Sedation Fig 1 Mucosal Atomisation Device (MAD)
of delivery of midazolam through an intranasal atomiser could prove an invaluable form of sedation, particu- larly for children and adults with a needle phobia. Delivering midazolam through the nose is a simple and convenient method, as access is easy, delivery is painless and the risk of a needlestick injury to the sedationist is avoided. The olfactory mucosa is in direct contact with the brain and CSF allowing the medication absorbed to directly enter the brain. This method avoids ‘first pass
Fig 2
Midazolam 40mg/1ml and lidocaine 20mg/1ml solution
metabolism’ by the portal circula- tion and, as such, the administered drug is not subject to destruc- tion by hepatic enzymes. Overall, this allows for a bioavailability of between 55-ı00 per cent. Midazolam should be delivered in a low-volume and high-concentration solution, as large volumes are likely to be unpleasant for the patient. Atomisation of the drug results in
Fig 3 The MAD in action Fig 4 Inhalation sedation of nitrous oxide and oxygen REFERENCES
1. ‘The Scottish Health Survey 2009 – Dental Health”
www.scotland.gov.uk/Publica- tions/2010/09/23154223/24. Accessed 28/10/2012 2. General Dental Council. Maintaining Standards. Guid- ance to dentists on professional and personal conduct. Publisher City, Country: Publisher, 1997; modified 1998 3. SDCEP ‘Conscious Sedation in Dentistry – Dental Clinical Guidance.’ May 2006 4.
www.intranasal.net
a higher bioavailability than either spray or drops. The broad 30-micron spray is designed to ensure excellent mucosal coverage and the highest bioavailability possible. Mucosal Atomisation Devices (MAD) (fig ı) are single use, disposable and can fit onto a standard syringe. In an atomised form, midazolam has a bioavailability of up to 85 per cent, with a clinical onset of action of around five to ı0 minutes. About 40 minutes of useful sedation are available for clinical procedures to be carried out. Intranasal midazolam has been studied extensively, with hundreds of studies published regarding its effectiveness in sedation, partic- ularly in relation to paediatric patients. It is also highly valuable in the treatment of acute seizures and status epilepticus. A study by Wood in Society for
5. The safety and efficacy of intranasal midazolam sedation combined with inhalation sedation with nitrous oxide and oxygen in paediatric dental patients as an alternative to general anaesthesia – M Wood (
www.ncbi.nlm.nih.gov/pubmed/20151606). Accessed 29/10/12
6. Outcomes of moderate sedation in paediatric dental patients (
www.ncbi.nlm.nih.gov/pubmed/22624753). Accessed 29/10/12
52 Scottish Dental magazine
the Advancement of Anaesthesia in Dentistry Digest aimed to deter- mine whether a combination of intranasal midazolam and RA seda- tion was a ‘practical alternative’ to general anaesthesia. A clinical audit of ı00 cases on paediatric patients aged three to ı3 years who had been referred for GA were treated with a combination of intra-nasal midazolam and RA. The study found that 96 per cent
of the required dental treatment was successfully completed using this technique. No clinically rele-
vant oxygen desaturation occurred during the procedures and the study concluded that in selected cases, this technique provides a safe alter- native to general anaesthesia 5. A study in the Australian Dental
Journal 20ı2 by Özen et al aimed to evaluate the outcomes of moderate sedation alone or combined with different dosages and adminis- tration routes of midazolam in unco-operative paediatric patents. The study examined 240 children and randomly allocated them to one of four groups where midazolam was administered intra-nasally, orally or sedation was achieved with nitrous oxide only. The highest success rate (87 per
cent) was found in the group who received 0.2mg/kg intra-nasally. The authors were able to conclude that the evidence indicates a suffi- cient basis to justify the use of this technique in primary care “as part of the spectrum of anxiety and behav- iour management for this group”. At Clyde Dental Practice, we
have used the intra-nasal route to sedate adult needle-phobic patients and also to manage dental anxiety in children. All patients referred to the practice attend for an initial sedation assessment appointment at which a full medical history is taken, including baseline oxygen saturation, and heart rate and blood pressure are recorded. Dental history, including reasons
for dental anxiety, is noted. Options for sedation are discussed with the patient and with children and their parents/guardian. Written consent for both sedation and treatment is signed and scanned into the practice computer system. Where intra-nasal sedation is
being used, the patient’s weight is recorded and used to calculate the dose of midazolam required, for example, a child of 40kg at 0.2mg/ kg, 8mg of midazolam, giving a volume of 0.2ml of a solution of 40mg/ıml. (figure 2). This high concentration/low volume results in greater bioavailability. Volumes over ıml result in run off out of the nostril, lower bioavailability and poor patient experience. Intra-nasal midazolam is given
in conjunction with inhalation sedation of nitrous oxide and oxygen. Following administration of intra-nasal anaesthesia, it is not uncommon for children to cough
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92