Hemodynamics and oxygen saturation during intravenous sedation for office-based laser-assisted uvuloplasty.

PURPOSE: Patients undergoing office-based laser-assisted uvuloplasty (LAUP) for snoring or mild obstructive sleep apnea are generally obese and have a high Mallampati score. Because avoidance of supplemental oxygen during laser procedures is generally mandated, the potential for intraoperative desaturation is high. This study was designed to look at intraoperative hemodynamic changes, respiration patterns, and oxygen saturations during intravenous sedation with midazolam and fentanyl during LAUP procedures. MATERIALS AND METHODS: This was a retrospective anesthesia chart review of 15 consecutive patients undergoing midazolam/fentanyl intravenous sedation for office-based LAUP treatment for snoring and/or mild obstructive sleep apnea. Data recorded were noninvasive baseline and intraoperative hemodynamic measurements at 5-minute intervals for systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), pulse pressure (PP), pulse (P), and rate-pressure product (RPP). Data collected were reported as mean values with standard deviation. Statistical analysis using the Student's t test was performed and found significant for P<.05. RESULTS: All changes from baseline were statistically insignificant, SBP (P=.4), DBP (P=.2), MAP (P=.2), P (P=.1), PP (P=.9), RPP (P=.5), RR (P=.9), and SpO2 (P=.4), and all within +/-20% of baseline (range, -5.0% to +7.5%). CONCLUSION: Midazolam and fentanyl intravenous sedation with local anesthesia maintained intraoperative hemodynamic and oxygenation variables close to baseline for office-based LAUP procedures.     

Intensity and duration of amnesia from intravenous midazolam given for sedation

A clinical study was performed investigating the ability of intravenous midazolam to cause amnesia for visual, auditory and painful stimuli presented during surgical removal of third molars. Various stimuli were presented prior to and after administration of a sufficient quantity of midazolam to produce profound sedation. Recall was then tested immediately after, one day, and one week following the surgery. The study found that midazolam produces at least 20 minutes of profound amnesia for all stimuli in 93 +/- 6% of individuals. However, little correlation was found between the dose of midazolam and the duration of amnesia. Anesthesia literally means the loss of sensation. In the clinical dental situation, the principle sensation lost, when using either regional or general anesthesia, is pain perception. Although prevention of pain sensation is the primary reason patients request local anesthesia prior to invasive dental care, for many patients, control of pain only partially prepares them to receive dental care. These patients request the adjunctive use of sedation or general anesthesia, not for further pain control, but rather requiring periodontal or oral/maxillofacial surgery in which such factors as the sight and taste of blood, the noise of bone-cutting equipment, or the pressure placed on the jaws is not eliminated by local anesthetics. Although effective anxiolytic oral, inhalational, or parenteral agents have been available for several decades, patients still usually retain their memory of events occurring during their dental care, particularly anxiety-provoking events. This memory of the uncomfortable portions of dental care stimulates additional anxiety so that patients may procrastinate when dental care is necessary.(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparing efficacy and safety of four intravenous sedation regimens in dental outpatients.

