Jim Berry: [00:00:00] Welcome to the WSAVA podcast. Today's discussion looks at anaesthesia and analgesia in veterinary dentistry. A topic closely linked to both patient safety and welfare. As you listen, consider this. How do perceptions of risk influence decisions around dental care? Our interviewer, Gottfried Morgenegg-Wegmüller speaks first with Brook Niemiec and later with Eva Eberspächer-Schweda.

Let's listen in. 

Gottfried Morgenegg-Wegmuller: Brooke, from a clinical perspective, what are the primary anatomical and physiological barriers that make  anaesthesia free dentistry inherently inadequate for full oral evaluation in veterinary patients? 

Brook Niemiec: There's a whole bunch. I think the biggest issue with trying to do it without anaesthesia is just controlling the patient.

They're not gonna sit still. But on top of that, especially when we talk about patients that are prone to gum disease, meaning [00:01:00] small breed dogs. Their mouths are so small to be able to get into them is almost impossible to get any type of oral exam. One of the places that is first affected by periodontal disease is the molars in the back of the mouth, and there is literally no way that you're gonna be able to evaluate the teeth on the back of the mouth.

Other anatomical things that get in the way, if you're trying to look at the lower canines, the frenulum from the lower lip gets in your way and you can't really see the lower canines very well. These mouths are so small, they're just not gonna allow you to do it appropriately without sedation. 
Gottfried Morgenegg-Wegmuller: How does the inability to perform sub gingival scaling without anaesthesia impact long-term periodontal disease progression?

Brook Niemiec: If you can't clean underneath the gums, you're not doing anything at all. There's been studies on the human side where they looked at cleaning above the gum line versus cleaning below the gum line versus cleaning the whole thing. And what they found was that if you clean the [00:02:00] super gingival plaque and calculus, meaning the stuff that you can see on the surface of the tooth, but left everything at and below the gum line, zero inflammation was controlled. It was essentially like you did nothing. If you cleaned below the gum line and left everything above the gum line, everything went away without cleaning the surface, it came back faster because you had a roughened tooth surface. But the problem is that everything that you can see on the surface of the tooth does nothing to the patient.

It's cosmetic, it's ugly, but it's not the cause of disease. The cause of disease is the plaque below the gingival margin, and until you clean there, you're not doing anything medically for that patient. 

Gottfried Morgenegg-Wegmuller: Could you explain the limitations of conscious oral examination with respect to detecting early stage lesions such as furcation exposure, root fracture, or resorptive lesions?

Brook Niemiec: It's impossible to see root fractures on awake exam. If the tooth was rostral or forward in the mouth and [00:03:00] incredibly mobile, then maybe you'd think it's a root fracture, but there might be gum disease as well. The big limitations that were brought out, there was a study by Stella several years ago, and they found that conscious oral exams were pretty decent at finding the disaster cases. If you had a dog that came in with stage four periodontal disease and you did an oral exam, and then you anaesthetised that patient and you did a anaesthetised exam, the results were fairly close. That's a disaster. They all need to come out. Where the conscious exam really fails is in the earliest stages, and it was proven in that study and my study, which we'll get to later, that you cannot evaluate the early stages of gum disease, that when you did oral exams, that they missed the earliest stages of gum disease. Stage one and stage two were almost universally underdiagnosed. And the main reason for that is that most gum disease actually starts on the inside. And the second thing [00:04:00] is that you just really can't appreciate the earliest stages because the first stage of gum disease is actually bleeding upon probing or brushing.

The problem is you can't probe without anaesthesia effectively. It's anecdotal because we know as veterinary dentists, but it's actually been proven that the earliest stages of gum disease and even into stage two, you just can't see unless you have them under, and you can actually probe and take x-rays, which we'll get to.

Gottfried Morgenegg-Wegmuller: Yes. This is the next question. Radiography is a cornerstone of dental diagnostics. Why is diagnostic quality intraoral radiography, essentially impossible to obtain in awake animals? 

Brook Niemiec: Because the way that x-rays are taken is that you put the sensor in the mouth, the animal has to stay there and I know in America, they're going away from people holding animals during full body x-rays.

They're recommending sedation for all full body x-rays because people are being exposed to the radiation. If you're talking about taking intraoral [00:05:00] X-rays in a patient, first of all, you need to put the sensor in the mouth. And they're gonna hate that, especially if you're talking about in the back of the mouth where you have to shove it in, which is a little uncomfortable and you have to hold it in there.

