look discoloured and start to make it look abnormal compared to younger teeth. It's completely normal. .

And yeah, your peripheral enamel will last until the junctions of the roots, at which point, once your enamel completely wears out, then you're generally left with a smooth mouse. The other thing to note with sort of normal copping out teeth is if they've been left untreated for quite a long time, if you've got no enamel left in the centre of your tooth, And you're just left with that sort of thin enamel ring. Those teeth can be some of the sharpest you'll ever see, because the enamel literally wears into like a razor edge, and if you get a bit of a sharp point on that, these older horses can end up with pretty horrendous ulceration, .

So I think at vet school, you know, we're always told to leave as much on these older teeth as we can, but actually, you know, reducing sharp points is really important to maintain comfort. Of these horses, and you know, making sure the teeth are really nice and blended in. So common geriatric pathology, wear abnormalities, as we've just discussed, you know, their teeth can start to wear differently, once they're copping out and they're getting aged.

Also, as you get to the end of . The reserve crown, you know, in younger horses, you've got the opposing angulation of your sixes and your 10s and elevens. As the teeth grow out, this angulation becomes less, which can lead to secondary wear problems like wave mouth, diastoma, cross sectional area decreases, you.

Increased incidence of diasthma in older horses, periodontal disease, secondary thasthma, loose teeth, excessive wear, overgrowths. EOTRH, which is quite a big topic of this talk. Incisor pathology, incisors, aged incisors can be quite prone to excessive wear.

After about 13 to 15 years, incisor eruption stops. And then wear continues. So actually, all the horses can end up with pretty worn incisors, as the crown length isn't continuing to be replaced.

Obviously, incisor eruption happens at different times. So the central incisors erupt, you know, 2 years before your corner incisors. So your central incisors will start to wear first.

I call this riding on the corners because as you can see in this horse. You've got gaps through your ones and twos, and then all the occlusions being put on the corner of the threes. It's a bit more obvious from the side angle.

You know, obviously, in terms of short grazing, this horse can't occlude its central incisors, so it can't grab at grass. Most horses will completely cope with this because they, it happens slowly, so they'll adjust to it. But if you get less severe cases like this, I quite like just with, An enamel, in inside the handpiece, just to reduce the corner incisors and reduce the angle to try and increase the occlusion across the incisor tables.

So in this horse, he's actually a little bit higher on his lower 03. So I'd probably just knock this back a little bit and then maybe just reduce the angle of this corner. You're probably not going to get perfect occlusion from doing this, but I think you'll improve it, and I think that will help the horse ultimately.

So, equine odontoclastic tooth resorption and hypersementtosis, otherwise known as EOTRH. I think previously this has been considered to be a fairly rare disorder in horses. I think actually, as we're gonna discuss, it is pretty common, but it's just underrecognized.

In a study of 142 horses in Germany. At least mild radiographic changes were identified in 94% of horses over 10 years old. And moderate to severe changes were identified in 62% over 10 years old.

And in horses over 20 years old, moderate and severe changes were identified in 81%. I think we can conclude from that, it is not a rare disease. It is a very common disease.

And I think once you start looking for it, you'll start seeing it a lot, particularly in your sort of late teen, 20 plus year old horses. It doesn't mean you need to treat it a lot, but identifying it is the first step. The clinical signs for the OTRH, what are we looking for?

It can be associated with various signs of, or varying the signs of oral pain. Some horses, I think, are really painful with it. Others can have pretty severe changes and not show clinical signs of pain.

But the main signs of pain that you're looking for are weight loss and decreased appetite. This is, I think, particularly where your hay nets come in. Sometimes the only signs of pain you'll get is that they're not eating as well out of a hay net anymore because they have to grab and pull, particularly with your small hole hay nets, and that's what they'll find painful.

