Jim Berry: [00:00:00] Welcome to the WSAVA Podcast. Today's discussion highlights the vital role of veterinary technicians and nurses in improving dental care within veterinary practice. As you listen, consider this, how can the wider veterinary team help influence better dental outcomes? 
This episode features two conversations with veterinary technicians. First, Maggie Burley speaks with Mary Berg about the essential instruments to improve your dentisty. Then Marcella Perez-de-Tudela is joined Stephanie Johnson, who shares her techniques for implementing a successful home care program. 

Let's listen in.

Maggie Burley: Hi there, Mary. What do you think is the most necessary instruments to have in a basic kit so that our practitioners can do a good examination and we can get a really good cleaning done? 

Mary Berg: I think there's a lot of things that go into that. Personally, I love my periodontal probe. I have my special one, and it's a [00:01:00] UNC 15.

The reason I like that probe is that every millimetre is marked. If you're looking at it under a bright light, it's not reflecting and you can read it very easily. And then obviously on the opposite end of most of those is an explorer. I don't think we use the explorer as much in veterinary medicine as we do in human dentistry.

I use it more primarily for checking to see if the pulp is open, possibly a little bit for looking for tooth resorption. The explorer is a very sharp instrument, so I never really want to go below the gum line with that because it will cause bleeding.

The only time I will take it below the gum line is if the point is pointed towards the tooth itself to see if I can feel a defect from potentially tooth resorption or something like that.

Maggie Burley: That's a really valuable point. 

Mary Berg: I think in addition to that, for a periodontal kit is to have a good hand scaler. I prefer a sickle scaler. That's my preference, maybe 'cause I've been using it for so long. It's not something that is a [00:02:00] necessary need. But I really like one that's called the Morse Scaler, M-O-R-S-E.
It is a tiny little scaler. First time I saw one, I thought, oh my God, they sent me a broke scaler. But it's just a little tiny scaler and it's wonderful to get into tight places. Let's say that the groove on a felines canine tooth. It works wonderfully for that, in between overcrowded teeth. 

Maggie Burley: Yeah, so true. I have to agree with that.

I see so often where practitioners are struggling to use the ultrasonic scaler to clean those developmental grooves and it's just not designed to do that. 

Mary Berg: No.

Maggie Burley: But those hand scalers perfect for the job. So what we were talking about was using that scaler on the developmental groove, and you had advice for clinicians when you're in practice?
Mary Berg: So if you can't get the stain, which is what is in that groove, out easily with just a couple swipes of the scaler, have a conversation with the pet owner and let [00:03:00] them know that there's going to be a little bit of stain there, a little bit of brown line so that they realise that this is normal and you don't want them to think you didn't do your job.

Maggie Burley: Exactly.

Mary Berg: So, communication is so vital in veterinary medicine overall with the pet owner, but this is a place that it's really important to talk about. 

Maggie Burley: So true. What else do you like in your perio kit? 

Mary Berg: Another instrument that I really like, obviously, is a curette and I find for most general practices, I'm gonna recommend a universal curette over the gracey.

The gracey curette has one sharp side and a dull side on each end. The universal both sides are sharp and the advantage of the curette over a scaler is that the tip is rounded. The toe is rounded, so it is designed to go into that periodontal space, that periodontal pocket, to help with root planing and subgingival curettage.

And I like the universal. In fact, in my periodontal kit I [00:04:00] put universal tips or universal curettes in it, as opposed to graceys. 

Maggie Burley: It's gotta be safe and it gets into, you know, those interdental spaces between the teeth, it can get into those areas, it's gonna be safe to use very closely to the gum line or just below the gum line.

Mary Berg: Yep.

Maggie Burley: I'm glad that you've raised both curettes and scalers because they do have different applications and we wanna make sure our patients are always safe. So can you just go into a little bit more detail about what we're doing with our curettes, because we hear now a lot of talk about root planing, but perhaps not really understanding exactly what that's meaning and what's gonna be the right instrument, especially to address that little pocket of infection that often gets missed. 

Mary Berg: I'm actually a big believer in starting with sub gingival scaling with my power scaler and a periodontal tip because I think the advantage there is the vibrations of the periodontal tip burst the cell walls of the bacteria and break up the calculus that may be below the gum line, [00:05:00] but the water then flushes it out.

So to me, that's a win-win. Making sure you're using actually the periodontal tip, not a universal tip.

Maggie Burley: Mm-hmm.