And when, then you get your finger bit and you have to precisely align it. And then you have to lay the patient in a unnatural position for the most part. And then you have to place the tube head in the proper orientation and expect the patient not to move that entire time. And then you take the x-ray.
A lot of the first attempts, especially with untrained technicians, nurses, veterinarians, their first attempt at an x-ray is not gonna be perfect. They're gonna wanna adjust it to get a correct x-ray. Now you've got that patient not moving for at least 10 to 15 seconds. It's just not gonna happen. And even if you're pinning them down, a little bit of movement is enough to make that x-ray non-diagnostic. I get clients that ask me all the time, why do you need to sedate for x-rays? It's like you are gonna [00:06:00] put a sensor in your dog's mouth, have 'em lay there and not move? One in a million dogs will lay there, but it's not gonna be standard for 99.999% of patients. 

Gottfried Morgenegg-Wegmuller: Many proponents claim anaesthesia free dental cleanings reduce risk because they avoid anaesthetic complications.

How do current anaesthesia monitoring and safety protocols compare with the risks of leaving dental disease untreated? 

Brook Niemiec: Clients are universally afraid of anaesthesia, and unfortunately, veterinarians are afraid of anaesthesia. The problem is that these animals don't get the care they need because of this unfounded fear of anaesthesia.

40, 50 years ago, anaesthesia was dicey, but with the advances of anaesthesia and monitoring and training and drugs, the risks of anaesthesia in healthy patients has plummeted. I don't have the numbers off the top of my head, but it's really [00:07:00] low, the risk factor for healthy patients undergoing anaesthesia. The amazing thing about that is that most of those patients in the first study that expired or had major complications of anaesthesia actually happened in the recovery phase.

So it wasn't the anaesthesia, it was that they were not appropriately recovered and they didn't do well because of that. Simply adding a few tiny little things, adding a pulse oximeter, adding in preoperative exams, adding in monitoring until that patient can stand. All of those things would even further decrease the incidents of anaesthetic problems under anaesthesia.

So, from that standpoint, all these advances and the ability to consult with a veterinary anesthesiologist are pretty much available now, at least in developed countries. I have anaesthesiologists I work with all the time. In my opinion, you took a bigger risk driving over to the clinic, getting on the roads, especially in the wintertime [00:08:00] than you did putting your patient under anaesthesia because it is so safe if it's done correctly now, is there risk?

Yes, but there's a risk to getting on an airplane, yet we do it all the time. There's a risk crossing the street, yet we do it all the time. The benefits of proper oral health cannot be overstated, not only from a pain standpoint, but also from a local and systemic infection standpoint. So if we start looking at the kidney disease, the heart disease, the liver disease, the inflammatory disease, all these things that are happening, plus the pain of broken teeth and resorptive lesions, the risk is so far outweighed by the benefits of oral care that it's not even a consideration anymore, in my opinion. 

Gottfried Morgenegg-Wegmuller: My next question, which specific diagnostic steps cannot be performed reliably in awake patients? And why are they clinically important? I was thinking about probing depth or mobility scoring or pulp testing.

Brook Niemiec: Yes, all of the [00:09:00] above. The only thing that can be reliably done on an awake patient, the vast majority of times, is a limited oral evaluation. You cannot probe effectively. You can't take dental x-rays. If you can see the furcation, like sometimes on a awake exam, you see so much recession. You can see the furcation.

Sure, you can do that. Sometimes you can feel if they're mobile, sure you can do that. But honestly, it goes back to the fact that if we allow this disease to progress to the point where you can see it on a awake exam, you've waited way too long, then you're missing this stuff early. 

Gottfried Morgenegg-Wegmuller: How does the use of sharp ultrasonic or rotating dental instruments in awake animals increase the risk of iatrogenic injury?

Brook Niemiec: By orders of magnitude. If you're talking about using a probe, the probe is relatively safe, but if the dog moves or the cat moves, you're gonna shove that into the sulcus. You're gonna damage the sulcus. If you're doing ultrasonic, you have to have water. Any of these machine activated products, you're going to have water [00:10:00] coolant. That water coolant is full of bacteria, not only from the mouth, but from the water lines in most cases. So the problem is now you've got a dog, because you have not anaesthetised them, their airway is not protected, and I've seen this. You crack off a piece of tartar and the dog aspirates it.