You can get periodontitis and periodontal pockets, secondary to this from Like they'll start to get in incisor diastoma which can accumulate a lot of necrotic food material which can pack into the periodontal pockets and cause a lot of pain. You can get gingival hyperplasia and recession. Bulbous enlargement of the dental structures, tooth mobility, fractures, and sometimes by the time you find it, they'll already be missing teeth.

And calculus accumulation. This is a pretty good example of calculus accumulation. Calculus accumulation in these cases is probably a sign of pain that they're not using these teeth properly.

And as they're not using them, they're not wearing the surface, so they get a bigger and bigger biofilm, which then, secondary, happens before this plaque accumulates or, you know, provides the foundations for these plaque to accumulate. Once the plaque was removed from this tooth, you can see actually this horse had. Mild to moderate, gingival recession and actually fairly significant gingivitis secondary to that plaque.

And this also had plaque accumulation across all of its teeth. All of its in sizes anyway. This is the same horse, again, you can see here the gingival recession, and also the gingival edoema in inside the diastoma starting to develop.

He at least did not have bad food packing between his incisors. Again, these bulbous enlargement, you know, part of this disease is the hypersementosis. So potential enlarging and thickening of the tooth roots, which you can get this, like, really sort of, like lumpy bumpy looking tooth roots, thickened tooth roots.

Again, this is pretty severe gingival recession. And you can also get these carious like lesions on the surface of the tooth. I think this probably happens from the resorption, while the, reserve crown is under the gingiva, and then as the gingiva recess, that's when you see them more obviously on the surface of the tooth.

You can see also in this horse he's probably had some bone resorption, you know, you'd probably expect your alveola bone to come down to somewhere around here, . And you can also see here where he's got this gingivore hyperplasia, like that gum's really quite thick over the surface of the next tooth. Again, you carious like lesion.

This horse had obviously sustained quite a lot of damage before this ginger recession had occurred. This was actually just quite a lot of necrotic food material packed into the tooth. That's once it was, that necrotic material was removed, at least most of it was removed.

I did X-ray this horse. I don't actually have the X-rays to hand unfortunately, but this tooth basically, like the root was completely moth eaten, to the point that I'm surprised it hadn't already fractured off. I think it was not very far away.

I did extract the tooth, and basically the root just came out in bits. I almost just snapped the crown off and cured the alveolus, the socket just to remove all the bits as much as possible. This is another horse where, you know, basically it had already had the crown fractured off, .

So here, just the, the remaining route was extracted. But you know, this shows what can happen if they're left, and more severe severe changes are left to occur. This is a video.

So this horse is a 28 year old Arab. He had received regular dental treatments. He'd had a lot of other dental disease before.

He'd had a couple of cheek tooth extracted. He'd had some diastoma managed. You can see he's got a pretty severe slant mouth, and basically all of his incisors were loose.

Over the six months prior to this exam, he had had significant weight loss. So, basically, I concluded by this point that, you know, probably these incisors were causing him a problem. His cheek teeth were not too bad by his standards at this point.

I'd say ideally in his case. Potentially, you could remove all of those incisors. They're all causing a problem.

You can see there's extensive, you know, gingival recession here. Again, this gingival hyperplasia around the teeth. He didn't actually have any obvious sort of draining tracts, which they can also get.

If we could go back to earlier in the video, he had already lost some of his upper cheek teeth. Upper incisors, sorry. He'd lost two of them.

So basically, what we did in this horse was we extracted all of his lower incisors, which is something that I've done a few times before, where cost is an issue, or, you know, if the horse has got other problems and they don't want to put them through too much. And sometimes you might only get, you know, enough sedation and analgesia to get half of the teeth extracted in one go. So we started off with his lower incisors.

These are all 6 of those that were removed. And actually, in the following 6 months, he improved loads, because at least with the lower incisors gone, there was nothing to rub on the upper incisors and make them pain, like cause him pain frequently with those. I think realistically, even with the lower incisors gone, the disease is going to progress in his upper incisors, so he may at some point have those extracted, but it can be a pretty good, pretty good compromise to remove just half of their incisors.

