Retrospective audit of the efficacy and safety of the combined intranasal/intravenous midazolam sedation technique for the dental treatment of adults with learning disability

Sedation of Adults with Orally Administered Midazolam in Dentistry - A Retrospective Study

OBJECTIVE

The use of midazolam (MZ) has increased in dentistry, but the effect in adults is sparsely studied. The aim of this study was to investigate doses, effects, and side effects of orally administered MZ as a sedative for adults in a dental care organization.

MATERIAL AND METHODS

A retrospective record review was performed including all adult patients in the dental care organization ≥20 years receiving MZ, identified through a logbook for addictive drugs, during 2020. From patients' records, the following data were extracted: age, gender, medical history, reason for sedation, performed treatments, doses, effects, and side effects of MZ.  Results: In total, 265 patients on 418 occasions had been sedated, which constituted 2.3 sedations per 1,000 visits and 3.3 sedations per 1,000 treated patients. Mean age was 40.8 years and 67.7% were females. The most common reason for sedation was anxiety. Mean dose in primary dental clinics was 7.9 mg and in specialist clinics, 6.8 mg (p < 0.001). Older patients (>70 years) had lower doses than younger (p < 0.001), while no difference was found between ages 55-70 years and those who were younger. Dental treatment was completed in 91.9% of occasions, and side effects were registered in 2.2%. Successful dental treatment was related to type of treatment performed.

CONCLUSIONS

Sedation is rarely used, particularly in primary dental care, and the use varies widely between clinics. MZ administered by dentists seems to be safe and effective. A sedation record should be used to make patient data such as weight and medical conditions available.

Bibliometric analysis of pediatric dental sedation research from 1993 to 2022

Statement of problem

Bibliometric analysis methods were used to evaluate pediatric dental sedation research and to identify topical hotspots using quantitative and qualitative methodologies.

Purpose

To conduct bibliometric analysis on the retrieved data and to foresee the development of trends and hotspots in this research area.

Material and methods

We retrieved appropriate research articles from the Web of Science Core Collection on January 1, 2023. VOSviewer, Citespace and the Bibliometrics website were used to conduct bibliometric analysis on the retrieved data. GraphPad Prism 10.0 (GraphPad, San Diego, CA, USA) was used to conduct the statistical analysis.

Results

A total of 396 publications on pediatric sedation in dentistry, published between 1993 and 2022, were retrieved from online databases. The USA published most papers. Furthermore, the most frequent countries who cooperated were the USA and Canada. Six of the top ten publishing establishments were USA based. Papers on the research have appeared primarily in the journals of Dentistry and Anesthesiology. Keyword co-occurrence and co-citation cluster analysis revealed that the most common topics mainly were: dental anxiety; conscious sedation; dental caries; midazolam; propofol; hypoxemia.

Conclusions

During the three decades, the focus of pediatric sedation research has been on drugs, dental anxiety and procedural sedation. Keyword burst detection indicated that procedural sedation; adverse event; respiratory depression is an emerging research hotspot.

Intranasal Midazolam With Lidocaine for Sedation in Pediatric Myringotomy and Tube Surgery: A Randomized Controlled Trial

Background and Aims: Intranasal midazolam (INM) sedation for children has been associated with side effects. This prospective, double-blind, placebo-controlled trial assessed whether the addition of lidocaine to INM (INM+L) affected efficacy or discharge time among pediatric patients undergoing elective bilateral myringotomy and tube placement (BMT).

Methods: This trial enrolled children aged between 18 months to seven years undergoing BMT, physical status class 1 or 2, in a single academic medical center. Interventions were placebo (intranasal saline), INM only (0.2mg/kg of INM concentration 5mg/ml), and INM+L (0.2mg/kg INM with addition of lidocaine 4% based on 25% of midazolam volume). Outcomes included post-anesthesia care unit times, observed behavioral distress (OBD) visual analog scale (VAS) (by nurse and parent), and sedation scores by certified registered nurse anesthetist (CRNA) and registered nurse (RN).

Results: Forty-two subjects were included, 14 in each group, with 52% female, 41% physical status 2, and an average age of 2.7 years. Post-anesthesia care unit times averaged 36.5 minutes (range 15-132 minutes), with no delay in discharge with INM or INM+L versus placebo (p=0.88). Verbal complaints were highest among INM+L at the time of administration (p=0.01). RN-scored OBD at one minute post administration differed significantly across the three groups (p=0.01). Parental OBD scores did not differ across treatment groups. Agitation was greatest at time of induction of anesthesia in the placebo group (p=0.01).

