Dr. Bharat Joshi
Dentistry
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hi doctor,
My son is 11 years old. He got a dental checkup last week. I received two different opinions on his issue of what is showing on his X-rays. I am concerned about it.
Kindly suggest.
Hi,
Welcome to icliniq.com.
Please be calm. See as per my interpretation, there seems to be an additional canal in the molar which is either separated or isolated. I suggest you please have RVG (radiovisiography) or CBCT (cone beam computed tomography) of the molar for clarification.
The Probable causes
Investigations to be done
Differential diagnosis
Probable diagnosis
Treatment plan
Preventive measures
Regarding follow up
Patient's Query
Thank you doctor,
So this is not a supernumerary tooth right?
Hi,
Welcome back to icliniq.com.
See it is not a supernumerary tooth. But definitely, an additional canal that is not connected with the pulp chamber will create problems for treatment. Hence CBCT or RVG is a must to know the nature of the canal, any calcification, and origin.
Thank you.
Patient's Query
Thank you doctor,
I have sent you new images of the lesion. Can you help me with a better understanding of these images? Please mention whether it is a supernumerary tooth or a root tip that remains broken. He does not have any previous extractions. I hope that it is not a tumor. This is what makes me really anxious.
Hello,
Welcome back to icliniq.com.
See the two images are very much clear (attachment removed to protect patient identity). They show developing third molars and a supernumerary tooth. In the second image, the extra canal is also prominent in the molar and it is clear that there is no tumor.
The Probable causes
Investigations to be done
Differential diagnosis
Probable diagnosis
Treatment plan
Preventive measures
Regarding follow up
Patient's Query
Thank you doctor,
Why there is an extra canal in the molar, and what is the root stump present on the other side?
Hi,
Welcome back to icliniq.com.
See there are three canals in the molar. If there is an accessory or additional canal, it starts from the pulp chamber. But you have an extra canal in the periphery of the normal canal which is not normally present there. Hence it is called an extra canal. A root stump is known as the tooth having a minimal crown and maximum root which could be carious or destroyed. Thanks.
Patient's Query
Hello doctor,
Thank you for your reply.
I saw the oral surgeon, and he said it was a supernumerary tooth. He said he was going to perform the surgery to extract it. I asked him for laughing gas, and he said that since he has to drill, it is better to have IV (intravenous) conscious sedation. He does it every day, but it is scary on my eyes.
Hello,
Welcome back to icliniq.com.
Thank you.
Patient's Query
Hi doctor,
Can you give me your feedback on your preference between laughing gas and IV sedation for this type of procedure?
Hello,
Welcome back to icliniq.com.
As per efficacy, IV is better than conscious sedation, but in terms of cost, conscious sedation is cheaper. Overall I am in support of IV.
Patient's Query
Hi doctor,
Thank you for your reply.
Are you concerned that IV conscious sedation can get too deep and that reversal drugs do not work?
Hi doctor,
Welcome back to icliniq.com.
See, there are chances, but as per my knowledge and experience in hospitals in my country, it is better than conscious sedation.
Patient's Query
Hi doctor,
Thank you for your reply.
How reliable are the reversal medications in your experience?
Hi,
Welcome back to icliniq.com.
It is very less.
I hope this was helpful.
Patient's Query
Hi doctor,
Thank you for your reply.
Does it mean that they are not that reliable?
Ivermectin is not used in your country. Do you know if Ivermectin has interactions with any of the sedation medications? My son stopped taking Ivermectin three days ago. By the time surgery comes, it will be like two weeks. To my understanding, one of the sedation drugs crosses the brain-blood barrier, and Ivermectin does not work well with that.
Hi,
Welcome back to icliniq.com.
Yes, it will interfere. I request you first to update what medications your son is taking?
Whatever I had recommended is meant for a person who is not on any medication except antibiotics?
Would you please list all medications your son is taking?
Patient's Query
Hi doctor,
Thank you for your reply.
How long should he be on Ivermectin to have a safe surgery?
He was taking Ivermectin two times a week. For three months, we have been doing that.
Hi,
Welcome back to icliniq.com.
Please specify the reason.
Patient's Query
Hi doctor,
Thank you for your reply.
He was taking Ivermectin two times a week for the past three months or longer. He was also taking,
Omegas.
Quercetin.
Vitamin C.
Vitamin D.
Probiotics.
Multivitamins.
Hi,
Welcome back to icliniq.com.
Since Ivermectin is immunomodulatory, it is not given normally.
Patient's Query
Hi doctor,
Thank you for your reply.
What do you mean by immunomodulatory?
Hi,
Welcome back to icliniq.com.
It is given for immunity alleviation.
Patient's Query
Hi doctor,
Thank you for your reply.