So the diagnosis of the OTRH I think in a horse like in that video, it's fairly obvious what's going on just from clinical signs, but he was probably also, you know, a more advanced case, . You'll definitely see radiographic changes in most cases before clinical signs. The radiographic changes you're looking at, there's various grading systems, but basically, you're looking for dental resorption or lysis of the roots, possibly hypersementosis, so thickening.

Hypersementosis doesn't happen in all cases, and it's thought to be the body's way of trying to repair the damage after resorption. Some horses will get it pretty spectacularly, but I'd say in a lot of cases you might only see resorption without hyper without obvious hypersematosis. You might see a loss or widening of the periodontal ligament space, loss of alveolar bone, potentially osteomyelitis, and tooth fractures.

This is one grading system. That I've taken from Roy at all, which was, adjusted from Heelsaal. So grade 0 or normal was no no radiological changes.

Mild, with, you know, preserved tooth shape, a slightly bunted root. Irregular and slightly rough surface, moderate, it's sort of progressed to less, preservation of the tooth shape, but it's still largely there. And the intra-alveolar tooth part is not wider than the clinical crown, which is quite important when considering instructions that, you know, the whole tooth can still fit through the bone socket.

And moderate teeth had an obviously blunted tooth root. 3, there's severe loss of tooth shape. The intra-alveolar tooth part is wider than the clinical crown.

So these are probably more difficult to extract because you're not going to be able to fit the tooth through the hole so easily and potentially tooth fractures. So these are some X-rays to demonstrate that. So the top two are.

Maxillary teeth, the bottom two images are mandibular teeth. The two images on the left show moderate changes, whereas the two images on the right show real severe changes. And you can see from the images on the right, you know, these teeth are probably gonna be a nightmare to extract.

Like if you can get them out at all, they just look like they're gonna crumble as soon as you get an elevator anywhere near them. So potentially, you know, you're better off extracting while you've got more moderate changes as opposed to waiting till changes are really severe. Again, this is just another X-ray showing, again, quite nice changes, like your central incisors.

You've got pretty obvious, blunting of your roots with some hypercementosis. And in your twos and threes, you've got some pretty, obviously lytic lesions. And one corner in size has already been lost.

Again, I think there's an argument to extract all those teeth. The treatment. There is no treatment for ATRH other than extracting teeth.

Mhm It is a painful condition, which is often asymptomatic until severe periodontitis develops, . You can manage it with regular removal of impacted food material, which you can get the owners to do. If, you know, there's obvious in insides of the asthma, I often encourage people to get a very soft toothbrush and just remove any impacted food material sort of once or twice a week.

You can follow that with flushing, with dilute hippy scrub, just to try and kill any bacteria that's in there. To prevent any further damage to the periodontal ligament, but I think the mainstay is really regular monitoring, to monitor them up to the point where they need to be extracted. Which again, you're probably gonna get changes on radiographs sooner than you will with clinical signs.

So I think if you can diagnose the condition as early as possible, then you can manage it, monitor it and. Be proactive with your extractions when you need to. Screening radiographs is something which, to my knowledge, is not widely advised at the moment.

I do wonder if that's gonna change over the next 5 to 10 years, and we'll start, you know, taking screening radiographs of horses anywhere between age 15 and 20. . I think if you're suspicious that sort of mild to moderate changes are occurring and particularly if you're starting to see subtle signs of pain, I think it is worth taking radiographs.

Even if you don't end up extracting teeth at that point. I think it's really useful to have a baseline of, what the teeth look like. And then if you end up getting, you know, progression down the line and you end up re-adiographing, you can at least see how quickly the lesions have progressed, because, like I say, you're gonna see a lot more on your radiographs than you will see clinically.

And I think that can really help inform when to extract if it's rapidly progressing, then, you know, potentially you need to be extracting these teeth sooner rather than later. Yes, the indications for extraction. Any severe radiographic changes, you've probably got an argument to extract those teeth, particularly when you get, to inflammation in the bone and signs of osteomyelitis, .

