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Effectiveness and safety of dentist-led conscious sedation using fentanyl with midazolam in dentistry: a five-year retrospective service evaluation

British Dental Journal (2023)Cite this article

Abstract

Background Fentanyl provides systemic analgesia and enhances the sedative effect of benzodiazepines. When midazolam-only sedation is ineffective, fentanyl can be considered as an adjunct, but this advanced sedation technique requires additional training. Studies reporting on the safety and effectiveness of dentist-led conscious sedation using fentanyl and midazolam are lacking.

Aims To review the indication of use, safety and effectiveness of fentanyl and midazolam sedation at The Royal London Dental Hospital since its introduction into the service.

Method Retrospective data collection of sedation cases from October 2016 to October 2021 was carried out.

Results Of the 109 cases included, the majority of patients who had fentanyl (90.8%) had a history of unsuccessful sedation with midazolam. A lower average dose of midazolam was administered when fentanyl was used; the difference was statistically significant (p <0.0001). A higher proportion of patients who had fentanyl and midazolam presented with lower Ellis scores (better operating condition) compared to midazolam-only sedation. No adverse incidents were recorded.

Conclusion In this evaluation, the synergistic effects of fentanyl and midazolam resulted in enhanced sedation, anxiolysis and intraoperative conditions. This service evaluation showed some encouraging data regarding the potential safety profile and effectiveness of fentanyl in dental sedation when used by experienced clinicians; however, larger scale studies are required to validate this.

Key points

  • Adding fentanyl to midazolam sedation improved operating condition, especially in patients with a history of failed midazolam sedation.

  • Fentanyl reduced the average dose of midazolam required to achieve the sedation endpoint.

  • The fentanyl-midazolam sedation technique showed low adverse events when carried out by trained personnel in a sedation-compliant environment; however, further larger scale studies are required to validate its safety profile.

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References

  1. Arrowsmith J B, Gerstman B B, Fleischer D E, Benjamin S B. Results from the American Society for Gastrointestinal Endoscopy/U.S. Food and Drug Administration collaborative study on complication rates and drug use during gastrointestinal endoscopy. Gastrointest Endosc 1991; 37: 421-427.

  2. Daneshmend T K, Bell G D, Logan R F. Sedation for upper gastrointestinal endoscopy: results of a nationwide survey. Gut 1991; 32: 12-15.

  3. NHS Digital. Adult Dental Health Survey 2009. 2011. Available at https://digital.nhs.uk/data-and-information/publications/statistical/adult-dental-health-survey/adult-dental-health-survey-2009-summary-report-and-thematic-series (accessed March 2022).

  4. Royal College of Surgeons of England. Standards for Conscious Sedation in the Provision of Dental Care: Report of the Intercollegiate Advisory Committee for Sedation in Dentistry. 2015. Available at https://www.rcseng.ac.uk/dental-faculties/fds/publications-guidelines/standards-for-conscious-sedation-in-the-provision-of-dental-care-and-accreditation/ (accessed December 2021).

  5. Ellis S. Response to intravenous midazolam sedation in general dental practice. Br Dent J 1996; 180: 417-420.

  6. Ben-Shlomo I, Abd-el-Khalim H, Ezry J, Zohar S, Tverskoy M. Midazolam acts synergistically with fentanyl for induction of anaesthesia. Br J Anaesth 1990; 64: 45-47.

  7. Moore P A, Finder R L, Jackson D L. Multidrug intravenous sedation: determinants of the sedative dose of midazolam. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997; 84: 5-10.

  8. Stander M, Wallis L A. Procedural sedation in the emergency centre. S Afr Med J 2011; 101: 195-201.

  9. Lobb D, Clarke A, Lai H. Administration order of midazolam/fentanyl for moderate dental sedation. J Dent Anesth Pain Med 2018; 18: 47-56.

  10. Hase I, Oda Y, Tanaka K, Mizutani K, Nakamoto T, Asada A. IV fentanyl decreases the clearance of midazolam. Br J Anaesth 1997; 79: 740-743.

  11. Ouchi K. Intravenous sedation accompanied with fentanyl is effective for intramaxillary fixation in trauma patients. Glob Anesth Perioper Med 2016; DOI: 10.15761/GAPM.1000144.

  12. Bennett J A, Abrams J T, Van Riper D F, Horrow J C. Difficult or impossible ventilation after sufentanil-induced anaesthesia is caused primarily by vocal cord closure. Anesthesiology 1997; 87: 1070-1074.

  13. Dionne R A, Yagiela J A, Moore P A, Gonty A, Zuniga J, Beirne O R. Comparing efficacy and safety of four intravenous sedation regimens in dental outpatients. J Am Dent Assoc 2001; 132: 740-751.

  14. Bailey P L, Pace N L, Ashburn M A, Moll J W, East K A, Stanley T H. Frequent hypoxaemia and apnea after sedation with midazolam and fentanyl. Anesthesiology 1990; 73: 826-830.

  15. Saiso K, Adnonla P, Munsil J, Apipan B, Rummasak D, Wongsirichat N. Complications associated with intravenous midazolam and fentanyl sedation in patients undergoing minor oral surgery. J Dent Anesth Pain Med 2017; 17: 199-204.

  16. Lord D A, Bell G D, Grey A et al. Sedation for Gastrointestinal Endoscopic Procedures in the Elderly: Getting Safer but Still Not Nearly Safe Enough. Br Soc Gastroenterol 2006.

  17. Craig D, Boyle C A. Practical Conscious Sedation. London: Quintessence Publishing, 2017.

  18. Welsh Government. Service Standards for Conscious Sedation in a dental care setting. 2018. Available at https://www.gov.wales/sites/default/files/publications/2019-03/service-standards-for-conscious-sedation-in-a-dental-care-setting.pdf (accessed May 2023).

  19. NHS England. Clinical guide for dental anxiety management. 2023. Available at: https://www.england.nhs.uk/long-read/clinical-guide-for-dental-anxiety-management/ (accessed May 2023)

  20. Scottish Dental Clinical Effectiveness Programme. Conscious Sedation in Dentistry: Guidance Development Methodology. 2017. Available at https://www.sdcep.org.uk/media/oxtb4tut/sdcep-conscious-sedation-methodology.pdf (accessed December 2022).

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Acknowledgements

The authors would like to thank the dental core trainees who were involved in the data collection for this project (Lucinda Simpson, Balpreet Sambi, Chloe Bass).

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Authors and Affiliations

  1. Speciality Trainee Registrar in Special Care Dentistry, Bart´s Health NHS Trust, United Kingdom

    Xin Hui Yeo

  2. Clinical Lead and Consultant in Special Care Dentistry, Bart´s Health NHS Trust, United Kingdom

    Zahra Shehabi

Authors
  1. Xin Hui Yeo
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  2. Zahra Shehabi
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Contributions

Xin Hui Yeo: study design, data collection, data analysis, interpretation of results and manuscript preparation. Zahra Shehabi: study proposal and design, supervision of data collection, review of results and data analysis and manuscript preparation. The final manuscript was reviewed and finalised by both authors.

Corresponding author

Correspondence to Xin Hui Yeo.

Ethics declarations

The authors declare no conflicts of interest.

Ethical approval was not required based on the Medical Research Council HRA toolkit: this is a retrospective service evaluation where the findings were not expected to be generalisable or comparable without a control group, the participants were not randomised and there was no change to usual clinical practice.

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Yeo, X., Shehabi, Z. Effectiveness and safety of dentist-led conscious sedation using fentanyl with midazolam in dentistry: a five-year retrospective service evaluation. Br Dent J (2023). https://doi.org/10.1038/s41415-023-5889-3

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