That's just full of bacteria. Now you got an aspiration pneumonia. So simply the fact that the dog is not intubated is enough for me to go, these dogs need to be intubated for this procedure. And yes, you're gonna say we are not intubated for it, but we have control of our airway when they have suction, and that protects us a lot more.

And we don't typically have the level of disease that animals do with the ultrasonic instrument. You could burn the gums, but I would never even consider using a dental bur on a dog's or cat's tooth awake. Because if that dog moves at all, you're just drilling into it and you gotta pull the tooth. If you were trying to do anything like that on an awake patient, that would be really scary.

The bottom line is that the combination [00:11:00] of using sharp instruments or power instruments, and if that animal moves at all, you're gonna cause a lot of damage. Plus you have to worry about the ultrasonic creation of aerosols, and that's gonna damage your patient too. 

Gottfried Morgenegg-Wegmuller: What evidence or case studies have you encountered in which anaesthesia procedures directly resulted in delayed diagnosis of significant oral pathology?

Brook Niemiec: I mentioned one already, and that was the Stella article. I finally published the study that I worked on for a long time on anaesthesia free dentistry versus anaesthetised dentistry. The title of the article says it all, is that anaesthesia Free Dentistry Demonstrated No Medical Benefit. None. I had patients that came in because they were going for anaesthesia free and they would still have bad breath.

One patient that had anaesthesia free dentistry and two weeks later a tooth fell out and then they saw me, and the crowns looked great, but we literally [00:12:00] extracted every tooth in the mouth. My opinion is that it is essentially worse than doing nothing. What it does is it makes the crowns look clean and unfortunately in veterinary medicine to this day, even though veterinary dentists have been railing against this for decades, the way that most veterinarians and owners determine whether a patient needs dental care is the level of calculus or tartar on the tooth surface, the level of tartar is not an accurate determination of the level of gum disease. The level of tartar on the surface of the tooth does nothing to the patient, so is it associated with it? Yeah. 

Usually dogs that have heavier tartar have more gum disease, but not always. I've got tons of animals with relatively clean teeth that have horrible gum disease, and I have dogs that have caked on tartar and no gum disease because it's a genetic thing.

The bottom line with that is that you [00:13:00] have to really look at the level of inflammation. In my opinion, the animals just need their teeth cleaned every year under anaesthesia. The big thing is how does it really delay it? It gives clients and veterinarians a false sense of security that the teeth are cleaned when in actuality the crowns are cleaned, but there's a disaster underneath the gums in many of these cases.

Gottfried Morgenegg-Wegmuller: How do professional dental standards address anaesthesia free dentistry, and what scientific rational supports these positions? 

Brook Niemiec: Even if you look at the first dental guidelines, there are, I don't know, I think I wanna say 25 different associations that had a position statement against that, and that basically includes any organised veterinary dental association or college, the European Veterinary Dental Association and college.

American Veterinary Dental Association and College, the Academy of Veterinary Dentistry, FECAVA, all these international groups. And then there's [00:14:00] tons of countries, AVMA, CVMA, all throughout Europe, Australia, all these different places. As a matter of fact, both the Australian Veterinary Medical Association and World Small Animal Veterinary Association considers anaesthesia free dentistry to be an animal welfare concern.

The fact that these animals are not getting proper dental care, leaves them in pain and infection. Overall, these position statements were developed anecdotally because all of us veterinary dentists or anybody that does a lot of dentistry is like, yeah, this doesn't work. 

Gottfried Morgenegg-Wegmuller: Can you give me five key points, how veterinary teams effectively counsel clients and give them good arguments to do a proper procedure?

Brook Niemiec: Yeah. Okay. The first one is pretty straightforward, and when you talk about costs, costs vary all over the place. I tell people all the time, you get what you pay for. If you're gonna go and have this service done what you need to understand is that veterinary [00:15:00] dentistry, proper dental prophylaxis, or whatever you wanna call it, COHAT, HIP, whatever that is, is numerous steps.

Cleaning above and below the gum line, polishing the teeth, which is controversial, but I still do it. Doing a full mouth evaluation, taking full mouth dental x-rays, lavaging out the sulcus, plus or minus fluoride, plus or minus some barrier sealant and all these different things. There are numerous steps that go into it, and the oral exam being critical.

