Intranasal/intravenous sedation for the dental care of adults with severe disabilities: a multicentre prospective audit

Re-audit of the use of flumazenil following midazolam-induced conscious sedation

INTRODUCTION

Flumazenil is an antagonist drug of Benzodiazepam (BDZ) that has been used as a reversal agent of midazolam-induced conscious sedation (CS) in both emergency and elective procedures. For CS procedure, a high-quality record keeping and clinical justification prior to admission of flumazenil are recommended. Clinical Audit (CA) enables clinicians to evaluate the quality and standard of recorded clinical procedures.

METHODS

This re-audit investigated the reasons for the use of flumazenil and record keeping's quality with particular emphasis on CS. In this retrospective reaudit, the authors looked at the patients' records who had received dental care under CS in the Sedation and Special Care Department of (SSCD), United Kingdom from January to June 2022.

RESULTS

Out of 665 patients who received midazolam-induced CS, 21 patients were administered IV Flumazenil. The commonest reason (9, 42.8%) was due to prolonged recovery.

CONCLUSION

This re-audit highlighted the need for administrating flumazenil in certain patient groups, and/or circumstances (not emergency). The importance of maintaining high-quality record keeping is discussed.

Conscious Sedation for Dental Treatments in Subjects with Intellectual Disability: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis was aimed to investigate the conscious sedation efficiency in patients with intellectual disability undergoing dental treatment (PROSPERO CRD42022344292). Four scientific databases were searched by ad-hoc prepared strings. The literature search yielded 731 papers: 426 were selected, 42 were obtained in full-text format, and 4 more were added after hand searching. Fourteen studies were finally included, 11 of which were included in the meta-analysis (random effect model). A high heterogeneity in the drugs used and route of administration was retrieved. Success rate, occurrence of side effects, and deep sedation occurrence were combined to give an overall efficiency of each drug. N2O/O2 reported the highest efficiency (effect size = 0.90; p < 0.01) and proved to be more efficient when used alone. Nine papers reported a success rate of sedation of 80% or more. The prevalence of side effects (6 studies) ranged from 3% to 40%. Enteral and parenteral benzodiazepines showed the same overall efficiency (effect size = 0.86). No meta-analysis has yet been conducted to define the most effective and safest way to achieve conscious sedation in patients with intellectual disability; nitrous oxide appears to be the best choice to perform conscious sedation in patients with intellectual disability undergoing dental treatment.

Quality of dental treatments under intravenous sedation among patients with disability: A self-matching study

Background/purpose

Patients with disabilities usually have difficulties in communication and mobility, and the quality of the dental treatments are often inferior. This study uses the Taiwan National Health Insurance Database to analyze the quality of dental treatment for patients with disabilities who receive intravenous sedation (IVS).

Materials and methods

This study selected patients with disabilities who received dental treatment under IVS. Their oral cavity was divided into three major sections: anterior teeth, upper posterior teeth, and lower posterior teeth. Self-matching of the same section was conducted to observe whether operative dental treatment (OD) with or without IVS affected the occurrence of dental retreatment. This study observed the occurrence of refilling and the duration from the end of treatment until retreatment to compare treatment differences with or without IVS.

Results

After self-matching, this study found 158 patients who received dental treatment within the same section with and without IVS. During a follow-up period of 17 years, 75.18% of the patients who received OD treatment required refilling, 10.87% required endodontic treatment, and 5.67% required tooth extraction. After OD treatment with IVS, the risks of refilling, endodontic treatment, and tooth extraction were 0.71 (95% CI: 0.58-0.87, P < 0.001), 0.77 (95% CI: 0.48-1.23, P = 0.28), and 0.64 (95% CI: 0.32-1.27, P = 0.20), respectively.

Conclusion

For patients with disabilities, OD treatment with IVS significantly reduces the risk of refilling compared with OD treatment without IVS. IVS can be ideal for people with disabilities who receive dental treatment.

Effects of antipsychotics on intravenous sedation with midazolam and propofol during dental treatment for patients with intellectual disabilities

BACKGROUND

Some patients with intellectual disabilities (ID) are prescribed antipsychotic drugs for symptomatic treatment of behavioural disorders. Nevertheless, it can still prove difficult to perform dental treatments safely for some patients with ID. In such cases, treatment under intravenous sedation (IVS) is one option. Sedative, hypnotic and α-blocking effects of antipsychotic drugs may cause adverse events, such as severe hypotension, among patients who take antipsychotic drugs regularly. This study aimed to investigate the effects of oral antipsychotic medication on cardiovascular function during IVS. Accordingly, we compared mean blood pressure (MBP) and heart rate (HR) between patients who regularly take antipsychotic drugs and patients who do not.

METHODS

Thirty-seven patients with ID were enrolled in this study. All participants were outpatients of Special Care Dentistry of general hospital and received dental treatment under IVS performed with a combination of midazolam and propofol. Eighteen patients regularly took antipsychotics (medication group), and 19 patients were not currently taking antipsychotics (non-medication group). MBP, HR, dose, and effect-site concentration of intravenous sedative medications were measured at three points: 'before IVS', 'at optimal sedation', and 'during dental treatment'.