Conclusions: The addition of licodaine to INM does not adversely influence time to discharge and does not reduce side effects, improve efficacy, or change duration of action of INM.

Retrospective audit of midazolam dose and intravenous sedation record keeping in a primary care oral surgery service

Regular and robust audit of conscious sedation practice is key to the delivery of safe and effective patient care in all clinical settings. Analysis of outcomes will help to highlight any necessary modifications to procedures and techniques. The Intercollegiate Advisory Committee for Sedation in Dentistry (IACSD) states that conscious sedation procedures must be the subject of robust and regular audit in which every member within the team takes part.¹ This completed audit cycle highlighted the efficacy of intravenous (IV) midazolam in anxious patients undergoing oral surgical procedures and the suitability for its use in the primary care setting. No patient safety concerns or complications were recorded in this audit and midazolam was administered within the recommended dose range. By the conclusion of two audit cycles, all clinicians providing intravenous sedation within the service were aware of the missing elements in sedation record-keeping and were able to complete accurate contemporaneous records before, during and after conscious sedation, ensuring the continuous delivery of high-quality, safe, and patient-centred care.

Sexual hallucinations during conscious sedation for dentistry - an update of the phenomenon

Background Sexual hallucinations have been suggested as an infrequent side effect during sedation and cases can result in sexual assault allegations. The aim of this article is to review the literature on this rare side effect during sedation.Methods Publications were chosen using inclusion criteria: hallucinations and/or alleged sexual assaults and/or paradoxical reactions to either sedation or anaesthesia, that were of a sexual nature. Non-English language papers were excluded. Studies were analysed for: methodological quality, sedative agent, dose, population, treatment undertaken and outcome of the hallucination.Results Twenty-eight publications were reviewed. There was literature discussing sexual hallucinations to midazolam (13 studies), propofol (12 studies) and nitrous oxide (three studies). This side effect to sedative agents has a low incidence and can depend on factors like the sedation agent, dosage and type of procedure undertaken.Conclusions Current literature suggests that on rare occasions, sedation may induce sexual hallucinations and higher dosages are more likely to be implicated. In an occurrence of this side effect, presence of a third party and record-keeping is essential. Thorough patient assessment, appropriate clinician training and adhering to national dental sedation guidelines will help maintain the excellent safety record of UK dental sedation.

Sedation or General Anaesthetic for Special Care Patients?

When faced with an anxious patient with complex needs who requires dental care, it can be difficult to decide on the most appropriate method to manage their pain and anxiety. There are a range of conscious sedation techniques that may be used, and on some occasions, general anaesthesia may be required. This paper describes the methods available and the factors influencing the decision-making process. The general dental practitioner (GDP) may not be able to offer care in their setting, but knowing more about the decision-making process and the information required to make that decision can help them guide patients and their families.

The impact of 0.2% chlorhexidine gel on oral health and the incidence of pneumonia amongst adults with profound complex neurodisability

AIMS

Investigate the effect of toothbrushing with 0.2% chlorhexidine gel on oral health and pneumonia amongst patients with a neurodisability who are fed via percutaneous endoscopic gastrostomy.

METHOD

Forty-nine patients at the Royal Hospital for Neuro-disability were recruited to an observational study. Daily toothbrushing with 0.2% chlorhexidine gel was undertaken for 12 months by trained nursing staff. Plaque and gingival health were assessed every six weeks using the Simplified Debris Index and the Basic Periodontal Examination. The annual incidence and prevalence of episodes of pneumonia experienced by patients whilst using the chlorhexidine gel were compared to rates from the previous year.

RESULTS

Plaque levels and the proportion of patients with periodontal pocketing > 3.5 mm significantly reduced, P < .001, with chlorhexidine toothbrushing. Total number of pneumonia episodes (75-67), antibiotics administered (73-64), and radiographs taken (19 to 16) were lower in the year wherein chlorhexidine was employed, and hospitalisations dropped by 31% (16-11), but these reductions were not statistically significant. No adverse events were reported.

CONCLUSION

Daily toothbrushing with 0.2% chlorhexidine undertaken by a trained and supported nursing staff was effective in improving oral health but did not significantly affect annual rates of pneumonia amongst patients.

Safety and predictability of conscious sedation in dentistry -- a multi-centre regional audit: South and West Wales experience

INTRODUCTION

There are no previously published reports of audits in conscious sedation from a group comprising the general dental services (GDS), community dental services (CDS) and hospital dental services (HDS).

