Evaluation of maximum dose intravenous midazolam used in dental intravenous sedation: a West of Scotland regional audit

Abstract

Background Intravenous (IV) midazolam sedation is commonly used in the delivery of dentistry for phobic patients. There is currently no guidance on a maximum dose for use specifically in dentistry. Dentists practise with the British National Formulary recommended maximum dose of 7.5 mg; however, anecdotally, this is often exceeded. We aim to evaluate prescribing and propose recommendations for a maximum dose for dentists. Method Data was collected from ten dentists across four Scottish health boards regarding their last 20 IV sedation patients, giving a total of 200. Data obtained from standard Dental Sedation Teachers Group IV logbooks included: dose of midazolam administered; justification for doses over 7.5 mg; flumazenil or supplemental oxygen usage; significant medical/social factors; and the Ramsay Sedation Score. Results Mean midazolam dose was 6.1 mg with a range of 14 mg. The recommended maximum dose of 7.5 mg was exceeded in 28% of cases. The mean sedation score was 2.7 and there were no reported adverse events or use of flumazenil. Conclusion IV midazolam is an effective way to achieve conscious sedation in dentistry. Acknowledgement of current off-label prescribing is important; however, 7.5 mg as a recommended maximum dose is too conservative as it is regularly exceeded without adverse events. Further investigation and expert opinion is required to set a maximum dose specifically for dentistry.