Mary Berg: Because periodontal tip is much tinier and gets into those pockets and then I follow up with the curette and what the curette is designed to do is you go down with, it's hard to explain this verbally, but you go down with the blade almost parallel to the edge of the tooth. And then when you get down to the bottom of the pocket, you're gonna rotate it a bit about 30, 35 degrees so that the cutting edge is along the cementum and then one pull up, and that is called root planing. And what that's doing is removing any additional debris that may be on the cementum in that periodontal pocket.

It also smooths out the cementum a little bit, and cementum is something that will regenerate. So we can remove one layer of that to help readhere that pocket back to where it needs to be. And you do that repeatedly. So it's go down, engage, pull up, go down, engage, pull up. Don't go back and forth because you're [00:06:00] gonna pack all that bacteria into the pocket.

After I've done that, then I'll go and turn the other direction and I'll go down to the bottom of the pocket, engage the cutting edge, but towards the gingiva, toward the inside of the gingiva. And I usually just put my finger along that gingiva and I pull up. And what I'm doing is called a curettage, or subgingival curettage, and it's basically I am removing a layer of the epidermal cells. If you're repairing a wound you always wanna freshen the wound, debride the debris. 

Maggie Burley: Yeah. Makes total sense.

Mary Berg: Yeah. So I'm taking that layer of the epidermal cells off so that I have a fresh layer and that helps them better to adhere to each other. So those are some of the instruments that I want in my periodontal kit.

Now in practice, I have a pouch that, a sterilised pouch, and I always have my periodontal probe, explorer, a hand scaler and a hand curette in that pouch. So that's [00:07:00] there. That's always with me. And as far as other instruments, not necessary, but gosh, I love them a lot and I think they're real useful is a Minnesota retractor.

It is a more wide blade, silver, stainless steel. And I like it because it is a great tool to retract the cheek, say for those wonderful before and after pictures that we all should be taking. Our owners see the value, and then one of the ends has just a little bit of a curve on it and it's great for retracting gingival tissue while the veterinarian is removing bone for an extraction.

Maggie Burley: Protecting the flap. 

Mary Berg: Yeah, protecting the flap. Please if there's one thing you take away from this, do not use your periosteal elevator to hold the flap away. You'll tear up.

Maggie Burley: Thank you so much, Mary. 

Mary Berg: And don't use your technicians or your nurse's finger to do that either.

Maggie Burley: No. 

Mary Berg: Yeah. 

Maggie Burley: Thats a big no no too. 

Mary Berg: Yeah. Big no no and I know people will use a tongue depressor blade but I personally think the little Minnesota [00:08:00] retractor is so versatile and so useful and it's not very expensive. 

Maggie Burley: Yeah. The one thing that we struggle the most with dentistry, if we don't have good visualisation or good access and it's the Minnesota that that helps give us that. 

Mary Berg: It doesn't really have mirror properties. So you aren't gonna necessarily see like a mirror with it, but it does help reflect the light a little bit down into the site. That brings up another instrument that I think is super, super, super important, light.

Maggie Burley: Yes. Yes. 

Mary Berg: You have to have good light. You cannot go and try to do dentistry efficiently if you're only using an overhead fluorescent light or a can light at the top of you. It's not enough to get into that little black hole called a mouth. I mean a good surgical light or a good headlamp can change your world and it just makes so much more difference for what you're doing.

You can see what you need to do. 

Maggie Burley: Definitely.

 I've been in the industry for now for 20 years and as we get older our eyesight does start to struggle a little bit. We need a little bit of help [00:09:00] and I find those loupes as soon as I put those on and it was like, oh, what have I been missing?

I can now see so much better. 

Mary Berg: I also love my loupes, my magnifying loupes. Because it makes those little tiny cat teeth look like tiger teeth all of a sudden, and amazing what you miss. You know, looking to buy a set of loupes, I would recommend getting the adjustable ones, and it takes a little bit of learning curve to get used to wearing them because you have to hold your head.

You have to be 18 inches away. That's one of the pluses for me. It forces me to be at a normal, I'm not leaning down and causing neck issues and other issues. 

Maggie Burley: Yeah. Good posture makes such a difference, doesn't it? I mean it just reduces that fatigue at the end of the day as well. 

Mary Berg: Ergonomics is becoming my, my new passion.

Maggie Burley: It's a missed area isn't it? 

Mary Berg: Yeah. 