BACKGROUND: Management of patients' fear and anxiety during dental treatment is a primary concern of dental practitioners. Pharmacological strategies used in outpatient dental settings must be both safe and effective. Regimens of intravenously administered sedative drugs were evaluated in a collaborative, multicenter study of outpatients undergoing removal of impacted third molars. METHODS: A total of 997 patients randomly received one of five treatments: placebo; midazolam administered to a clinical endpoint of conscious sedation (mean dose, 8.6 milligrams); midazolam plus additional midazolam as needed during the procedure (mean total dose, 12.2 mg); fentanyl (1.4 micrograms/kilogram) plus midazolam to achieve the same endpoint of conscious sedation (mean dose, 5.7 mg); or fentanyl (1.4 (micrograms/kg), midazolam (mean dose, 5.8 mg) and methohexital as needed during the procedure (mean dose, 61.0 mg). RESULTS: Each drug regimen reduced anxiety during surgery in comparison with placebo, with the combination of midazolam, fentanyl and methohexital resulting in significantly less anxiety in comparison with the other treatment groups. Pain reports by patients during surgery also were reduced significantly by the combination of fentanyl, midazolam and methohexital. Patients' global evaluations of the efficacy of sedation ranked midazolam with supplemental midazolam and the combination of fentanyl, midazolam and methohexital as significantly more efficacious than the other two drug regiments. The authors noted transient respiratory depression in patients in the two opioid-treated groups, but no other physiological changes were detected. CONCLUSIONS: These data provide evidence that the drugs and doses evaluated resulted in therapeutic benefit to dental outpatients, with minimal incidence of potentially serious adverse effects. CLINICAL IMPLICATIONS: The results of this large-scale study provide assurance to both the public and the dental profession of the safety of parenteral sedation with these drugs and combinations of these drugs when titrated slowly in the recommended doses by appropriately trained dentists.     

Conscious sedation by oral administration of midazolam in paediatric dental treatment

Midazolam is a short-acting benzodiazepine with rapid onset, short duration of action and minimal side effects. The aim of this study was to evaluate the oral administration of midazolam as pre-operative sedation in the dental treatment of uncooperative pediatric patients. Included in the study were 160 children with a mean age of 6.7 +/- 2.6 years (1-14 years), 83 boys and 77 girls. All the patients had been referred for specialist treatment due to behavioral management problems. Treatment was performed in 250 sessions. All the children received an oral dose of 0.2 mg/kg body weight of midazolam. Acceptance of treatment was evaluated according to Rud & Kisling. Local anesthesia followed by restorative treatment and/or extractions constituted more than 90% of the performed treatments. Of the 250 sessions, 63% were performed with total acceptance and 30% with doubtful acceptance. In 7%, no treatment could be performed. No serious complications were registered during or after treatment. All the children were able to leave the clinic one hour after treatment. In conclusion, we consider oral administration of midazolam a safe form of premedication. The route of administration, the short waiting-time and half-life, in combination with a level of sedation that allows treatment to be performed, are the principal advantages of conscious sedation with orally administered midazolam.     

Comparison of remifentanil with fentanyl for deep sedation in oral surgery.

PURPOSE: The aim of this study was to compare recovery for oral surgery patients given a deep sedation regimen of midazolam, propofol, and remifentanil with a standard control of fentanyl in place of remifentanil. MATERIALS AND METHODS: This investigation was designed as a randomized, prospective, single-blinded controlled study. Group 1, the control, received midazolam 0.03 mg/kg, fentanyl 1 microg/kg, and propofol initially at 140 microg/kg/min. Group 2 received midazolam 0.03 mg/kg, remifentanil: propofol (1:500) given at an initial propofol infusion rate of 40 microg/kg/min. Outcome measures included time to response to verbal command, Aldrete score = 9, Postanesthesia Discharge Scoring System = 7, and assessment by the Digit Symbol Substitution Test. RESULTS: Forty-seven subjects were entered in the study. Baseline findings were homogenous between the 2 groups. Subjects in group 2 recovered earlier (P < .005) and required less propofol for both the induction (0.8 +/- 0.4 versus 1.2 +/- 0.6 mg/kg; mean +/- SD, P < .01) and maintenance of deep sedation (46 +/- 9 versus 131 +/- 17 microg/kg/min; P < .005). There were minor differences in vital signs. CONCLUSIONS: This study demonstrated that this remifentanil regimen provided significantly more rapid recovery and used significantly less propofol compared with the fentanyl regimen.     

IV sedation in pediatric dentistry: an alternative to general anesthesia.