If you have extensive absorption of the reserve crown, any severely loose teeth, those teeth are probably really quite painful, . Any severe signs of clinical pain and any fractured teeth are all worth extracting. I don't have a slide on it, but just talking about X-rays, these X-ray views are really quite simple to take.

They're basically an in put the plate in the horse's mouth and do a, you know, top maxillary teeth, do a DV shooting down, mandibular teeth do a DV shooting up. One thing to say with these X-rays is, it is worth investing in something to some kind of gag. To put in the horse's mouth to prevent the horse biting on the plate.

When I was first getting into X-raying incisors, I spoke to Chris Pearce about a case, and, he said he had, a particularly well sedated pony that somehow managed to wake up enough to bite his, X-ray plate hard enough to completely break it. And it cost him more to replace the plate than it did to buy the X-ray system in the first place. You can get, plastic bike plates that you can put in your gag, just take the metal ones out and put the plastic ones in.

They're almost completely. Radio Lucent. So you just pop the gag on as normal, open it a couple of notches enough to fit your plate in, and then there's no risk to your plate.

I'd always sedate horses to do this so that they stay still. You still don't want them throwing their heads around and causing other damage to your plate. That's one option.

You can get various other blocks that you can sort of put further back that they can bite on, so they can't bite on the plate. And if all else fails, you know, putting something like a towel or something in their mouth just to keep it open. But I think if you're gonna start doing a lot of these, I definitely think about investing in some plastic plates for your gag.

They are really quite useful. You can get those from Eine Bas Direct. They started selling them and also from the extras.

So how do horses do post extraction? The vast majority of horses do really well immediately post extraction. You know, over 70% of horses after incisor extractions have no adverse effects and can eat and graze normally post extraction.

You know, some horses, even having all their incisors removed. So long as they're on longer grazing, they can just grab it with their lips, so they can still go out and graze. Extracting painful incisor teeth can have a massive positive effect on a horse's quality of life.

I've definitely heard of a few horses that, you know, have become, you know, quite slow, quite dodgery. They look a bit stiff, you know, they're not as lively. They have their painful teeth extracted and they're acting like 5 year olds again, just because they're no longer in chronic pain.

They're generally treated for 7 to 10 days with non-steroidals and antibiotics. There's no significant difference between what non-steroidal and what antibiotics, . And then, you know, as soon as the surgical site's healed, they're away.

A few horses, you know, up to 30% may struggle or show signs of pain, but generally these resolve as soon as the surgical site's healed. So what can we do diet wise to help these horses while we're managing them before extractions? Their incisors are basically used for food apprehension, getting food in.

Once they've got food beyond their lips, you know, they're they're masticating with their cheek teeth and sizes are not involved in that. So we basically just need to make food apprehension easier. As I've already mentioned, you know, hay nets, ideally, you want to be feeding hay loose, either on the floor or in a hay bar, so they don't have to grab and pull.

Again, with grazing. If, if possible, put them onto slightly longer grazing, slightly better grass. Or if that's not possible, there's only short grazing, then supplement with alternative forage, hay in the fields, or, you know, buckets of soaked fibre, whatever is possible.

Moving on to the cheek teeth. Common cheek teeth pathology, sasthma, secondary periodontal pockets, wave mouth, step mouth, smooth mouth, sheer mouth, displaced and loose teeth. As we've mentioned previously, the cross-sectional area of teeth starts to decrease, which predisposes horses, all the horses developing diastoma.

These often start as valve asthma, so they're a lot tighter at the top than they are at the bottom. You know, often with these, you get food packing just around the base of the teeth. These can actually be some of the worst, most painful diastoma because the food packs so much more into the gingiva and creates periodontal pockets.

I think regular. Treatment of these, regular removal of food, you know, correcting any web abnormalities, reducing pressure on these diastoma. In the vast majority of cases, I'd say you'd get away without having to widen them, because eventually, as the clinical crown continues to grow out, they will widen themselves.