AIM

The main aim of this audit was to assess current practice within the group in relation to the safety and predictability of dental treatment undertaken with the aid of conscious sedation.

METHODS

A total of nine centres collected data prospectively on 1,037 sedation episodes over the course of one year. Audit standards were locally agreed based on current evidence and local experience. They were set at a completion rate of 90% and an adverse incident rate of 2% or less.

RESULTS

Based on the data collected, a completion rate of 92% and a minor adverse incident rate of 2.6% were recorded.

CONCLUSIONS

The participating centres met the standards set locally for this audit. Current practice in the participating centres was found to be safe and predictable. The audit tool is being refined to improve the quality of data collection. Further research and service evaluation is recommended.

Conscious sedation procedures using intravenous midazolam for dental care in patients with different cognitive profiles: a prospective study of effectiveness and safety

The use of midazolam for dental care in patients with intellectual disability is poorly documented. This study aimed to evaluate the effectiveness and safety of conscious sedation procedures using intravenous midazolam in adults and children with intellectual disability (ID) compared to dentally anxious patients (DA). Ninety-eight patients with ID and 44 patients with DA programmed for intravenous midazolam participated in the study over 187 and 133 sessions, respectively. Evaluation criteria were success of dental treatment, cooperation level (modified Venham scale), and occurrence of adverse effects. The mean intravenous dose administered was 8.8±4.9 mg and 9.8±4.1 mg in ID and DA sessions respectively (t-test, NS). 50% N₂O/O₂ was administered during cannulation in 51% of ID sessions and 61% of DA sessions (NS, Fisher exact test). Oral or rectal midazolam premedication was administered for cannulation in 31% of ID sessions and 3% of DA sessions (p<0,001, Fisher exact test). Dental treatment was successful in 9 out of 10 sessions for both groups. Minor adverse effects occurred in 16.6% and 6.8% of ID and DA sessions respectively (p = 0.01, Fisher exact test). Patients with ID were more often very disturbed during cannulation (25.4% ID vs. 3.9% DA sessions) and were less often relaxed after induction (58.9% ID vs. 90.3% DA) and during dental treatment (39.5% ID vs. 59.7% DA) (p<0.001, Fisher exact test) than patients with DA. When midazolam sedation was repeated, cooperation improved for both groups. Conscious sedation procedures using intravenous midazolam, with or without premedication and/or inhalation sedation (50% N₂O/O₂), were shown to be safe and effective in patients with intellectual disability when administered by dentists.

Guideline for oral healthcare of adults with Huntington’s disease

SUMMARY These guidelines present an overall strategy for oral healthcare based on the principles of achieving a disease-free, pain-free and safe mouth. The standards of care referred to in the document seek to provide guidelines for the care and treatment that is no less a standard provided for an individual that does not have this condition. Such care and treatment will take into account the health and safety of each individual within the context of their condition. Particular emphasis is placed on dental professionals working within a multidisciplinary team, focusing on prevention of oral disease and providing treatment appropriate to the various stages of the progression of this condition. It is intended that by providing and subsequently promoting these guidelines, it will focus the dental professions work on this condition and the implementation of good care for people with Huntington’s disease.

Complications Associated with Intravenous Midazolam Sedation in Anxious Dental Patients

Aim

This prospective study was designed to establish the nature, frequency and sequelae of complications arising in patients receiving dental treatment under intravenous midazolam sedation.

Methods

All patients attending the Sedation Department at Newcastle Dental Hospital for intravenous sedation over a six-month period were audited. A standardised data-collection pro forma was designed in order to collect data relating to the patient, the sedation episode, the dental treatment and any complications arising. The published standard used in this study states that the incidence of complications should be no more than 8%.

Results

Four hundred and one patients were included. The mean dose of midazolam administered was 7.6 mg with a mean titration rate of 0.9 mg/min. Complications were reported in 12 patients (3%), 11 of which were minor and one moderate. All complications were managed successfully within the department with no lasting sequelae. Treatment was completed in 382 (95.7%) patients, with failure to complete treatment in 17 (4.3%) patients due to disinhibition (1), poor cooperation (10), and the sedation wearing off (6).

Conclusion

The standard was met because complications arising were infrequent (3%) and predominantly minor in nature. Complications were managed conservatively and effectively, with all patients being discharged home the same day with no lasting sequelae. The study demonstrates that intravenous midazolam provides a safe sedation technique, suitable for adult dental patients in primary care, when administered by trained personnel on carefully selected patients and in accordance with nationally agreed protocols and guidelines.