This prospective study was conducted to determine the sedative effects of IV ketamine and fentanyl on vital signs and behavior. Twenty-seven children, classified as ASA I, with a mean age of 34 months, were studied. The dosages of IV ketamine and fentanyl given were 0.5 mg/kg and 0.5 mcg/kg, respectively, approximately every 15-20 min. The pulse rate averaged 125 throughout the case. Blood pressure averaged 112/64. The respiration rate averaged 22 breaths per min. Mean behavior composite scores were 1.9 at the initial examination and 3.3 during treatment. One child vomited during treatment. Post-treatment complications were discomfort in 19% (5), nausea in 22% (6), and vomiting in 15% (4) of the patients. We concluded that IV sedation of precooperative healthy pediatric patients with ketamine, fentanyl, and nitrous oxide/oxygen appears to be a safe and effective sedation modality with minimal side effects when administered and monitored by a qualified anesthetist, offering the practitioner an alternative to general anesthesia.     

Temperament and acceptance of dental treatment under sedation in preschool children

The major aim of the study was to investigate whether differences concerning acceptance of dental treatment and amnesia after rectal sedation with midazolam can be explained by temperament traits in the child. Fifty children (1.5 4.0 years), consecutively referred for dental extractions because of dental trauma or caries, were sedated with midazolam 0.3 mg kg(-1) rectally. Level of sedation (state of mind) was assessed according to Wilton before and 10 min after administration of the sedative. The children's acceptance of procedures during the oral examination, the administration of the sedative, and the dental treatment were assessed according to Holst. Acceptance of an injection of local anesthesia and tooth extraction was dichotomized as satisfactory (n = 26) or unsatisfactory (n = 24). The parent assessed temperament using the Emotionality Activity Sociability (EAS) Scale of Child Temperament. Amnesia was evaluated by the parent on the following day. The relation between temperament and outcome variables was analyzed using a multiple logistic regression analysis. Children regarded as shy by the parent were at significantly greater risk of unsatisfactory acceptance of the dental treatment (P< 0.05). High scores of negative emotionality were significantly related to less amnesia (P < 0.05). We conclude that parental ratings of their child's temperament are valuable in predicting a child's acceptance of dental treatment under sedation.     

Rectal sedation with diazepam or midazolam during extractions of traumatized primary incisors: a prospective, randomized, double-blind trial in Swedish children aged 1.5-3.5 years.

The aim of this study was to compare rectal sedation with diazepam and rectal sedation with midazolam with regard to sedative effect, treatment acceptance, and amnesia. Ninety children, 1.5-3.5 years of age, consecutively referred for extractions of traumatized primary incisors were randomly sedated with diazepam (0.7 mg/kg body weight) or midazolam (0.3 mg/kg body weight). The study design was randomized and double-blind. The level of sedation (state of mind) was assessed prior to and 10 and 60 min after administration of the drug by use of a behavioral scale (Wilton). The children's acceptance of procedures was assessed using another behavioral scale (Holst) during administration of the sedative, application of topical anesthesia, injection of a local anesthesia, and extraction. Amnesia was evaluated by the parents on the following day, with the child being asked standardized questions. Parental ratings of the child's and their own distress during and after treatment were made on a visual analog scale (VAS). No differences were found between the sedatives concerning level of sedation during treatment, acceptance of procedures, or amnesia. At discharge, 60 min after administration of the sedative, the children receiving diazepam were significantly more agitated (P=0.006). Parental rating on a VAS of the child's discomfort after treatment was significantly higher in the diazepam group (P=0.006). There was a tendency for children with poor acceptance of the rectal administration to display a more negative acceptance of the dental treatment. In conclusion, the present results, in combination with known pharmacological advantages, indicate that midazolam is preferable in outpatients when sedation is needed and amnesia is desirable.     

