Key Points
-
Intravenous sedation in combination with inhaled nitrous oxide or inhaled nitrous oxide and sevoflurane provides a safe alternative to general anaesthesia in anxious paediatric dental patients.
-
With the appropriate staff, training and facilities, these conscious sedation techniques may be safely used in a 'non hospital setting' without the risk of 'deep sedation' or anaesthesia.
-
It is essential that future research in the field of paediatric conscious sedation be carried out in the United Kingdom.
Abstract
Aim To add to the evidence base for acceptable and effective paediatric conscious sedation techniques in dental primary care.
Objectives To compare three conscious sedation techniques for primary care as an alternative to dental general anaesthesia (DGA) in children. To assess the feasibility and practicality of running the trial in general dental practice. To form the basis for sample size calculations and assess scales of measurement.
Design Single centre, randomised control trial (RCT).
Setting Queensway Anxiety Management Clinic (QAMC). A primary care based general and referral dental practice for the management of anxious patients.
Subjects, materials and methods Sixty five children too anxious for management with relative analgesia, requiring invasive dental procedure for which dental general anaesthesia (DGA) will be required if an alternative cannot be found.
Interventions Group 1 (n = 20) — A combination of inhaled medical air and titrated intravenous midazolam. Group 2 (n = 22) — A combination of inhaled 40% nitrous oxide in oxygen and titrated intravenous midazolam. Group 3 (n = 23) — A combination of an inhaled mixture of 0.3% sevoflurane and 40% nitrous oxide in oxygen with titrated intravenous midazolam.
Main outcome measures Successful completion of the intended dental treatment with a child who is co-operative and responsive to verbal commands.
Results Fifty per cent (ten children) successfully completed treatment in Group 1, 73% (16 children) in Group 2 and 83% (19 children) in Group 3. This difference was not significant at a 5% level (χ2 = 5.53, df = 2, P = 0.07) Of the total of 20 failures, eight children in Group 1 and one child in Group 2 were successfully treated with the addition of sevoflurane and nitrous oxide in oxygen. Only two children required referral to a hospital setting for DGA and the remaining nine children were managed with an alternative conscious sedation technique.
Conclusion This pilot shows that intravenous midazolam especially in combination with the addition of inhaled nitrous oxide or sevoflurane and nitrous oxide were promising safe and effective techniques, sufficient to justify progression to a definitive RCT with appropriate methods.
Similar content being viewed by others
Log in or create a free account to read this content
Gain free access to this article, as well as selected content from this journal and more on nature.com
or
References
Veerkamp JS, Gruythuysen RJ, van Amerongen WE, Hoogstraten J . Dental treatment of fearful children using nitrous oxide. Part 2: The parent's point of view. ASDC J Dent Child 1992; 59: 115–119.
Scottish Intercollegiate Guidelines Network. Safe sedation of children undergoing diagnostic and therapeutic procedures. A national clinical guideline. 2002.
Harrison M, Nutting L . Repeat general anaesthesia for paediatric dentistry. Br Dent J 2000; 189: 37–39.
Holt RD, Chidiac RH, Rule DC . Dental treatment for children under general anaesthesia in day care facilities at a London dental hospital. Br Dent J 1991; 170: 262–266.
Department of health. A conscious decision. A review of the use of general anaesthesia and sedation in primary dental careW. London: Department of Health, 2000.
Worthington LM, Flynn PJ, Strunin L . Death in the dental chair: an avoidable catastrophe? Br J Anaesth 1998; 80: 131–132.
Rosen DA, Rosen KR . Intravenous conscious sedation with midazolam in paediatric patients. Int J Clin Pract 1998; 52: 46–50.
Shannon M, Albers G, Burkhart K, Liebelt E, Kelley M, McCubbin MM et al. Safety and efficacy of flumazenil in the reversal of benzodiazepine-induced conscious sedation. The Flumazenil Pediatric Study Group. J PediatrW 1997; 131: 582–586.
Hosey MT . UK National Clinical Guidelines in Paediatric Dentistry. Int J Paediatr Dent 2002; 12: 359–372.
Erlandsson AL, Backman B, Stenstrom A, Stecksen-Blicks C . Conscious sedation by oral administration of midazolam in paediatric dental treatment. Swed Dent J 2001; 25: 97–104.
Wilson KE, Welbury RR, Girdler NM . A randomised, controlled, crossover trial of oral midazolam and nitrous oxide for paediatric dental sedation. Anaesthesia 2002; 57: 860–867.
Wilson KE, Welbury RR, Girdler NM . A study of the effectiveness of oral midazolam sedation for orthodontic extraction of permanent teeth in children: a prospective, randomised, controlled, crossover trial. Br Dent J 2002; 192: 457–462.