So I'd say the main issue with these is managing the food packing to prevent irreversible periodontal pocketing. I think if you're getting into real severe periodontal pocketing, there may be an argument for partial widenings just to reduce that pressure, but I'd say in most well managed horses, you can get away without. So they asked them a treatment, I would say flush, flush and flush again.

I know some vets who flush pretty regularly, like once a month. I think there is a balance between, Flushing to remove food material and allowing the gums time to heal between treatments. So my preference would be 6 monthly treatments.

In maybe in particularly bad cases, you might move that to 3 to 4 monthly treatments, just to keep a real closer eye on them. But yeah, I'd say in most cases, 6 monthly is adequate. So once you've flushed out all the food material, you want to contour the teeth.

I think having a nice small apple core really helps with that to round the teeth in to the diastoma, just to reduce food pressure going in. Any opposing ridges obviously reduce those to reduce the pressure down. If you have one particularly bad one, you might even want to consider reducing the opposing tooth slightly out of occlusion, just to give that diastoma a break, give it time to heal.

Again, widening or partial widening, . I suppose if you don't do a lot of dentistry, you might not have the equipment to do that. You basically just need the little diastoma bus to put on your apple core.

. You can always refer to do this, but I'd say if, you know, as long as you've got a decent dias and a flush, you probably don't need to. Temporary bridging, so packing. With, some dental putty.

I think there's definitely some cases where this is useful, particularly if you're not getting on top just with flushing alone. And then, you know, in more severe cases, maybe looking at permanent bridging, or maybe even extracting teeth just to reduce pressure. But I'd say that's, you know, most cases, you don't need to do that.

Flushing and regular flushing alone will be sufficient. Periodontal pockets happens secondary to the asthma. These can be extremely painful.

And I think the one thing about them, you know, if you've got a dental mirror, they can be extremely visual for owners. You know, if you've got a big deficit in a gum with a lot of bleeding, you know, that looks painful to owners. So it makes them pay a bit more attention to what you're doing.

You want to try and get as much impacted food material out as you can. Again, a diastoma flush is, can be a really useful thing for this. A pick, alligator forceps, sometimes even a K file can help get any little bits that are stuck in there.

You know, definitely, if you're considering any kind of packing, you want to make sure all food materials removed first. And if you haven't convinced yourself of that, you definitely shouldn't be putting any packing on because you don't want to steal any food in there. In really deep lesions, you could consider packing the periodont pockets with metronidazole as an antibiotic, .

Again, I think, you know, if you're catching these lesions relatively early, in most cases you can probably avoid that, . And, you know, especially in non-healing cases, if you're seeing them regularly and they're not resolving, definitely consider Cushing's as an underlying cause for lack of healing, or if it's already on Cushing's medication, just checking whether their blood levels are at and making sure it's still under control. Smooth mouth, so as we discussed, hipsodont teeth, they will eventually wear out or expire and you're just left with like cemental knobs and on the gingival surface.

This won't happen all at the same time, you know, upper teeth will expire before lower teeth or vice versa. So often once you start to get exploration of teeth, you will get opposing teeth overgrowing. These overgrowths really need to be managed.

Because they will lead to a step mouse, Large steps need to be reduced. I often find that just a large step alone, without any other obviously painful lesion is enough to cause some horses to quit. I basically think, think of a horse's teeth like a conveyor belt.

So each pair of upper and lower teeth works as a functional pair. And I always describe to owners that they pass tooth from one food to the food from one set of teeth to the next to the next to the next. So if, say you get a massive.

Lower 09 step, you've passed food from one food, one tooth to the next, and all of a sudden you've got this big barrier in the way. So once the horse's mouth is closed, there's not that much space around its teeth. So often it's just as easy to spit that food out as it is to try and get it over the step.