Maggie Burley: We really, we've not had to education in dentistry to start with, but then not had any thought process put into how important it is to actually look after our bodies to be able, you know, show that we can continue to look after our patients for a long [00:10:00] career. So I hope all of our young listeners are really taking note of both of us with our aches and pains. Look after your body.
 
Mary Berg: But I agree to that if you can't afford loupes, at least invest. There's other types that you can get that aren't quite so expensive. I know that people who do a lot of sewing or quilting have loupes, and those may work if you don't wanna invest. A good pair, it's always worth the investment for me to do that in my team and everybody else.

But the other thing is, even just a good set of reading glasses will make a difference. 

Maggie Burley: It's a simple set, isn't it? 

Mary Berg: Yes. 

Maggie Burley: It's a very small set. 

Mary Berg: Doesn't cost much. 

Maggie Burley: It's a simple set, four instruments, really? 

Mary Berg: Yeah. I don't know for sure prices in other countries, but I could probably buy all four of those instruments I need for under a hundred or maybe $120.

So you could use 'em over and over again. So as long as you take care of them. 

Maggie Burley: Yes, and that's another good point. How do we take care of them? 

Mary Berg: You need to take care of them. First of all, dental instruments do need to be sterilised, autoclaved and [00:11:00] wrapped. Don't just wash 'em off, rinse 'em off and throw 'em in a drawer or throw 'em in a basket for the next dental cleaning.

Maggie Burley: Mm-hmm. 

Mary Berg: What happens then is all that bacteria is on 'em, and even though I know I hear it all the time, well Mary the mouths a dirty environment anyway. Yes. 

Maggie Burley: But not below the gum line it's not. 

Mary Berg: Yes, but do we want to introduce additional bacteria that may be not in there? What happens if you maybe didn't realise the patient before the last one, maybe it's a cat and maybe weren't aware that it have FIP or something like that. It could be transferred that way. So always autoclave them and wrap them. I have seen people that we autoclave them, but then we put 'em back in the drawer and I'm like, why? 

Maggie Burley: Treat them with the same respect as we would for our surgical instruments. 

Mary Berg: They should be.

Also, make sure that they're sharpened routinely. You're not gonna sharpen your periodontal probe or your explorer, but making sure you understand how to sharpen the scaler and the curette appropriately so you [00:12:00] don't wear them away too fast and there's a lot of YouTube videos and things available to find out how to sharpen those.

Maggie Burley: Yeah. If they're not sharp, they're not gonna do the job. That's wonderful. Mary. That's taken us through what is the basic kit that we need for doing our cleanings and our assessments. Fantastic. So then now we can move into what would be the basic kit that we would need for extraction. So what should every clinic have? What's the set? 

Mary Berg: Okay. First of all, we established how important the Minnesota retractor is to that. I would always recommend a, a set of elevators and I would recommend that the elevators, because we are becoming a much more female led industry, get the short, I call 'em the short stubby handles, but the littler stubby handles that fit into the palm of your hand, so there's less fatigue on your hand when you're working with them.

I like the winged ones. I think if you've got a set that goes from a size one to probably about a five or six size. 

Maggie Burley: Sounds perfect 

Mary Berg: That's all you really [00:13:00] need. It is nice to have one big one. If you got a Irish wolf hound in there, you need a little bit bigger. 

Maggie Burley: On the occasion, yeah. 

Mary Berg: Yeah.

But you don't need it very often. I actually like the ones that come in a kit that has like a stainless steel box that you can kind of lock it down and you can autoclave the whole thing. So it's all in one. You have it right there, it's done. 

Maggie Burley: What? We're not gonna put them in a drawer and have them rattling around loosely?
Mary Berg: I'd seen it where somebody put a board on the wall and drilled holes and just put 'em in their holes on the walls. So yeah, I've seen it all. Take care of them. Don't use them as an impromptu screwdriver. 

Maggie Burley: And it's important to look after that instrument, isn't it? Otherwise it's gonna undermine that flap and that's the one thing that we don't wanna see is that complication postsurgery, where that flaps broken down.

Mary Berg: Yeah. So take care of that instrument and we sharpen it just like we do in a regular elevator. But yeah, I've seen 'em that are so mangled because we've used it to retract tissue and then we hit it with the high speed burr and it's, and they're still using it to elevate, and I'm like, don't please just don't.

Maggie Burley: Yeah. Too traumatic for the patient.