Alcaino EA . Conscious sedation in paediatric dentistry: current philosophies and techniques. Ann R Australas Coll Dent Surg 2000; 15: 206–210.
Rang HP, Dale MM, Riller SH . Pharmacology. 4th edn, 1994.
Haraguchi N, Furusawa H, Takezaki R, Oi K . Inhalation sedation with sevoflurane: a comparative study with nitrous oxide. J Oral Maxillofac Surg 1995; 53: 24–26.
Ganzberg S, Weaver J, Beck FM, McCaffrey G . Use of sevoflurane inhalation sedation for outpatient third molar surgery. Anesth Prog 1999; 46: 21–29.
Hoerauf KH, Hartmann T, Zavrski A, et al. Occupational exposure to sevoflurane during sedation of adult patients. Int Arch Occup Environ Health 1999; 72: 174–177.
Ibrahim AE, Taraday JK, Kharasch ED . Bispectral index monitoring during sedation with sevoflurane, midazolam, and propofol. Anesthesiol 2001; 95: 1151–1159.
Katoh T, Bito H, Sato S . Influence of age on hypnotic requirement, bispectral index, and 95% spectral edge frequency associated with sedation induced by sevoflurane. Anesthesiol 2000; 92: 55–61.
Lahoud GY, Averley PA, Hanlon MR . Sevoflurane inhalation conscious sedation for children having dental treatment. Anaesthesia 2001; 56: 476–480.
Lahoud GY, Averley PA . Comparison of sevoflurane and nitrous oxide mixture with nitrous oxide alone for inhalation conscious sedation in children having dental treatment: a randomised controlled trial. Anaesthesia 2002; 57: 446–450.
Averley PA . Queensway Anxiety Management Clinic Referral Protocols. www.anxietymanagement.co.uk.. 2003.
Wong DL, Baker CM . Children's visual and verbal rating scale. Paediatr Nurs 1988 1988; 14: 1.
Venham L, Quatrocelli S . The young child's response to repeated dental procedures. J Dent Res 1977; 56: 734–738.
Girdler NM, Hill CM . Sedation in dentistry. 1st edn. London: Wright publications, 1998.
General Dental Council. Maintaining Standards November 2001. London: GDC, 2001.
Clinical guideline on the elective use of conscious sedation, deep sedation and general anaesthesia in pediatric dental patients. Chicago: American Academy of Pediatric Dentistry (AAPD), 1998.
Department of Health Review Group Chaired by the Chief Medical and Dental Officers. A Conscious Decision. London: Department of Health, 2000.
Department of Health. Department of Health circular (from the director of Health Services), letter to all GDPs, Health Authorities, NHS trusts and Dental Practice Board. London: Department of Health, 2001.
Malamed SF . Sedation, a guide to patient management. 3rd edn. Boston: Mosby publications, 1995.
Morton NS, Oomen GJ . Development of a selection and monitoring protocol for safe sedation of children. Paediatr Anaesth 1998; 8: 65–68.
Acknowledgements
The authors thank all the patients involved in this pilot study. They are grateful for the support of an NHS R&D National Primary Care Researcher Developers Award (2002). They thank consultant anaesthetists; I. Riddle, G. Lahoud, S. Gooneratne, N. Syresh and H. Mohan for their participation in running the studies. In addition we thank dental surgeons, S. Brown, M. Hanlon, O Hobman, U. Mansoor, B. Smith and A. Weston for their valuable contribution. We thank all the staff at QAMC for their hard work and Abbott Laboratories for providing the sevoflurane.
Author information
Authors and Affiliations
Corresponding author
Additional information
Refereed Paper
Rights and permissions
About this article
Cite this article
Averley, P., Lane, I., Sykes, J. et al. An RCT pilot study to test the effects of intravenous midazolam as a conscious sedation technique for anxious children requiring dental treatment — an alternative to general anaesthesia. Br Dent J 197, 553–558 (2004). https://doi.org/10.1038/sj.bdj.4811808
Received:
Accepted:
Published:
Issue date:
DOI: https://doi.org/10.1038/sj.bdj.4811808
This article is cited by
-
A comparison of the sedative effect of oral versus nasal midazolam combined with nitrous oxide in uncooperative children
European Archives of Paediatric Dentistry (2015)
-
Effectiveness and acceptability of intravenous sedation in child and adolescent dental patients: report of a case series at King's College Hospital, London
British Dental Journal (2011)
-
Is intravenous conscious sedation for surgical orthodontics in children a viable alternative to general anaesthesia? – a case review
British Dental Journal (2007)
-
Conscious sedation technique for anxious children
British Dental Journal (2004)