RESULTS

The magnitude of reduction of MBP was significantly smaller in the medication group than in the non-medication group (P < 0.023). However, there were no differences in MBP, HR, dose, and effect-site concentration of midazolam and propofol between groups at any point.

CONCLUSION

These results suggest that antipsychotic medication may not have clinically significant adverse effects on cardiovascular fluctuations during dental treatment under IVS for persons with ID.

Audit of flumazenil use in special care and oral surgery sedation services

Background The National Patient Safety Agency (2008) has advised against routine reliance on flumazenil for reversal of sedation and encourages regular audit to help identify issues with excessive dosing of midazolam. This multi-centre audit of flumazenil use across both community-based special care and dental hospital oral surgery specialist services was conducted to compare practice against that reported from other UK sedation services.Methods A six-year retrospective audit was conducted using controlled drug records and patient case notes.Results Both services used flumazenil at very infrequent levels and far below the agreed standard. The dose of flumazenil and justification for its use was recorded in all records. There was variability in the nature of the justifications between the two services, which likely relates to the differing patient groups seen by the specialties. The majority of cases related to supporting the patient's escort for their journey home; however, this was not always pre-planned.Conclusions There was a low level of flumazenil use over an extended period of time, supporting the concept of a culture of safe sedation provision in both services. The audit highlighted variation in record-keeping and need for improved communication with patients about escort requirements.

Intranasal midazolam for the sedation of geriatric patients with care-resistant behaviour during essential dental treatment: An observational study

OBJECTIVES

To describe the efficacy and safety of intranasal midazolam for sedation during essential dental treatment of geriatric patients with major neurocognitive disorder (MND) and care-resistant behaviour (CRB).

BACKGROUND

Dental treatment is often impossible in geriatric MND patients with CRB. Intranasal midazolam may provide a non-invasive sedation method, but there is currently no information on its use in geriatric patients.

METHODS

In this observational study, we included geriatric patients with severe MND and CRB needing urgent dental treatment. Each patient received 5 mg midazolam intranasally. Agitation/sedation levels, heart rate, respiration rate and oxygen saturation were recorded at 5-minute intervals.

RESULTS

Thirty two patients were included. Mean age was 84 (±7) years. Mean (SD) time to treatment start was 13 (±5) minutes, and mean time to maximum sedation 17 (±11) minutes. Sedation was sufficient to enable dental treatment to be completed in 31 (97%) patients. Anxiolysis/light sedation occurred in 16 (50%) patients, and moderate to deep sedation occurred in 16 (50%) patients. No patients suffered from apnoea, although 3 patients required a chin-lift manoeuvre. Hypoxaemia occurred in 1 of these patients and in 2 other patients without airway obstruction. All patients recovered uneventfully. In a regression model, age, weight and other sedative medication use were found not to be associated with maximum sedation depth.

CONCLUSIONS

Of 5 mg intranasal midazolam facilitates treatment of geriatric patients with MND in the comfort of their own environment. More information is needed to guide titration to balance the desired sedation level and patient safety.

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.

The feasibility of office-based propofol sedation for dental care in patients with intellectual disability by sedation practitioners

BACKGROUND

The quality of oral health care for intellectually disabled patients is a significant challenge due to behavioral issues. Intravenous propofol sedation may be useful to relieve the anxiety and fear, and make dental procedures more acceptable. The aim of this study was to evaluate the safety and effectiveness of propofol sedation, by trained nonmedical sedation practitioners, during dental treatments in an office-based setting.

METHODS

Intellectually disabled patients (124) were subjected to restorative dental procedures and moderately sedated using intravenous propofol. Vital signs, cooperation of the patient, and sedation depth were continuously assessed.

RESULTS

Propofol sedation was effective for dental treatment. All procedures resulted in a sufficient level of sedation without moderate or severe complications.

CONCLUSION

Propofol sedation can be safely and effectively performed in an office-based setting by sedation practitioners, who have experience in propofol sedation and are trained in the care of patients with disabilities.

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.

Risk factors with intravenous sedation for patients with disabilities

The purpose of this study was to identify the risk factors associated with low peripheral oxygen saturation (SpO2) and delayed recovery of dental patients with disabilities after intravenous sedation. A total of 1213 patients with disabilities were retrospectively investigated with respect to demographic parameters and sedation conditions. Multivariate logistic analyses were conducted for patients with an SpO2 <90% and a recovery period of >60 minutes to identify the risk factors for poor sedation conditions. A significant odds ratio related to decreased SpO2 was observed for age, sex, midazolam and propofol levels, concurrent use of nitrous oxide, cerebral palsy, Down syndrome, and mental retardation. The most problematic patients were those diagnosed with Down syndrome (odds ratio, 3.003-7.978; 95% confidence interval; P < .001). Decision tree analysis showed an increased risk of decreased SpO2 in males with Down syndrome or after administration of >0.493 mg/kg propofol in combination with midazolam. An increased risk of delayed awakening was seen in patients aged less than 21 years and in males administered >0.032 mg/kg of midazolam. Intravenous sedation for dental patients with disabilities, particularly those with cerebral palsy, Down syndrome, or mental retardation, increases the risk of decreased SpO2. In addition, delayed recovery is expected after midazolam administration.