Book Review - Midazolam in Pediatric Dentistry
Reviewed by:
P. Anand, BDS, IQE, MMedSc (Oral surg), FDSRCS(Eng), MPaedDent, FDS(Paed Dent), Cert. Pain and Sedation.
Consultant in Paediatric Dentistry Royal National ENT and Eastman Dental Hospital, University College London Hospital NHS Trust, 47-49 Huntley Street, London WC1E 6DG
Email: prabhleen.anand1@nhs.net
D. Drysdale, BDS, MFDS RCSEd, Diploma Conscious Sedation, MSc, MPaedDent RCSEd.
Specialist in Paediatric Dentistry Royal National ENT and Eastman Dental Hospital, University College London Hospital NHS Trust, 47-49 Huntley Street, London WC1E 6DG
Email: daviddrysdale@nhs.net
Midazolam in Pediatric Dentistry
Authors: Ashwin Rao, Shweta Tiwari
Springer 2024 175pp Hardback £119
ISBN 978-3-031-45146-1 ISBN 978-3-031-45147-8 (eBook)
DOI: 10.1007/978-3-031-45147-8
Summary of contents
This comprehensive book offers an in-depth exploration of midazolam's use in paediatric dentistry, authored by experienced clinicians from India. It critically examines the drug’s pharmacological properties and sedation protocols, focusing on its application in paediatric patients. This resource is especially pertinent to SAAD readers who undertake conscious sedation using midazolam on paediatric patients
.
The book is divided into nine chapters:
1. The Practical Role of Midazolam in Pediatric Dentistry: Discusses midazolam’s history, benefits in paediatric cases, and the levels of sedation (minimal, moderate, deep) although the term conscious sedation is not covered.
2. Understanding Midazolam: The Key to Its Safe Clinical Use: The chemistry and pharmacodynamics are outlined. Anterograde amnesia and paradoxical reactions are discussed. There is a paragraph outlining the evidence for midazolam and respiratory depression, which readers of SAAD should interpret with caution.
3. Pre-operative Assessment: The Key to Safe Sedation Outcomes: Provides a comprehensive guide on pre-assessment, including the ASA classification and physical assessment of children.
4. Basic and Advanced Behaviour Guidance Templates: Introduces the Frankl behaviour rating and discusses its relevance in selecting sedation techniques.
5. Routes of Midazolam Administration: Describes various administration methods: intravenous (IV), nasal, oral, rectal and intramuscular, including continuous IV infusion, which is not standard in the UK.
6. Local Anaesthetic Techniques in Children: Outlines techniques for administering local anaesthesia in paediatric patients, including dosage guidance on the maximum recommended dose.
7. Midazolam: A Step-by-Step Clinical Protocol: Guides readers through the sedation process, from induction to peri-operative monitoring and discharge.
8. SAFE: Sedation Attitudes to Forestall Emergencies: Discusses emergency preparedness and safety protocols during sedation.
9. Documentation: Covers important aspects of consent, documentation, and discharge procedures.
Critical evaluation
This book effectively blends theoretical insights with practical guidance on administering midazolam in paediatric dental settings. Its thorough discussion of sedation techniques and practical advice make it particularly useful for specialists and general dentists who treat children. A standout feature is the detailed chapter on pre-operative assessment, which offers valuable advice on airway evaluation.
The book also examines different techniques for providing midazolam sedation and recognises its limitations. The behaviour modulation chapter helps understand different behaviour patterns in children and relevant sedation techniques concerning a child’s behaviour. It also highlights the importance of selecting appropriate cases for sedation. The authors emphasise that while midazolam is a powerful tool for moderate sedation, it is most effective when combined with good communication, behavioural guidance and local anaesthesia.
The book provides useful, practical step-by-step protocols for the different midazolam techniques. It is supported by equally valuable annexures with examples of templates for record keeping at various stages. It also provides examples of pre- and post-operative leaflets and consent forms. This would be helpful for anyone wanting to start providing sedation to children.
However, practitioners in the UK should approach this text with the understanding that the terminology and protocols largely adhere to American standards. For instance, the book refers to sedation levels such as ‘moderate’ and ‘deep’, whereas UK guidelines typically use the term ‘conscious sedation’.
The book outlines various midazolam administration routes and states that the intravenous route is the ideal, safe and titratable route. It then discusses potential difficulties in IV access and venepuncture, which could agitate young children, causing paradoxical reactions once the midazolam is administered. They seem to advocate oral, intranasal, intramuscular and rectal routes in the younger, non-adolescent age group, in preference to IV sedation, to avoid having to cannulate a child. Whilst the reviewers are sympathetic to the experience and skill needed to cannulate young children, this experience and skill can be achieved with clinical expertise, and we, the reviewers, believe the IV route to be a safe, efficient and predictable technique to administer midazolam conscious sedation in children, where possible. It has limitations in young and special needs children where cannulation is challenging. While the text acknowledges the challenges of IV access in paediatric patients, UK practitioners may note that cannulation remains mandatory for patient safety, regardless of the sedation route.
The IV technique described in the book also uses an infusion method, which is not used in UK dental sedation. It is interesting to see a cap of 6 mg dose for IV sedation; luckily, in the UK, this is not the highest amount that can be given intravenously for a child; midazolam is titrated to effect.
Including protective stabilisation techniques, such as papoose boards, also highlights a divergence from UK practices, where such methods are not employed. Additionally, this text discusses the combination of nitrous oxide and midazolam as a safe and effective method, regarded as advanced in the UK.
Other differences include PALS (paediatric advanced life support) training for the sedation observer and no routine cannulation for non-IV sedation. Flumazenil reversal via an intramuscular or nasal route is outlined before the IV route, likely due to a lack of IV access.
The book’s SAFE (Sedation Attitudes to Forestall Emergencies) strategy is well-articulated. However, it notably omits the escalation process, such as calling for emergency assistance, which may be due to differing resource availability.
In summary, while this book presents valuable protocols and insights, UK-based professionals should supplement it with their national guidelines to ensure adherence to local best practices.1,2,3,4,5 Despite its cost, this book will be a worthwhile reference for those seeking to enhance their knowledge of paediatric sedation.
References
1. Anand P, Lyne A, Fulton A, Tanday A, Chaudhary M. Service evaluation of an intravenous sedation service within a hospital paediatric dentistry unit: Ten-year results. Br Dent J. 2021. DOI: 10.1038/s41415-020-2596-1
2. Intercollegiate Advisory Committee for Sedation in Dentistry (IACSD). Standards for conscious sedation in the provision of dental care. 2020. Online information available at: https://www.saad.org.uk/IACSD%202020.pdf (accessed October 2024)
3. Scottish Dental Clinical Effectiveness Programme (SDCEP). Conscious sedation in dentistry: dental clinical guidance. 3rd ed. SDCEP; 2017. Online information available at: https://www.sdcep.org.uk/media/iota3oqm/sdcep-conscious-sedation-guidance-unchanged-2022.pdf (accessed October 2024)
4. Academy of Medical Royal Colleges (AoMRC). Safe sedation practice for healthcare procedures. London: AoMRC; 2013. Online information available at: https://www.aomrc.org.uk/wp-content/uploads/2024/05/Safe_Sedation_Practice_ 1213.pdf (accessed October 2024)
5. National Institute for Health and Care Excellence (NICE). Sedation in children and young people. NICE Clinical Guideline 112. 2010. Online information available at: https://www.nice.org.uk/Guidance/CG112 (accessed October 2024)