What do you think of length-wise that I will have to wait with Ivermectin and the other supplements to get my son into the surgery?
Hi,
Welcome back to icliniq.com.
These medications are fine and could be started postoperatively after 24 to 48 hours. There are no chances of any toxic reaction, but for Ivermectin, you need to take consent from the physician who has given that.
Patient's Query
Hi doctor,
Thank you for your reply.
Yes, but you said Ivermectin causes interactions with anesthesia, which means I will not be able to have the procedure done soon because my son came off with Ivermectin only a week ago.
Hi,
Welcome back to icliniq.com.
That is why it has no problem. It could be stopped, but when to start this, only the physician could clear. I suggest you, please ask the physician who has given this medication and begin only after his recommendation. Ivermectin is the only obstacle, so please ask the physician about the reduction or stoppage of Ivermectin, from what date, and what time. You can go for the procedure, but this medication needs to discuss the time and dosage.
Patient's Query
Hi doctor,
Thank you for your reply.
Let me ask you something else. I feel really uncomfortable with the IV sedation situation, as you can see. Is it possible to extract the impacted supernumerary tooth as my son has with only local anesthesia? He is not a nervous child, he cooperates, and I am trying to find other options.
Hi,
Welcome back to icliniq.com.
Definitely, in fact, we prefer local anesthesia in my country since both cost and side-effects are less. But you have given only two options, so I preferred IV.
Patient's Query
Hi doctor,
Thank you for your response.
The reason why they are giving me the option of IV is that they do not want him to remember even though they keep on saying that he will not be deep, he will still have stimulation, and next, because the tooth been extracted is near the nerve I think is called foramen or something. I believe that they do not want to damage that. I am just the one uncomfortable with anesthesia. I have an anesthesia phobia.
Hi,
Welcome back to icliniq.com.
Fine, then go for IV because local anesthesia has a short duration of action. Regarding your phobia, I understand that, safety and efficacy cannot be compromised based on phobia. But among these three, the merits go to IV. Just Ivermectin issue is there which your physician can sort out. Regarding conscious sedation, I do not support that.
Patient's Query
Hi doctor,
Thank you for your reply.
Why are you not in support of conscious sedation?
Hi,
Welcome back to icliniq.com.
I do not support conscious sedation because I have seen failures in my practice in my country. It did not achieve the challenge of maintaining oxygen concentration.
Patient's Query
Hi doctor,
Thank you for your reply.
Are not the IV sedation medications reversal, and do not do get monitored to prevent those scenarios?
Hi,
Welcome back to icliniq.com.
I am telling you about the hospital scenario in my country. They are get monitored, but it depends upon the facility available and the operator's experience. Still, in the overseas country, conscious sedation could probably be better, and the medications given during IV will not be detrimental to cause reactions if they are easily reversed. But what I am telling you is the feasibility associated with conscious sedation in my country. So please do not worry. I have faith in an oral surgeon and associated anesthetist for good results.
Patient's Query
Hi doctor,
Thank you for your reply.
My last question is, in the scenarios that we have read about children dying in destiny office with sedation, is that not be because of the reversal medications not working? If a patient has been closely monitored, which is how they told me they do at that facility, can they easily pick up any drug reaction or anything and quickly reverse it?
Hi,
Welcome back to icliniq.com.
Yes, now the conditions have changed. Any side effects can be reversed and treated well. We have good types of equipment.
Thanks.
Patient's Query
Hello doctor,
Thank you for your reply.
I spoke to other oral surgeons in my area, and they have a different opinion on the surgery. They suggested waiting and monitoring the tooth every six months. They advised me that even though you have chances of root resorption, cysts, or tumors, the chances based on the evidence in the English literature and what they have seen in their practice through the years are very low. They also said that once the tooth grows and possibly erupts on the lingual side, it is easier for extraction instead of having to go and extract it. What have you seen in your country in your practice with these supernumerary teeth in your experience? I will rather wait.
Hello,
Welcome back to icliniq.com.
I hope I can clear your doubts. I thought you were planning for extraction in urgency. Yes, we can wait for some time. Right now, I am treating a patient, will respond to you after some time.
Patient's Query
Hi doctor,
Thank you for your reply.
Have you seen how these supernumerary premolars erupt and how difficult it is to extract after they erupt in your practice, meaning whether it needs stitches or is it a simple extraction?
Hello,
Welcome back to icliniq.com.
Yes, I have seen and operated on many such cases. But unfortunately, patients in our country report at a very later stage, so the teeth are extracted at a very later stage when malocclusion has already developed. However, they should be removed at the earliest stage. It is a simple extraction, and no sutures are required except when bone cutting is the must.
Regards.
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Dentistry
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