Evaluation of maximum dose intravenous midazolam used in dental intravenous sedation: a West of Scotland regional audit

Intravenous sedation for adults with profound acquired brain injury undergoing dental treatment - a seven-year service evaluation

BACKGROUND

Dental treatment may not be possible for patients with a profound acquired brain injury without pharmacological support. Intravenous (IV) sedation with midazolam is a widely accepted, safe, and effective mode of treatment for people with a disability, but there is limited evidence in this patient cohort.

AIMS

This evaluation aimed to review the IV sedation service for patients with profound acquired brain injury within the dental department at the Royal Hospital for Neuro-disability.

METHOD

This study was a retrospective service evaluation of IV sedation for dental treatment over seven years. Descriptive statistics are presented.

RESULTS

In total, 303 episodes of sedation were undertaken at the Royal Hospital of Neurodisability over seven years. Ninety-two percent were graded with an American Society of Anaesthesiologists (ASA) grade 3, and one-third had a history of stroke. 91% had treatment completed successfully. Complications occurred in 7.9% of cases, but all were minor, with no resulting patient harm (e.g. a transient drop in oxygen saturation).

CONCLUSION

Dentist-led IV sedation with midazolam is safe and effective for dental treatment for patients with a profound acquired brain injury in a specialised setting with experienced clinicians.

Adult intravenous sedation in general dental practice: indication, effectiveness and patient experiences

Background Conscious sedation is an option in primary dental care for anxious patients or those undergoing extensive procedures. The objective of this retrospective service evaluation was to study the range of treatments delivered during sedation with intravenous midazolam, together with patient-reported experience measures.Methods Data from 100 consecutive patients treated under sedation at a single private dental practice were evaluated retrospectively. All patients were asked questions about their experience of sedation during a post-operative follow-up phone call.Results Over half of patients were treated under sedation due to anxiety. The mean dose of midazolam was 7.8 mg and the average treatment time was 1 hour 25 minutes. Of note, the average dose for the most extensive procedure - implant immediate full arch loading - was 11.7 mg; however, this equated to an average dose of 4.5 mg per hour. One patient needed supplemental oxygen; flumazenil was never required. Additionally, 91% of patients felt they had enough sedation, and 50% could remember the events of treatment.Conclusion With the British National Formulary recommending a maximum dose of 7.5 mg midazolam, this study demonstrates that this dose can be safely exceeded in dental treatment; therefore, a dose that accounts for the length of the procedure is a more valid approach. Moreover, patients undergoing a variety of dental treatments were satisfied with the amount of intravenous sedation received and age is not an absolute limit for sedating older people.

Advantages of Sedation With Remimazolam Compared to Midazolam for the Removal of Impacted Tooth in Patients With Dental Anxiety

PURPOSE

Although midazolam is commonly used to sedate patients with dental anxiety, it has shortcomings that reduce the satisfaction of patients and doctors. The aim of this study was therefore to explore the advantages of remimazolam as a sedative.

METHODS

The study design was a prospective randomized controlled trial. Patients with dental anxiety and who were to undergo impacted tooth removal were randomized into remimazolam and midazolam groups. They were sedated with remimazolam or midazolam prior to receiving nerve blocker. The predictor variable was the type of sedative, while the primary outcome variables were the onset time, awakening time, recovery time, and postoperative side effects. Secondary outcome variables were the Modified Dental Anxiety Scale score before and after surgery, patient satisfaction and comfort levels scores, and doctor satisfaction level scores. Other variables included the patient demographics and the operation time. Data were analyzed using the Student's t-test, Mann-Whitney test, χ² test, and two-way repeated measurement ANOVA test (SPSS Version 25.0).

RESULTS

A total of 83 patients were included in this study, with 42 randomized to the remimazolam group and 41 to the midazolam group. There were no significant differences between the two groups in terms of demographic features and operation time. Patients in the remimazolam group had significantly shorter onset time, awakening time, and recovery time compared to those in the midazolam group (each P < .001). Postoperative side effects were more frequent in the midazolam group (P < .001). Following surgery, the Modified Dental Anxiety Scale scores in both groups were significantly lower than prior to surgery (P < .001). Satisfaction levels scores for the patients and doctor were higher in the remimazolam group than in the midazolam group (P < .001).

CONCLUSIONS

The use of remimazolam results in faster onset, more rapid recovery, and lower incidence of postoperative side effects compared to midazolam, leading to improved satisfaction for patients and doctors. Remimazolam therefore appears to have several advantages over midazolam for the sedation of patients with dental anxiety associated with the removal of impacted teeth.