Can intravenous conscious sedation with midazolam be effective at facilitating surgical dentistry in adolescent orthodontic patients? A service evaluation.

Background Surgical dentistry during orthodontic care often occurs in adolescence and may involve surgical removal or exposure of teeth. The invasive nature of treatment, combined with dental anxiety, means care can often be provided under general anaesthesia (GA). Best-practice guidelines however endorse conscious sedation as an alternative, where appropriate. Although a limited number of studies have shown safe and effective use of intravenous conscious sedation (IVCS) with midazolam in this cohort, robust evidence to support routine use is lacking. Aim To assess whether IVCS with midazolam can effectively facilitate surgical dentistry in adolescent orthodontic patients in primary care.Method A retrospective service evaluation was undertaken reviewing clinical records of adolescents (aged 12-15 years) undergoing surgical exposure and/or surgical removal of teeth under IVCS with midazolam.Results A total of 174 adolescents (mean age 14.2 years) attended for treatment between 2009 and 2015. Of these adolescents, 98.9% (N = 172) allowed cannulation, with all surgical dentistry completed during a single visit. Midazolam dose ranged from 2-7 mg with 79.1% of patients having good or excellent cooperation and three minor adverse events occurring.Conclusion This service evaluation shows IVCS with midazolam can effectively facilitate surgical orthodontics in carefully selected adolescents. There is however a distinct need to further explore potential for this technique to provide a viable alternative to GA.

Investigation of inhalational conscious sedation as a tool for reducing anxiety in adults undergoing exodontia.

AIM: To determine whether adult patients' dental anxiety levels decrease following exodontia carried out under inhalational conscious sedation with nitrous oxide and oxygen (IHS) and local anaesthetic (LA). DESIGN: Retrospective analysis of pre- and post-operative modified dental anxiety score (MDAS) questionnaires completed by patients treated in a primary care oral surgery service between 21 July 2010 and 17 December 2010. METHODOLOGY: 138 patients who had undergone exodontia were divided into three groups: moderate to severe anxiety (MDAS scores 11-25) treated under IHS and LA (n = 60), mild anxiety (MDAS scores 5-10) treated under IHS and LA (n = 43) and mixed anxiety (MDAS scores 5-15) treated under LA only (n = 35). The mean pre- and post-operative MDAS scores were analysed by means of one-tailed, paired t-tests. RESULTS: The moderate to severely anxious group treated under IHS and LA showed a statistically significant decrease of 3.68 between the mean pre- and post-operative MDAS scores (p = 0.000). The IHS mildly anxious group showed a decrease of 0.07 (p = 0.392) and the LA group showed a decrease of 0.23 (p = 0.227). Neither of these results were statistically significant. CONCLUSION: These results support the use of IHS, to reduce anxiety of exodontia, in moderate to severely anxious adults undergoing minor oral surgery (MOS) procedures under LA in primary care oral surgery.

Is intravenous conscious sedation for surgical orthodontics in children a viable alternative to general anaesthesia?--a case review.

AIM: The aim of this case review was to describe the use of local anaesthesia (LA) and intravenous conscious sedation (IVCS) as a safe and effective means of managing patients requiring surgical orthodontic procedures as an alternative to general anaesthesia (GA) in children between the age of 11 and 15 years. MAIN OUTCOME MEASURES: 1) Whether treatment was completed, partially completed or not completed; 2) assessment of physiological parameters to verify safety profile of the technique. METHODS: Records were reviewed retrospectively for all patients included in the series undergoing planned surgical orthodontic procedures between January 2001 and January 2004 under IVCS. All patients had been pre-assessed and deemed to be of sufficient mental and physical maturity to be treated with IVCS. Written informed consent was gained from patients and their parents/guardians with full discussion of the alternative pain and anxiety control methods available including GA. All cases were undertaken by experienced SAS grade surgeons assisted by two dental nurses holding the certificate in dental sedation nursing and their recovery was supervised by registered general nurses. Patients were clinically monitored throughout together with continuous pulse oximetry and intermittent recording of non invasive blood pressure and pulse at 10-15 minute intervals. Patients were reviewed post operatively and any complications or comments noted. RESULTS: Over a three year period a total of 107 patients underwent surgical procedures to aid orthodontic treatment, 28 (26%) under IVCS and 79 (74%) under GA. Twenty-five out of 28 patients in the IVCS group successfully completed all of their planned treatment. CONCLUSIONS: Based on this case series, IVCS would appear to offer a safe and effective alternative to GA for this group of patients providing they are selected and managed by an appropriately trained team in a suitable setting. Further prospective evidence is needed if IVCS is to be recommended for general dental treatment in patients under the age of 16 years.

The use of an intra-oral injection of ketorolac in the treatment of irreversible pulpitis.

AIM: To examine whether an intra-oral injection of a nonsteroidal anti-inflammatory drug (ketorolac), in association with conventional local anaesthetic techniques, would improve the pulp extirpation rate in teeth with irreversible pulpitis. METHODOLOGY: A two group double-blind clinical trial was undertaken in the Dental Casualty Department of the University of Manchester School of Dentistry. Patients were randomly allocated to either the test or control group. The test group received an intra-oral injection of ketorolac (30 mg in 1 mL) in the buccal sulcus adjacent to the tooth being treated. After an interval of 15 min, they then received 2.2 mL of 2% lidocaine with 1 : 80 000 epinephrine by buccal infiltration in the maxilla or by inferior dental block in the mandible. The control group received an intra-oral injection of normal saline (1 mL) in the buccal sulcus adjacent to the tooth being treated, followed by the same local anaesthetic regime as the test group after the 15 min interval. Fifteen minutes after the local anaesthetic injections, pulp extirpation was attempted. All patients completed the short-form McGill pain questionnaire prior to treatment and completed identical questionnaires at 6 and 24 h after treatment. RESULTS: The study protocol set the number of patients to be treated at twenty. However, as the study progressed it became apparent that the intra-oral injection of ketorolac caused significant pain to four of the five patients who received it; therefore the study was terminated after ten patients had been treated. The results from the patients treated showed no significant difference in the pulp extirpation rate between the test and control groups. However, patients with higher pain scores at baseline were less likely to have the pulp completely extirpated, irrespective of whether they were in the test or control group. Pain scores for all patients decreased significantly from baseline to 24 h. CONCLUSION: An intra-oral injection of ketorolac did not improve the pulp extirpation rate in a small group of patients with irreversible pulpitis compared with a placebo. In addition, it was associated with such significant pain on injection that it cannot be recommended as a treatment in this situation.