Reversal of midazolam sedation with flumazenil following conservative dentistry

The purpose of this double-blind randomized study was to assess recovery of mental function following reversal of midazolam-induced sedation with the specific antagonist flumazenil (R015-1788) or placebo following conservative dental procedures. Recovery was assessed using choice reaction time and critical flicker fusion threshold, both objective tests of psychomotor function; linear analogue sedation scores and simple memory tests. Assessments were repeated up to 3 h after administration of flumazenil or placebo to discover whether recovery was sustained or whether resedation occurred due to the short duration of action of flumazenil. Flumazenil in doses from 0.5 to 1.0 mg rapidly reversed the sedative and amnesic effects of a mean dose of 8.2 mg of midazolam without apparent evidence of subsequent resedation. Since recovery of mental function in the control group had ordinarily occurred 45 min after administration of placebo, routine reversal of midazolam sedation with flumazenil cannot be justified. Nevertheless, in cases of undue sedation persisting after dental treatment, flumazenil may be used with minimal risk of resedation occurring.     

Temperament and acceptance of dental treatment under sedation in preschool children

The major aim of the study was to investigate whether differences concerning acceptance of dental treatment and amnesia after rectal sedation with midazolam can be explained by temperament traits in the child. Fifty children (1.5-4.0 years), consecutively referred for dental extractions because of dental trauma or caries, were sedated with midazolam 0.3 mg kg^-1 rectally. Level of sedation (state of mind) was assessed according to Wilton before and 10 min after administration of the sedative. The children's acceptance of procedures during the oral examination, the administration of the sedative, and the dental treatment were assessed according to Holst. Acceptance of an injection of local anesthesia and tooth extraction was dichotomized as satisfactory (n = 26) or unsatisfactory (n = 24). The parent assessed temperament using the Emotionality Activity Sociability (EAS) Scale of Child Temperament. Amnesia was evaluated by the parent on the following day. The relation between temperament and outcome variables was analyzed using a multiple logistic regression analysis. Children regarded as shy by the parent were at significantly greater risk of unsatisfactory acceptance of the dental treatment (P < 0.05). High scores of negative emotionality were significantly related to less amnesia (P < 0.05). We conclude that parental ratings of their child's temperament are valuable in predicting a child's acceptance of dental treatment under sedation.     

The effects of midazolam on pediatric patients with asthma

PURPOSE: This study was performed to evaluate the safety and efficacy of midazolam in asthmatic patients undergoing dental treatment. METHODS: Twenty-four children, aged 19 to 65 months, with a diagnosis of mild to moderate asthma were given an oral dose of 0.5 mg/kg of midazolam. Oxygen saturation, respiratory rate, and pulse rate were monitored before, during, immediately after, and 30 minutes following dental treatment. The child's asthma score was also determined before and after treatment. The dental operator assessed the overall sedation outcome immediately after treatment. RESULTS: Twenty-three of the 24 subjects had asthma scores of "0" before and after treatment. During dental treatment, 2 patients had oxygen saturations of 94% at one point during treatment. However, oxygen saturation increased when the patient's head and neck were repositioned. Twenty-three of the 24 subjects had oxygen saturations above 95% at 30 minutes following treatment. Pulse rates and respiratory rates exhibited transitory increases, linked to when the child was stimulated. Statistical analysis was conducted from within subjects repeated measures via ANOVA and with a general linear model approach. No statistically significant differences occurred in oxygen saturation and respiratory rate. However, significant differences did occur in pulse rate between 5 and 10 minutes (mean difference=10+/-3.84) and between 10 and 15 minutes (mean difference=19+/-5.50), as expected. No statistically significant differences occurred in asthma score before and after treatment. Twelve subjects were assessed to have excellent behavior, 5 subjects were satisfactory, and 7 subjects were unsatisfactory. No treatment was aborted. CONCLUSIONS: With adherence to the AAPD's sedation guidelines, midazolam at a dose of 0.5 mg/kg is a safe and effective mean for sedation of patients with mild to moderate asthma.     