So if by reducing that step, allowing food passage to continue, you will stop a lot of quitting just by managing the step, . Obviously, the other really important thing is. If you get a massive overgrowing crown on, in an aged horse where there's not as much root left, you'll have a lot more mechanical forces on a long crown, which puts a lot more pressure on the periodontal ligament, which can cause the periodontal ligament to break down and that tooth to become loose.

So often if you have a really overgrown tooth in an older horse, it probably does have a bit of movement in it. So getting that tooth reduced, reducing those forces on the periodontal ligament. Can go a long way to letting that tooth reattach.

Obviously we need to be a little bit careful about over reducing teeth. We don't want to be exposing pulps. So often you're gonna have to have a staged approach, doing this every six monthly, .

You know, monitoring the surface of the tooth with your dental mirror while you're doing it, checking that your pulps are staying nice and dark and as soon as they get lighter or start blushing, turning pink, you definitely want to stop by then. Sheer mouth, so one, side a lossal angle a lot steeper than the other, . I think these can develop from historical problems.

So just because you have a sheer mouth doesn't necessarily mean that the horse still has a really painful lesion. You know, potentially that painful lesion has resolved. But the horse's movement might have become blocked, so it's not, it's continued to not be able to eat on one side of the mouth, just because it can't physically move its jaw in that direction.

. Or potentially, you know, it could be an extra oral, cause of pain like a TMJ, osteoarthritis, as we discussed at the beginning. Again, you wanna try and reduce those occusal angle on the sheer mouth to get that, increase that movement again. Again, that might have to be staged over time.

But it's surprising how, even where it's not perfect, by reducing the angle and removing the sharp points, you know, you can actually really increase their movement. I think it's really important if these horses were really blocked before and you've really changed the amount that they can move. I think.

That difference. Can be quite painful, you know, the muscles are moving in ways that they haven't been moving for a while. Their joints exposed to a much wider range of motion.

You know, potentially these horses can be painful post-treatment. So it is worth considering giving them sort of 5 to 7 days of, non-steroidals, it's fine. Just to keep them comfortable while they adjust to their new range of motion.

Wave mouth. It's quite common in geriatric courses, they can be pretty severe, it can be unilateral or bilateral. I think you have to be a little bit more cautious with severe waves in geriatric courses, and you need to be mindful of the fact that you might only have a limited amount of reserve crown left.

The main aim is to maintain occlusion, . But to increase mastication and movement. So you do want to aim to improve the wave and definitely blend the wave, so that as we say, we don't get like a major step where food can't.

Passo. But probably want to avoid being heroes and getting it back to a flat level, balanced mouth. I think, you know, if they're so far gone, that's not realistic.

It's not achievable. And it's more important that we keep the eating. Again, we're probably looking at stage reductions every 6 months.

Again, as the wave develops and you get altering mechanics on the teeth, you are quite likely to develop secondary diastoma, and other problems. So by reducing those pressures, you know, you can prevent or, secondary problems or manage secondary problems. It's quite a nice picture here.

You know, basically explaining the vicious cycle, you get maleclusion, uneven attrition, and the problem just perpetuates itself. So we want to try and get these horses out of that cycle as much as possible. So, you know, on this horse, definitely be looking to reduce that, those lower, 910.

That would probably help to resolve that 10-11 diastoma, and increase the range of motion. Of that horse's jaw. Loose and displaced teeth, again, quite a common finding in old horses.

Some movement is acceptable. 1 to 2 millimetres is normal. I particularly find in your older horses, you know, you might have a go palpating all the teeth, and you don't really feel like any are significantly loose.

And as soon as you put your asp on them, they're all starting to get a bit of a wobble on. Again, particularly with that, you know, 1 to 2 millimetres of movement, completely fine. It's probably just an indication that they haven't got a lot of root left.