Mary Berg: [00:14:00] Yeah, yeah, let's not do that. So a good periosteal elevator, and usually those are going to have a larger end and a smaller end. Smaller end for our felines and small dogs and of course the bigger one for our bigger patients. 

Maggie Burley: Yeah 'cause it's interesting, isn't it? We've got different sized instruments for different sized vets.

Mary Berg: Yes.

Maggie Burley: So that seems to be a misconception that there are instruments that are different lengths for different sized hands and it'll be more comfortable, more ergonomically sound for those practitioners to use the right size. Then we've also got different sized instruments for different sized animals, so different sized patients that we're seeing as well.

So we wanna make sure in our kits that we're going to have instruments that cater for both our smaller and larger patients as well. 

Mary Berg: Yeah. We wanna make sure that people understand that the right instruments make a huge difference in what you do and I know sometimes we're a little frugal in the veterinary world and we don't want to go out and buy new instruments. But it's an investment in your patients. It's an [00:15:00] investment in you as a human being for longevity in the field, it's an investment in your team, and I think that makes all the difference in the world. 

Jim Berry: After Maggie Burley's discussion with Mary Berg, the conversation continues as Marcela Perez-de-Tudela is joined by Stephanie Johnson.

Marcela Perez-de-Tudela: According to the WSAVA Dental guideline, daily tooth brushing is considered the gold standard, right? For home care? 

Stephanie Johnson: Yes. 

Marcela Perez-de-Tudela: How do you effectively demonstrate this technique to the client and ensure they will do it and minimise the pets stress? 

Stephanie Johnson: I always tell them to start small, start light, start by letting them lick the toothbrush, brushing their face with it a little bit, so that [00:16:00] way the dog and the cat can become familiar with the toothbrush around their face without being scared of it and the pets will adapt at different levels. Some will be fine with it within a day or two. Other pets might take a couple of weeks of this. I have told people to put toothpaste on the brush, if they're going to be using that, to see if their pet will just lick off the toothpaste or if they're using just a wet toothbrush, that's fine.
They can start with a sugar free whipped cream on the toothbrush. Pets will lick that off, get used to the feel and associate the toothbrush with something positive and doing it with something that the pet enjoys, whether it's going on a walk, eating dinner, playing with a specific toy. 

Do the toothbrushing immediately before that because then the pet will learn that if they sit through this thing that they enjoy comes next. Once they're used to the toothbrush, lift the lip, brush on the incisors by the gingiva, then [00:17:00] release. Give them a treat and you're done. Go do the thing that they enjoy. If they fight it, stop. As soon as they start fighting, it becomes negative, and we want to keep it positive, so don't drag it out. It can take several months of doing this repeatedly. 

When they tolerate brushing of the incisors at the gingiva I work my way back. Then the next time when they're tolerating the canine teeth and the incisors, they're sitting there really good for it. I'm gonna work back to the premolars and eventually the whole mouth taking it as fast or slow as the pet will let you, without making it a negative experience. 

Marcela Perez-de-Tudela: Oh, that's great.

How you do the validation for the dental products, how you do that with the client? 

Stephanie Johnson: When clients come in and I, I actually have a form for clients to fill out before their initial consultation and sometimes they do it, sometimes they don't. But I always [00:18:00] ask the same questions. How often do you brush your pet's teeth?

And do you give any dental products at home? Any other types of dental products, and what are they? And I also ask, does your pet do any sports like frisbee, flyball, french ring, things like that and that gives me an idea of how to go in and talk to these clients a little bit. But as far as the dental products, my spiel is actually almost always the same.

What I tell people is, anybody can make a pet dental product. Anybody can sell it. It doesn't have to work. It doesn't even have to be good for pets. So how do we choose which one we go for? There is a group called the Veterinary Oral Health Council, VOHC is their abbreviation, and they have established testing guidelines that companies can put their products through to prove that they do what they say they do and everything that has been approved and has passed that testing guideline gets [00:19:00] a seal of approval from the VOHC and is listed on the VOHC'S website. And so I will direct people to that website. 

Marcela Perez-de-Tudela: Yeah. That's perfect. Thank you. What about the red flag? When you talk to the owner, what is the routine at home they doing, and where is the point that they have to go to the doctor, to the vet, to specialised dentistry?