Bispectral index system (BIS) monitoring reduces time to extubation and discharge in children requiring oral presedation and general anesthesia for outpatient dental rehabilitation

PURPOSE: Pediatric oral rehabilitation patients who receive presedation with oral Versed and general anesthesia (GA) occasionally experience prolonged sedation and delayed discharge. The Bispectral Index System (BIS) is an EEG monitor that measures the anesthesia level. The purpose of this study was to compare the effects of monitoring the BIS to not monitoring the BIS on time from discontinuation of GA to extubation and to discharge. METHODS: Twenty-nine children were enrolled. BIS was monitored from admission until discharge. Each child received 0.7 mg/kg of oral Versed. In the operating room, GA with sevoflurane (IH), rocuronium 1 mg/kg (IV), fentanyl 1 microg/kg (IV), and ondansetron 0.15 mg/kg (IV) was administered. Randomly, in half the patients, the anesthesiologist maintained the level of anesthesia and BIS by adjusting sevoflurane. In the rest, the anesthesiologist did not know BIS. The time from turning off sevoflurane to discharge was compared. RESULTS: Group 1 patients were extubated 5+/-2 minutes sooner than group 2 patients (P=.04). The post-anesthesia care unit stay for group 1 patients was 47+/-17 minutes compared to 63+/-17 minutes in group 2. (p=0.02). CONCLUSIONS: Monitoring anesthesia with BIS promotes earlier extubation and discharge for pediatric dental patients who receive oral Versed and sevoflurane GA.     

Rectal sedation with diazepam or midazolam during extractions of traumatized primary incisors: a prospective,randomized, double-blind trial in Swedish children aged 1.5-3.5 years

The aim of this study was to compare rectal sedation with diazepam and rectal sedation with midazolam with regard to sedative effect, treatment acceptance, and amnesia. Ninety children, 1.5-3.5 years of age, consecutively referred for extractions of traumatized primary incisors were randomly sedated with diazepam (0.7 mg/kg body weight) or midazolam (0.3 mg/kg body weight). The study design was randomized and double-blind. The level of sedation (state of mind) was assessed prior to and 10 and 60 min after administration of the drug by use of a behavioral scale (Wilton). The children's acceptance of procedures was assessed using another behavioral scale (Holst) during administration of the sedative, application of topical anesthesia, injection of a local anesthesia, and extraction. Amnesia was evaluated by the parents on the following day, with the child being asked standardized questions. Parental ratings of the child's and their own distress during and after treatment were made on a visual analog scale (VAS). No differences were found between the sedatives concerning level of sedation during treatment, acceptance of procedures, or amnesia. At discharge, 60 min after administration of the sedative, the children receiving diazepam were significantly more agitated (P = 0.006). Parental rating on a VAS of the child's discomfort after treatment was significantly higher in the diazepam group (P = 0.006). There was a tendency for children with poor acceptance of the rectal administration to display a more negative acceptance of the dental treatment. In conclusion, the present results, in combination with known pharmacological advantages, indicate that midazolam is preferable in outpatients when sedation is needed and amnesia is desirable.     

The effect of midazolam premedication on discharge time in pediatric patients undergoing general anesthesia for dental restorations.

PURPOSE: The purpose of this study was to evaluate the effect of oral premedication with midazolam on recovery times of children undergoing dental restorations under general anesthesia. METHODS: The records of 106 children (1.2-11.3 years, ASA I or II) undergoing ambulatory dental restorations were randomly selected and retrospectively reviewed: 50 subjects received midazolam (M) 0.5 mg/kg orally approximately 30 minutes prior to their procedure and 56 control subjects received no premedication (C). General anesthesia consisted primarily of inhalational anesthesia. Time in the operating room (OR), post-anesthesia care unit (PACU) and same day surgery (SDS) were determined and compared between groups. RESULTS: Both groups were similar with respect to age and weight. There were no significant differences between groups in time spent in the OR, PACU or SDS (p>0.05). In a subset of children having shorter dental procedures (OR time < or =75 minutes, n=29), there remained no significant difference in discharge times between groups. CONCLUSIONS: Preoperative administration of oral midazolam does not delay discharge of children undergoing general anesthesia for dental rehabilitation.     