You know, at that point, particularly if one's a bit more mobile than the rest, I've probably warn owners that, that needs to be monitored, and at some point, it's going to get more loose and might need extracting. You know, if you have one that is a bit more mobile than the rest, it might be worth reducing that tooth a little bit. Reduce the crown length, reduce the pressure on the periodontal ligament, it might prolong the life of that tooth, .

Yeah, so significantly overgrown tooth teeth should be reduced. Because the teeth can reattach, and even if you're reducing that tooth out of occlusion. There's still a benefit in keeping it, in that it, you know, provides, functional support for the rest of the teeth, prevents, you know, dental drift and diastoma developing.

So even if it's not doing anything in terms of mastication, it is still probably better if it's not a disease too, to keep it. Significant displacements. I think if you look in a horse's mouth and there's one really displaced tooth, I find the most common is sort of lower 89, 10s.

Even if on initial exam and palpation, it doesn't feel significantly loose, I always wonder with these teeth is the reason they're displaced because they've become loose. . I'd say buckled placements are probably the most common.

Probably secondary to how they're chewing, how they're using those teeth. And it is amazing how when you remove impacted food material, even when you pop a rasp on these teeth, how all of a sudden they start really wobbling away. You know, they've probably been pushed and wedged into a position where they've got a bit fixed, but actually, if you slightly move them out of that position, They can become really quite loose.

I have seen some pretty impressive, buckle ulceration, secondary to these. You know, if they're a bit sharp and all of a sudden, they're jutting into the cheek, yeah, you can get some pretty significant holes. If the tooth is not loose, Then it is worth really rounding off that buckle surface of the tooth, getting your apple core on it to really round out the corners, reduce the pressure on the cheek.

But I'd say, yeah, these really significantly displaced teeth, if they are significantly loose, or if they're causing ulceration that you can't reduce or control, then it is worth extracting them. Teeth with more than 5 mL of movement, so they're really significantly loose, especially if they're causing pain, if you've got quitting. Associated and with no other reason, I think they are worth considering for extraction.

. And I probably wouldn't do that in an otherwise healthy looking tooth until you've got at least that much movement. I've seen a few older horses where, you know, potentially diseased, slightly mobile teeth are extracted that had sort of 2 to 3 minutes of movement. And basically, during the extraction, you're gonna put pressure on the teeth either side.

And again, you're gonna, once that tooth's gone, The teeth either side, I've lost some support. So, you know, I've done some rechecks where a, diseased tooth has been removed. It was slightly mobile, the others weren't.

And then a couple of weeks down the line, teeth either side have got 2 to 3 mil of movement. You know, potentially those will reattach a little bit, they might have just been a bit damaged from the extraction. But, you know, the more mobile the tooth is to begin with, the less pressure you're gonna have to put on it to extract it.

So the main aims of geriatric dentistry are to maintain and or improve mastication er and to maintain and improve oral comfort. So we've just got a couple of multiple choice questions. Oh no, first we've got some diet.

So, the diet modifications that can help aged horses. If they're, they've got, you know, advanced chee teeth pathology, a lot of diastoma, smooth mouth, they just can't grind hay very well anymore. Then definitely replacing part or all of the hay ration with some soaked fibres will really help these horses.

You know, the soaked fibres, they can basically. Swallow, like soup, they don't really need to chew them. I tend to use fast fibre for fat horses because it's relatively low in energy and fibre beat for thin horses because it's relatively high in energy.

I think even if horses are coping well with hay, and it looks like their dentition is starting to fail, I will at least start to talk to owners about swapping some of their hay ration, you know, particularly in summer when there's a lot of grass, the horse might be doing fine, but come winter. When they're having to eat a lot more hay, they then might start to struggle. And obviously, you know, slow diet changes are better than rapid ones.

So even if we start just supplementing them with soaked fibres early on, you know, then it's, the horses got used to digesting that, and over time, as they start to struggle with hay, then they can replace more and more. . I also think, even if, you know, horses have got barely any functional teeth left, if they're wanting to try and eat hay, I'm happy to still let them have a bit.