Stephanie Johnson: Even if you are doing home care and brushing every day, things can still happen. How frequently are you going to the dentist yourself? Twice a year and they're checking things on you and so at the very least, even if you're brushing every day, you should have an oral exam. A veterinarian should be looking in the mouth at least once a year, may recommend it more frequently, especially small toy breeds prone to periodontal [00:20:00] disease because owners can't get everything. We need that check to prevent it from getting worse and so even on an awake exam, a veterinarian will be able to see if there's little bits of calculus buildup in the back.

Which tends to be the most common. If there's signs of gingivitis and if there's signs of gingivitis on that oral exam, that awake oral exam, then we should get in there under anaesthesia and clean and polish and take x-rays just to make sure there isn't any progression beyond gingivitis. I tell clients if they notice a pet is shy on one side, whether they're brushing their teeth or eating. If they are hesitant to chew or have one side of their mouth brushed and another's not, they need to get in and be seen because there's something uncomfortable that's happening. If they notice any fractures on any teeth that are new [00:21:00] they need to go in and have that checked and looked at. If they notice any bleeding when brushing or chewing on a toy, they need to be seen. If anything changes in the pet's behaviour and reaction to what is normal, it could be their dropping food or they are not catching a ball a specific way or they are shying away from having a certain side of their mouth touched.

That is all an indication that something is happening, and even if we look and it looks fine, we need to get them under anaesthesia and take an x-ray because there could be something happening below the gumline. 

Marcela Perez-de-Tudela: Let's talk about kittens. They're very different. They're not small dogs. They're special. What about them?

Stephanie Johnson: So cats appreciate routine, but they tend to have smaller baby steps towards daily brushing. There are different flavours available for cats for toothpaste, so if you're going to be using them, but if they don't like any a wet toothbrush is fine it's the [00:22:00] actual mechanical brushing action that is the most important.

My cats love dental treats like tartar shield dental treats, there's a section on VOHC for cats. I find cats do well with the dental diets if they don't require other prescription things. The water additives can be very helpful for cats as well. But with cats is where I have found that if you just put a water additive in, they'll stop drinking water because they don't like the sudden change.

And so I will tell owners, okay, instead of doing the full dose to that amount, let's do a quarter. Make sure they don't freak out. Let 'em drink all of that for a couple of days and then you can up the concentration to half dose and work up to it so that way you ease them into the change. I find cats are motivated by treats, and so if I'm testing, what toothpaste am I gonna try to use on a cat?

Let's get a couple of different flavours and let 'em lick it and see which one they like [00:23:00] most. It's a matter of understanding your pet, their quirks, and working around that. I recommend doing it the same time every day because of the routine, not just for the pet, but also for the owner, because if the owner gets in a routine and then they'll be less likely to forget as well.

And then as far as when to take a cat into vet, what are the warning signs? Again, if you notice that they are dropping food, especially out of one side of their mouth, if they're not really chewing, if you see red gingiva or notice any bleeding. Cats, I have also noticed when they have oral pain, they can chatter their teeth a little bit, especially when you've touched a side of the face or you're trying to brush, or they're eating. Cats also with oral pain, sometimes if it's really severe, they'll actually paw at their face and they'll yell, and if you're seeing that, absolutely we need to have them seen right away. [00:24:00] Again, I still recommend most cats be seen at least once a year for an oral exam. Some cats need it more frequently. One condition we see quite a bit, especially in pure breeds like Maine Coons, Siamese, and Sphinxes are cats that have what we call juvenile gingivitis, and these are cats that are like seven or eight months old. Their adult teeth have just come in and the teeth look really good, but man, their gingiva is just so red and so angry, and I've seen a lot of veterinarians accidentally diagnose it as stomatitis.

But when you look in the back of the mouth, the back of the mouth isn't angry. It's all just the gingiva. It's really common in pure breeds. I feel like where I'm at the  Maine Coons tend to be the biggest representer of this, but those cats need to be seen very frequently. We see those cats initially every [00:25:00] three months for an anaesthetised procedure.

If it's looking better, we go to every six months and some of those cats that I've had have grown out of it and they eventually get down to once a year or every nine-ish months. I highly recommend all kittens have an oral exam between the ages of seven and nine months to look for that gingivitis because when the teeth first come in, there's gingivitis, but by the time they're 7, 8, 9 months old, the gingiva really should have calmed down by that point from the tooth eruption. If they have gingivitis and all their adult teeth have been in for at least a month we need to get them in, get them under anaesthesia, start aggressive home care and sealants, and see them awake every three months to determine how frequently we need to do their dentistry procedures and how well the home care is working. So one thing with cats I do tell people is even though they seem like they're healthy, if they're under a [00:26:00] year, but over six months, please don't assume they're just good.