The only thing that can be done anaesthesia for free is ineffective cleaning of the surface of the tooth, so you're not even getting below the gum line. It just really doesn't do anything medical. That's number one. Number two, you can't do proper diagnosis. Another thing to talk to the clients about, especially when it comes to cost, is that when you talk about low cost things, they're probably not monitoring great. They're probably not using the latest drugs, they're probably not using all those type of things and the preoperative workup, all of those things go into the safety. [00:16:00] So when you talk to the client about anaesthetised procedures you have to talk to about the safety factors and why it's more expensive, because you have to have a monitor because you have to have a temperature maintenance device, or two, you need to run preoperative lab work. Honestly, people are like, oh, that preoperative lab work, we should be running it, blood tests on animals every year anyway.

Your geriatric panel is your preoperative panel most of the time, if that's the way you wanna do it. But if you've got a patient that has chronic issues, you wanna do blood work even more often. So you know, from that standpoint, if you talk to your client about the safety of anaesthesia. Number one. And then number two, why anaesthesia is safe nowadays, it will make a huge difference and get them to come in. And then I guess the last thing I would say is the fact that we now have published evidence that it doesn't work and we have a litany of veterinary professional organisations that don't agree. And I guess point 5 is you say, Hey, there are veterinarians that believe this is an animal welfare concern and I don't think most [00:17:00] clients will perk up their ears with that. 

Jim Berry: After Brook Niemiec, Gottfried Morgenegg-Wegmüller is joined by Eva Eberspächer-Schweda, to continue the conversation. 

Gottfried Morgenegg-Wegmuller: What are the most critical pre anaesthetic patient factors that influence anaesthetic risk assessment? 

Eva Eberspacher-Schweda: I think the most important patient factors are you need to look at the species. That's number one, right? You need to know if you're dealing with a dog or a cat, or any other species. We shouldn't mix up cats with dogs because cats are not just small dogs. That's number one. Number two is the breed. We need to look at the breed because we have certain breeds that have higher risks for some comorbidities.

For example, brachycephalic dogs or some breeds that are very specific. For example, Cavaliers or Dobermans or something like that. And then of course, we have to do our homework and do our thorough history and clinical examination to find out if there are some patient [00:18:00] factors, some diseases, some underlying conditions that we need to be aware of.

Thorough history is really important because we could find out if the patient was under anaesthesia before, were there any problems, which drugs were used, was there something special? And then again, the thorough clinical examination to find out if there are underlying diseases. And when you're talking about dentistry patients, you know that there are some comorbidities associated with dental disease. I think it's important to not just focus on the teeth and the oral cavity, but to have a good look at the entire animal and find out what is going on, because this will help you in your preparation. This will reduce the risk at the end of the day. I think age is also really critical, especially when you're talking about dentistry patients.

We often deal with geriatric patients and the older patients have certain issues, they're just less able to [00:19:00] compensate with anything, respiration, cardiovascular system, metabolism, and so on. So I think age also plays a huge role. 

Gottfried Morgenegg-Wegmuller: Have modern multimodal anaesthetic protocols improved safety compared to traditional single agent approaches?

Eva Eberspacher-Schweda: A single agent approach, I hope no one of us has ever done because there is not a single anaesthetic agent that really provides a balanced anaesthesia for our patients. For many years, we've used two agent approaches like ketamine and xylazine, for example. Then ketamine, medetomidine, and then isoflurane and sevoflurane were added onto that.

The thing is, I think some people misunderstand occasionally that the less drugs you use, the safer it gets because then you have a lower number of drugs. But that is not really true. If you combine modern drugs, many of them are antagonizable, [00:20:00] they're very easy to titrate, very easy to dose. So it gives you, first of all, a good opportunity to combine the drugs, to pick your ingredients. What do you need in this patient? How much of which drug do you really need to get the best balanced anaesthesia technique? And then to choose agents that are short acting or longer acting depending on what you want, good to combine with.

So I think the modern multimodal anaesthetic approach has improved anaesthetic safety tremendously because it's much safer for the patient. Physiologic parameters are much safer when you target your anaesthetics to the patient's needs. 

Gottfried Morgenegg-Wegmuller: What advancements in monitoring technology have had the greatest impact on improving anaesthetic safety?