A study of the effectiveness of oral midazolam sedation for orthodontic extraction of permanent teeth in children: a prospective,randomised, controlled,crossover trial

OBJECTIVES: To assess the safety, effectiveness and acceptability of o:ral midazolam sedation for orthodontic extraction of permanent teeth in children. DESIGN: A prospective, randomised, controlled, crossover trial. METHODS: A total of 26 children aged 10-16 (ASA I), referred for orthodontic extraction of premolar or canine teeth under sedation, were included in the study. Each child required two treatment sessions for the extraction of equivalent teeth on opposite sides of the mouth. Each subject was sedated with either ora midazolam (0.5 mg/kg) or nitrous oxide and oxygen (30%/70%) at the first visit and the alternative form at the second visit. At each visit two teeth were extracted, one upper and one lower. Heart rate, arterial oxygen saturation, respiration rate, sedation and behavioural scores were recorded every five minutes. Overall behaviour, patient acceptance and patient satisfaction were recorded at the end of treatment. RESULTS: Of the 26 children included in the study there were 12 males and 14 females. The mean age was 12.5 years. The mean heart rate and respiratory rate for both groups were similar and within acceptable clinical limits. The lowest mean arterial oxygen saturation levels for nitrous oxide and midazolam sedation were 97.7% and 95.0% respectively. Although midazolam caused greater oxygen desaturation, the range (91%-100%) was within safe limits for conscious sedation. The mean level of sedation was greater in the midazolam group compared with the nitrous oxide group and all but one case completed treatment. A total of 23 patients (88%) said they would be prepared to have ora midazolam sedation again and 17 (65%) actually preferred oral midazolam to nitrous oxide sedation. CONCLUSION: Oral midazolam (0.5mg/kg) appears to be a safe and acceptable form of sedation for 10-16 year old paediatric dental patients.     

Outcomes of moderate sedation in paediatric dental patients

Background: The aim of this study was to evaluate the outcomes of moderate sedation with nitrous oxide/oxygen (N₂O/O₂) alone or combined with different dosages and administration routes of midazolam in uncooperative paediatric dental patients using the Bispectral Index System (BIS). Methods: This one‐year clinical study examined first‐visit moderate sedation performed in 240 healthy children aged 4–6 years. Subjects were randomly divided into four groups according to drug, route and dosage, as follows: Group 1 – 0.20 mg/kg midazolam (40 mg/ml) delivered intranasally; Group 2 – 0.75 mg/kg midazolam (15 mg/3 ml) delivered orally; Group 3 – 0.50 mg/kg midazolam (15 mg/3 ml) delivered orally. All children in these three groups also received inhalation sedation with 50%–50% N₂O/O₂, whereas children in Group 4 received inhalation sedation with 50%–50% N₂O/O₂ only. The outcome of sedation was evaluated as either ‘successful’, ‘failed’ or ‘not accepted’. Results: The highest success rate was found in Group 1 (0.20 mg/kg intranasally, 87%), followed by Group 2 (0.75 mg/kg orally, 79%). The overall mean success rate for all groups was 73%. Conclusions: Moderate sedation can be successfully used in the clinical management of paediatric dental patients, with both intranasal and oral sedation using midazolam in conjunction with nitrous oxide found to be effective methods.     