You know, obviously, they've spent their whole life eating hay. It's quite habitual for them. It's part of their normal routine.

So long as it's not causing them problems like choke, you know, even if they're having a go at it and spitting it out, you know, realistically, they're probably getting through. These soaked fibres faster than they would get through a hay ration, so it's something for them to do, they're still chewing, they're still producing saliva, there's still benefit to that, like I say, so long as they're not getting secondary problems. These thin horses, you know, we wanna probably be giving them a high energy feed, but we don't want to be overloading them with carbohydrates and sugars and giving them laminitis, .

So, my go to's are, Cush care, Keep calm, or is an Excel cubes. The Cush care and Keep Calm, you soak the pellets, and they soak to like a coarse fibre, so it's not quite, like a mash or a meal, but you can add more water to make it into that. But it doesn't, it's already broken down.

It doesn't really require much chewing. These Excel cubes are a relatively more recent addition to the market. They are just a normal cube feed, but you can soak them and make them into a mash, and they are really quite high in energy.

If that is not enough, we can supplement these horses with oil. So you can have up to 1 mL per kilo, to a 500 kg horse, 500 mLs of oil. That is really quite a lot.

And I think it is always a good idea to really, demonstrate that to owners. You know, you say, add oil, and some of them will just give them a tablespoon or two, which is really kind of neither here nor there. So making it pretty obvious, like a litre, they can have half of that per day.

. I think realistically maxing out on that is probably going to make it unpalatable. One feed stuff that I quite like, instead of that is cocker meal, which is basically coconut oil. It's made out of the white flesh of coconut.

Again, you feed it as a mash. It's not a complete feed, but it is really, really high in energy. 15 megajoules compared to, you know, all your other concentrate feeds listed, which are 12.

. But again it's really low in sugars and carbohydrates, so it's very laminate, it's safe, and it smells really nice, it smells quite sweet, the horses tend to really quite like it, so it can be a really useful addition. So, first multiple choice question. Should enamel points be reduced in all geriatric courses?

A. No, geriatric horses have less infoldings of enamel, so enamel should be preserved to aid mastication. B, only if they're causing buckle ulceration.

C. Yes, all sharp points should be removed to maintain oral comfort. D, geriatric horses do not develop sharp points.

The answer is C. Yes, we want to remove sharp points. They definitely still develop.

Like I said, at the start of the talk, some of the worst sharp points I've seen are in these geriatric courses where they've lost their unfolding and the enamel becomes sharper. So even if they haven't got to the point of ulceration, we still want to be removing these sharp points, to prevent them getting there. And I think, you know, even if they're sharp and they're not ulcerated, as they're chewing, they're probably feeling that in their cheeks.

So by improving the comfort levels, we're probably gonna improve the mastication and make these horses eat better just by removing those sharp points. Question 2. How often should th asmata be treated?

A. If there are no periodontal pockets, they don't need to be treated. Impacted food will only be replaced once the horse starts eating again.

B, every month, it's really important to allow the gums opportunity to heal. C, every 3 to 6 months. There needs to be a balance between allowing the gums to heal and trauma involved and flushing.

D. If the if the asthma have not resolved within 6 months, then more aggressive treatment options need to be considered. So I would say C.

Yeah, we want to keep on top of it, but like I said earlier, we don't wanna be too aggressive and cause more damage from the flushing than we're allowing to heal between each treatment. Question 3. Should all loose teeth be removed in horses over 20?

A, yes, loose teeth are painful and will have very little reserve crown, so should be extracted. B, know where possible, dentition should be maintained. Teeth with less than 5 mL of movement should have overgrowths, and where abnormalities are corrected and be checked after 6 months.

C. Only displaced teeth should be extracted. D.

Only teeth with negligible periodontal attachments should be extracted. B As we discussed, if there's some movement, we want to try and maintain those teeth, but once they get beyond a certain point, they're probably causing the horse more harm than good, so then we want to look at extracting them. Thank you very much for listening.