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An alternative sedation option for special care patients: combined inhalation sedation with nitrous oxide and oxygen and intravenous sedation with midazolam

MA Healthcare
Dental Update
Authors:
Stephanie Fenesan at Hertfordshire Community NHS Trust
Stephanie Fenesan
Sadie Hughes
Sadie Hughes
Sadie Hughes
  • This person is not on ResearchGate, or hasn't claimed this research yet.
Neha Patel
Neha Patel
Neha Patel
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Abstract and Figures

This article highlights an alternative sedation technique by providing inhalation sedation with nitrous oxide and oxygen alongside intravenous sedation with midazolam as an additional option for patients within special care dentistry. Two case reports are described, as well as a short overview of the available literature on this technique and the indications, advantages and disadvantages. This technique should be considered alongside other sedation techniques. As with all treatment for which sedation is provided, each case needs to be considered on an individual basis and the most appropriate option selected following discussion with the patient. CPD/Clinical Relevance: Although single sedation techniques provide a good level of sedation to facilitate dental treatment for the majority of patients, it is desirable to have an awareness of alternative sedation options that may be available for patients.
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July/August 2021 DentalUpdate 533
Sedation
An Alternative Sedation Option
for Special Care Patients:
Combined Inhalation Sedation
with Nitrous Oxide and Oxygen
and Intravenous Sedation
with Midazolam
Enhanced CPD DO C
Stephanie Fenesan
Sadie Hughes and Neha Patel
Stephanie Fenesan, BDS Dip SCD RCS(Ed) MJDF RCS(Eng) BSc (Hons) AKC, Specialty
Trainee in Special Care Dentistry, Department of Sedation and Special Care Dentistry,
Guy’s Dental Institute, Guys and St Thomas’ NHS Foundation Trust. Sadie Hughes, BDS
MFDSRCPS MSc, Specialist in Special Care Dentistry, Hertfordshire Special Care Dental
Service, Hertfordshire NHS Community Trust, Hoddesdon Health Centre, Hoddesdon,
Hertfordshire. Neha Patel, BDS MFDS RCS(Ed) Dip DSed BSc (Hons), Senior Dental
Officer Hertfordshire Special Care Dental Service, Hertfordshire NHS Community Trust,
Marlowes Health and Well Being Centre, Hemel Hempstead, Hertfordshire.
email: stephaniefenesan@nhs.net
Abstract: This article highlights an alternative sedation technique by providing inhalation sedation with nitrous oxide and oxygen
alongside intravenous sedation with midazolam as an additional option for patients within special care dentistry. Two case reports are
described, as well as a short overview of the available literature on this technique and the indications, advantages and disadvantages.
This technique should be considered alongside other sedation techniques. As with all treatment for which sedation is provided, each case
needs to be considered on an individual basis and the most appropriate option selected following discussion with the patient.
CPD/Clinical Relevance: Although single sedation techniques provide a good level of sedation to facilitate dental treatment for the
majority of patients, it is desirable to have an awareness of alternative sedation options that may be available for patients.
Dent Update 2021; 48: 533–538
Conscious sedation has become
indispensable in the dental management
of patients in special care dentistry. Special
care dentistry includes the provision of
dental treatment for those who are unable
to accept routine dental care due to
physical, intellectual, medical, emotional,
sensory, mental or social impairment, or a
combination of these factors.1 These factors
can make it difficult for patients to accept
dental treatment without additional anxiety
management techniques, such as behaviour
management techniques, conscious
sedation or general anaesthesia (GA).
The Intercollegiate Advisory Committee
for Sedation in Dentistry (IACSD) defines
conscious sedation as: 'A technique in
which the use of a drug or drugs produces
a state of depression of the central nervous
system enabling treatment to be carried
out, but during which verbal contact with
the patient is maintained throughout
the period of sedation. The drugs and
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Nitrous Oxide and Midazolam Sedation: A Systematic Review and Meta-Analysis
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Nitrous oxide and midazolam have been used as sedative agents to decrease fear and anxiety associated with dental procedures. Although these agents have been widely used individually, the combination of the two is also commonly used. Four clinical trials were identified that compared the combination technique with the individual use of the drugs. The standardized mean difference (SMD) for each outcome measure was considered for final analysis. Three studies with 534 participants were included in the final meta-Analysis, and the SMD [95% CI] was obtained as -0.15 [-0.32, 0.03] and was not statistically significant for cooperation scores. Two studies reported the dose of midazolam required for inducing sedation in 450 participants, and the pooled estimate of SMD [95% CI] was obtained as -0.29 [-0.48, -0.10] and was significant. Two studies with 450 participants reported the time taken to recover from sedation, and the pooled estimate of SMD [95% CI] was obtained as -0.20 [-0.39, -0.01] and favored the combination technique. To conclude, the combination technique combines the pros and cons of both drugs in causing fewer adverse effects due to midazolam by reducing the total dose and also helps to provide better acceptance of nitrous oxide inhalation.
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The safety and efficacy of outpatient midazolam intravenous sedation for oral surgery with and without fentanyl
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This study examined midazolam and midazolam plus fentanyl in a placebo-controlled, double-blind clinical trial. It tested the hypothesis that combined drug therapy results in significantly poorer safety but no difference in efficacy compared to the single drug approach. Subjects were among 207 mildly anxious young adults having their third molars removed. Fentanyl had a significant depressant effect on respiration. Fifty of 79 (63%) subjects who received a midazolam-fentanyl combination became apneic, while only two of 78 (3%) who received midazolam alone were apneic (Fisher's Exact Test, P < 0.001). Two subjects (2.5%) in the combination group and none in the midazolam alone group had oxygen saturations drop below 90%. About twice as many subjects in the combination group had end-tidal carbon dioxide (EtCO2) levels greater than 25% above baseline. While these results are consistent with those for apnea, contingency analyses of the oxygen saturation and EtCO2 results were not statistically significant. Subjects in the combination group were more than four times as likely to have excellent versus good, fair, or poor sedation at a given level of intraoperative pain, and behavioral (movement and verbalization) but not cognitive measures of anxiety were attenuated.
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A cost analysis estimation of a single episode of comprehensive dental treatment under general anaesthesia for adults with disabilities
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Benzodiazepines: Sedation and Agitation
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  • Jan 2016
Dental anxiety is common and frequently poses a barrier to necessary dental treatment. The increasing availability of conscious sedation in dental practice has made treatment much more accessible for anxious patients. At present, benzodiazepines are the most commonly used drugs in sedation practice and provide a pleasant experience for most, but not all, patients. An understanding of the mechanism of action of benzodiazepines should inform our practice and deepen our understanding of why and how sedation may fail. CPD/Clinical Relevance: As an increasing number of dentists provide sedation for their patients an update on benzodiazepines is timely.
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Obesity has increased at an alarming rate in recent years. It is now a worldwide public health problem. The World Health Organisation (WHO) classifies obesity as a chronic disease. Affected individuals are at increased risk of hypertension, heart disease and other illnesses. There are also important social implications.Within dentistry and particularly in the provision of conscious sedation, obesity can be a potential complicating factor. For example, the position of anatomical landmarks may be less obvious if surrounded by fatty tissue. Very obese patients may be housebound or have difficulty accessing dental surgeries. Dental chairs may not be of an appropriate design to accommodate some obese patients. However, little information or advice on this topic is available in the literature.This article reviews obesity from a dental perspective. Challenges in providing dental care for obese patients are identified and practical recommendations made for their management.
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Basic science of climate change
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