Nasal versus oral midazolam sedation for pediatric dental patients

PURPOSE: The purpose of this study was to evaluate and compare intranasal (IN) and oral (PO) midazolam for effect on behavior, time of onset, maximum working time, efficacy, and safety for patients requiring dental care. METHODS: Forty anxious subjects (20 IN, 20 PO, Frankl Scale 3 and 4, ages 2-6 years, ASA I and II) were sedated randomly with either IN (0.3 mg/kg) or PO (0.7 mg/kg) midazolam. The dental procedure under sedation was videotaped and rated by a blinded and calibrated evaluator using Houpt's behavior rating scale. RESULTS: There was no statistical difference for overall behavior (F3,27 = 0.407; P = .749). The planned contrasts showed significant interactions between time and route (IN vs PO) between 25 and 30 minutes after starting sedation. The time of onset (P = .000) and the working time (P = .007) were significantly different between IN and PO midazolam. There were no statistically significant differences in vital signs (O2 sat, HR, RR, BP) between PO and IN (P = .595). IN subjects showed more movement and less sleep toward the end of the dental procedures, and faster onset time but shorter working time than PO. Vital signs were stable throughout the procedures with no significant differences. CONCLUSIONS: Mean onset time was approximately 3 times faster with IN administration compared to PO administration. Mean working time was approximately 10 minutes longer with PO administration than it was with IN administration. Overall behavior under PO and IN was similar. However, more movement and less sleep were shown in subjects under IN than those under PO toward the end of the dental session. All vital signs were stable throughout the procedures and showed no significant differences between PO and IN administration.     

Psychoprophylaxis for oral conscious sedation for dental care in Down syndrome adults with behavioral disorder

Down syndrome (DS) presents with prevalent diseases in the oral cavity and the need of constant dental care and follow‐up. The use of conscious sedation (CS) for dental care in adult DS with behavioral disorders is poorly documented. The aim of this study was to evaluate the effectiveness and safety of CS procedures with oral midazolam using previous psychoprophylaxis sessions in DS adult patients with behavioral disorders. Methods: Twenty‐nine DS adults with behavioral disorders. The patients were managed with psychoprophylaxis followed by oral CS using 15 or 30 mg midazolam. Vital parameters were monitored. The Houpt and Brietkopf and Buttner scales were used. Results: Patients under CS received an initial dose of 15 mg midazolam; however, 51.72% needed a 30 mg dose at the following sessions. Results showed that 71.4% treated with the 15 mg dose had Houpt scale overall behavior scores of 4 or 5, while 93.33% of those receiving 30 mg had scores of 5 or 6 (chi‐square = 15.95 p < .01). Conclusion: Psychoprophylaxis sessions followed by CS procedures using oral midazolam in adult DS with behavioral disorders were shown to be a useful strategy to perform routine dental treatment safely. Midazolam produces anterograde amnesia, and participants were more cooperative in the following visits.     

Conscious sedation by rectal administration of midazolam or midazolam plus ketamine as alternatives to general anesthesia for dental treatment of uncooperative children

The trial included 24 children (aged 2–7 yr) referred for dental treatment under general anesthesia, since conventional behavioral management methods had failed to achieve treatment acceptance. As an alternative, they received, on two separate occasions with "identical" dental treatment, conscious sedation by rectal administration of either midazolam (0.3 mg/kg body weight (bwt)) or midazolam (0.3 mg/kg bwt) plus ketamine (1.0 mg/kg bwt). This allowed a double-blind, crossover design. The aims were to assess conscious sedation, combined with local anesthesia, as an alternative to general anesthesia, and further to evaluate the effects obtained by addition of a low dose of ketamine to rectally administered midazolam. The feasibility of dental treatment was rated as excellent or good for 16 of the 24 children when premedicated with midazolam, and for 18 of the 24 children when ketamine was added to midazolam. At least some treatment could be given to all children. Verbal contact was maintained with all children throughout both treatment sessions. The children were significantly less anxious when they arrived for the second session. Amnesia and drowsiness were significantly increased when ketamine was added to midazolam. The combination also tended to be more efficient in relief of anxiety and prevention of pain, but there were large variations in the children's responses to the drugs. Midazolam significantly reduced the blood oxygen level, but not with ketamine added. For most children, both regimens proved to be appropriate as alternatives to general anesthesia. From a pharmacologic point of view, the combination of midazolam and ketamine appears to be reasonable because 1) both drugs have sedative and amnestic properties, 2) ketamine adds an analgesic component, 3) midazolam counteracts the psychic side-effects of ketamine, and 4) ketamine counteracts the depressive effects of midazolam on vital body functions (respiration and circulation).