Eva Eberspacher-Schweda: I think it is not so much the technology, but awareness that we have to monitor our patients. 2025, [00:21:00] just recently, the new ACVA monitoring guidelines were published and what they state is that the minimum requirement for monitoring is number one, a dedicated anaesthetist. So this is actually number one, and this is obviously not technology, but we are aware now that we need one person that actually monitors the patient and the patient's vital parameters. So that's number one. On top of that, minimum requirements include five monitoring devices, blood pressure measurement, ECG, pulse oximetry, capnography, and temperature management. These monitors are made for cats and dogs, so they really fit the algorithm to our patients.

They're not human monitors that we refurbish and then buy and use. We have the technology nowadays that supports us in the monitoring. These monitors are now on the market and they're reasonably priced and contain everything we [00:22:00] need to monitor a patient thoroughly, so we just need to use them. The monitor doesn't make anaesthesia safe.

The person that monitors and that evaluates the numbers on the monitor, they make anaesthesia safe. So the whole package is basically what improves safety in anaesthesia. 

Gottfried Morgenegg-Wegmuller: How should veterinarians interpret trends rather than single values in real time monitoring data to anticipate and prevent anaesthetic complications?

Eva Eberspacher-Schweda: A single value is always a sneak peek into some situation. We all know, for example, from laboratory diagnostics or other measurement devices, that there is always a certain error. There's always a little bit of an error to the left, to the right, up or down. So just looking at a single number, for example, at a single blood pressure measurement does not really give you a true idea of what is going on.

So it makes a lot of sense [00:23:00] to look at trends. This is again true with blood pressure measurement. When we want to know the blood pressure of a cat, we measure three times and take the middle value in an awake animal. It's the same in anaesthesia because every two and a half or three minutes measure blood pressure and then we see where the numbers are going. Are they going down? Is the animal becoming hypotensive? We need to do something. Are the numbers going up? Is the animal becoming too light or does it feel something. We need to do something. Numbers more or less within a certain range stable. Everything looks fine. So I think the trend gives you more information of what we need to do.

Same thing with temperature. If you only measure with a rectal thermometer once during anaesthesia, and you are warming the patient on a warm air blowing device or a heating mat, and you measure temperature once, and it measures let's say 37.6. By the new guidelines, this is hypothermia [00:24:00] because hypothermia starts at 37.8 degrees celsius.

You don't know, is the animal getting more hypothermic or are you already warming it up so you actually don't have an idea where it is going. Continuous measurement gives you more information of what is going on, so it makes a lot of sense to look at trends, at continuous numbers, because it helps you to guide what you do with your patient.

Much more valuable than just looking at a single parameter. 

Gottfried Morgenegg-Wegmuller: Well, that means don't hyperventilate because of one value. Survey the trend. 

Eva Eberspacher-Schweda: Yeah, I think that sits very well into this question. Never look only at one parameter and try to fix that one parameter. If you're looking at capnography and your CO2 value is really high and your diagnosis is okay, this animal is hypercapnic, so it's hypoventilating, so let's ventilate that patient.

That [00:25:00] is, I think, not very wise. The smarter approach is to look at all of the other parameters. How is the animal doing? You have to get the, the big picture of the animal. Look at oxygenation, look at blood pressure, look at heart rate, look at rhythm, look at the temperature, and if everything else is just fine, a little bit of a higher entire CO2 is okay and tolerable. And for example, if blood pressure is really low, I would not put the animal on a ventilator because then your blood pressure decreases even further by a decrease in venous return to the heart caused by positive pressure ventilation, and the end result is a better CO2 value, but poorer blood pressure and blood pressure is an indicator for perfusion. And perfusion is really important because we need to transport oxygen to the tissues. It's always really important to look at the big picture and not focus on a single parameter, [00:26:00] but always it's a timeline plus the big picture and then you get the best results. 

Gottfried Morgenegg-Wegmuller: What are the most common causes for anaesthetic related adverse events in small animals and what protocols most effectively minimise these risks? 

Eva Eberspacher-Schweda: I guess number one complication in small animal anaesthesia is hypoventilation, followed by hypotension.

What is the consequence? An animal under anaesthesia or even deep sedation will not be able to ventilate the same way as if it would be awake. That is quite obvious, right? Because it's anaesthetised, there's muscle relaxation. We are more tolerable to CO2 when we're anaesthetised or deeply sedated, so it will most likely hypoventilate.

