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

British Dental Journal volume 233, pages 135–138 (2022)Cite this article

Abstract

Background Intravenous (IV) midazolam sedation is commonly used in the delivery of dentistry for phobic patients. There is currently no guidance on a maximum dose for use specifically in dentistry. Dentists practise with the British National Formulary recommended maximum dose of 7.5 mg; however, anecdotally, this is often exceeded. We aim to evaluate prescribing and propose recommendations for a maximum dose for dentists.

Method Data was collected from ten dentists across four Scottish health boards regarding their last 20 IV sedation patients, giving a total of 200. Data obtained from standard Dental Sedation Teachers Group IV logbooks included: dose of midazolam administered; justification for doses over 7.5 mg; flumazenil or supplemental oxygen usage; significant medical/social factors; and the Ramsay Sedation Score.

Results Mean midazolam dose was 6.1 mg with a range of 14 mg. The recommended maximum dose of 7.5 mg was exceeded in 28% of cases. The mean sedation score was 2.7 and there were no reported adverse events or use of flumazenil.

Conclusion IV midazolam is an effective way to achieve conscious sedation in dentistry. Acknowledgement of current off-label prescribing is important; however, 7.5 mg as a recommended maximum dose is too conservative as it is regularly exceeded without adverse events. Further investigation and expert opinion is required to set a maximum dose specifically for dentistry.

Key points

  • British National Formulary's intravenous midazolam recommended maximum dose of 7.5 mg was exceeded without adverse events in 28% of cases.

  • Intravenous midazolam doses over 7.5 mg are considered 'off-label' but are accepted as 'common practice' in dental conscious sedation where a single drug technique (midazolam) is used.

  • This study demonstrates intravenous midazolam doses from 1-15 mg were administered without adverse events.

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Acknowledgements

To West of Scotland Dental Sedation Group: data provided by members in NHS Ayrshire and Arran, NHS Lanarkshire, NHS Forth Valley and NHS Highland.

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Authors and Affiliations

  1. Oral and Maxillofacial Surgery, NHS Greater Glasgow and Clyde, Queen Elizabeth University Hospital, Glasgow, UK

    Hannah Lawler

  2. NHS Ayrshire and Arran, Public Dental Service, Ayr Hospital, UK

    Peter Walker

Authors
  1. Hannah Lawler
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  2. Peter Walker
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Contributions

Hannah Lawler: study design, data analysis, interpretation of results and draft manuscript preparation. Peter Walker: data collection and draft manuscript preparation. All authors reviewed the results and approved the final version of the manuscript.

Corresponding author

Correspondence to Hannah Lawler.

Ethics declarations

The authors declare no conflicts of interest.

As this audit was an evaluation of peers based on their logbooks, with no identifiable patient data included, it was advised by NHS Ayrshire and Arran that this research did not require ethical approval.

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Lawler, H., Walker, P. Evaluation of maximum dose intravenous midazolam used in dental intravenous sedation: a West of Scotland regional audit. Br Dent J 233, 135–138 (2022). https://doi.org/10.1038/s41415-022-4456-7

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