At least have an awake oral exam to look for gingivitis. 

Marcela Perez-de-Tudela: Yeah, it's so important that you just say, because the puppy, they have puppy dentals and then change in one moment they have all the dental in the small mouth, so the small breed and the kitten, they suffer a lot.

Stephanie Johnson: They do.

Marcela Perez-de-Tudela: Yeah and talking about the puppies, when they have three months, they start changing the teeth, right?

What do you recommend in that moment to the person that take care of the puppy? 

Stephanie Johnson: For a puppy going through teething, clients that they might not see the teeth fall out, or they sometimes will find a little bit of a tooth. They may notice some blood from the mouth. They might notice their pet seems grumpy, almost like they feel under the weather because teething can be [00:27:00] uncomfortable.

If their pet seems uncomfortable, they can try softening food, being gentle if they're doing toothbrushing, if they notice that a tooth has just fallen out or is about to fall out, hey, let's maybe not press that spot too much because we don't want to make it a negative experience. Looking at the teeth as they're coming in, are they pointing in weird directions? Hitting opposite teeth or tissue causing sores? Making it so the pet can't close its mouth. If that's happening, we need to prepare for possible work later, either extractions or orthodontics or anything like that. And so letting them know, Hey, we need to be watching how these come in, because if they come in and they're causing pain, we're gonna have to deal with that.

It's not gonna be something that waits till they're two or three or four. That's something that needs to happen sooner. When talking with owners, the key words are pain, discomfort, and infection [00:28:00] because owners understand pain and infection. They don't want that, so they're gonna be much more likely to watch it and come back for the follow up and so using those words, it sounds terrible almost like we're trying to scare the owners, but we want them aware of the consequences of ignoring problems and not recognising problems. Something that I'll tell general practices, if you are spaying a puppy or a kitten and they are over six months old, I highly recommend when they are under anaesthesia for that spay or neuter, taking a picture of the new teeth that have come in.

You could see how beautiful those teeth are, how clean they are, and you can give that picture to the owner and put it in the pet's record. When they come back, you can show the client what their teeth looked like compared to now. If owners see that [00:29:00] change, it's really gonna trigger something in their mind.

If it's not a big change, obviously it would be like, you are doing great with your home care. What are you doing at home? So you can use it to highlight differences in why we need to get the pet in for treatment, but also validate the owner's work at home. 

Marcela Perez-de-Tudela: So rescue dogs there? 

Stephanie Johnson: Oh yes. We see a lot of rescue dogs.

We see a lot of geriatric patients that come in that haven't had their teeth done. Those are the ones that we really need to get in soon because we don't know what's going on under the gumline. So if they've just gotten this pet, they have no history on it. We need to get them in, do a good deep cleaning, take full mouth x-ray so that we have a baseline for that pet at where they are now, and if they have any problems, address those so that they can start fresh and then start a home care regimen and then they can maintain from there.

And so, if there is unknown history on the pet I always recommend a [00:30:00] professional dental cleaning under anaesthesia with full mouth x-rays so that we can take care of any potential problems that we can't recognize and then that way the owners have a fresh slate to start with for home care and for their maintenance.

I do see a lot of geriatric patients that have dental problems that aren't getting the care they need because a lot of people say that you can't anesthetize a geriatric patient, which is absolutely not true. We just had to prepare, make sure we did it well. You just have to be aware that yes, there is a higher risk and we have to look at the risk versus benefit, but most patients, the benefit is gonna outweigh the risk, especially if you have a team that is planning appropriately to mitigate those risks as much as we can, and the senior patients should not be counted out. The patients with heart disease [00:31:00] need dentistry, and the patients with kidney disease, they need dentistry. 

Diabetic patients, oh goodness, their teeth really affect how well we can regulate their diabetes, and so these patients shouldn't be written off as not being able to have good dental care for them is vital to not just their oral health, but their overall health with these other coexisting diseases. It's up to us to help the owners realise and find something that will work for them and work for their pet so that we can make sure that their pet has the best quality of life that we can help them give them.

Jim Berry: Thanks for joining us on the WSAVA podcast, where we are transforming care one episode at a time. We hope today's discussion was helpful wherever you are in the world. You'll find more information and further resources on the topics discussed in the show notes, and [00:32:00] we look forward to sharing our next conversation with you very soon.