How can you handle that complication? It will most likely happen. Number one, you could be aware of that complication. Monitor [00:27:00] the appropriate value. Monitor end-tidal CO2 and evaluate if CO2 is still within a range that is acceptable. Usually we talk about up to 60 millimetres of mercury end-tidal CO2, anything above 60 millimetres of mercury end-tidal CO2 is not acceptable for a longer period of time. For a short period of time, no problem. For a longer period of time, we don't want that. So we monitor and evaluate. Is it still okay? Is it not okay? If it's not okay anymore, we need to have a plan. The plan could be do anything you can do to allow the animal to breathe better, adjust anaesthetic depth, reduce drug doses, position it, things like that.

Keep it warm and so on to do anything that you can that the animal ventilates more effectively spontaneously, or if that fails, have a means to ventilate that patient, to apply positive pressure ventilation. How can you minimise [00:28:00] risks or the most common complications? By being aware of them and occasionally it would be just lovely to think about all of the anticipated complications that you can encounter during anaesthesia and then have a means to monitor that value. For example, hypoventilation is a common complication. Monitor CO2. Okay, if CO2 is high, we do this. So have a plan, do what you need to do if the parameter gets out of hand. There will never be a complication because a complication is always something that happens unexpectedly.
But if you think of all of the complications ahead of time, know how to see them and have a plan, if the parameter gets out of hand, then there will never be anything unexpected. So I think being aware of what can happen, good monitoring, and then have a plan that helps you to minimise the [00:29:00] risk very effectively.

Gottfried Morgenegg-Wegmuller: Has our understanding of balanced analgesia evolved and what evidence supports combining opioids, NSAIDs, α2-agonists and local techniques for optimal pain control? 

Eva Eberspacher-Schweda: The one part of the balanced anaesthesia is analgesia and analgesia is a whole new world by itself. So if I'm giving methadone, there should not be any pain because there's not really a better analgesic than methadone.

This is not completely true because pain is something really complex and difficult and there are different pain types. What you need to do is you need to combine analgesics to approach pain and nociception from different angles. So for example, if you're doing a dental procedure, you will most likely always have some kind of inflammatory pain.

So a [00:30:00] non-steroidal anti-inflammatory agent is baseline treatment analgesia. Then local anaesthesia is probably the second line of defence because it's a highly effective method of providing analgesia by cutting off transmission of the signal. Local blocks don't really work a hundred percent. There is usually some kind of neuropathic or somatic component with the pain as well.

I think ketamine is also a very nice option on top of that because it covers something else again, and then what you're getting is a nice package which we call a multimodal analgesia technique. And of course, we must not forget there are the opioids, which are highly effective analgesic, so we can, on top of all of that, use some opioids potentially with the alpha two agonist.

There is some component of analgesia as well. The nice thing about multimodal analgesia is that you cover [00:31:00] pain more comprehensively, number one, and the second nice thing is that if you use only lower doses you reduce the side effects as well. 

Gottfried Morgenegg-Wegmuller: Very good, thank you. One last question to round things off, please name three key points for safe anaesthesia in dental patients.

Eva Eberspacher-Schweda: Number one, dedicated anaesthetist. We need someone that monitors the patient, which is not the dentist because that allows the dentist to do its job close to a hundred percent, which again improves quality, speeds up the procedure because duration is also quite important point. So we want to keep duration of anaesthesia short, but dedicated  anaesthetist is number one.

Number two in the dental patient is airway management. Have your patient intubated on the anaesthesia machine and monitored. So you need to do a thorough airway management. Intubation and appropriate cuff [00:32:00] inflation protects for gases, positioning the head a little bit lower than the rest of the body because the job of the cuff is not to prevent fluid aspiration, and then something like a sponge or a piece of gauze to protect for particles, so airway management. And then have someone that keeps a close eye on the endotracheal tube all the time because dentists tend to change positions of the head frequently and inadvertent extubation is something that can happen. So have someone that sits like a hen on that endotracheal tube and protects it. That's number two. And number three is probably something very basic. That is perioperative management because dental procedures can take quite a long time.

So  perioperative management includes infusion of fluids, providing monitoring, managing core body temperature, reapplying eye lube, expressing the urinary bladder, you know, on a regular basis [00:33:00] because the bladder will fill up and then it becomes uncomfortable. A huge sympathetic stimulus. Good positioning, soft positioning, especially when you're dealing with geriatric patients.
So perioperative management is all of what surrounds a good anaesthesia period. So I think that is number three in the dental patient because when you do that right, you have a very comfortable animal in recovery as well.

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 we look forward to sharing our next conversation with you very soon.