Why Midazolam?

A question I often get asked is “can you provide Propofol for sedation?” and “I’m used to working with patients under Propofol”.

Why don’t I use Propofol as a routine sedative? 

Propofol is a very good sedative, being a general anaesthetic inducer. It is easy to control the depth of sedation and recovery is quicker.

But it does have a narrower margin of safety, respiratory depression is higher and more equipment is required. Propofol sedation is considered an advanced technique.

Below are quotes taken from the IACSD sedation guidelines 2015, which apply to all providers of Conscious Sedation in Dentistry, regardless of their medical or dental training or level of qualification.

On Page 15:

“The selection of a technique must be appropriate for the individual patient and not chosen simply for operator or sedationist convenience or at the insistence of a third party”.

“Anaesthetic drugs and infusions (e.g. propofol) used as sedative agents have narrower therapeutic indices and reduced margins of safety, potentially increasing the likelihood of adverse events.” 

“No one technique is suitable for all patients. However, adopting the principle of minimum intervention, the simplest and safest technique that is likely to be effective, based on robust patient assessment and clinical need, should be used”.

“Multiple/anaesthetic drug techniques should only be considered by those skilled in their use, where there is clear clinical justification, after having excluded simple techniques”

Page 91 (in the example patient information leaflet) explains to the patient

“Intravenous sedation is usually given by using a single drug called midazolam”.

So, the guidelines heavily imply that when we sedate patients, we should start with the most simple, basic techniques first and then move on to alternative / advanced techniques when there is clear clinical justification, not just using one advanced technique because “that’s how we’ve always done it”.

Midazolam is the safest IV sedative used in dentistry. We can get high patient satisfaction levels even with longer appointments and more invasive procedures like Zygomatic implant cases. We can use an infusion pump to deliver a continuous infusion is required.

For more challenging cases, use of an opioid like Fentanyl enhances the sedative effect. Again this is used only following rigorous patient assessment, clinical need and the permission of the practice.

So, as with most things in Healthcare, we try the simplest and safest method first.

On page 26 of the guidance, the various drug techniques and requirements are listed. 

PCS (Patient controlled propofol) where the patient is in control of their sedation level via a hand held device, can be carried out in a Primary Care setting. The guidance suggests a lower level of safety as capnography may be required to spot desaturation incidents earlier.

TCI (Target controlled propofol) where the level of sedation is controlled by the Sedationist, is marked as Secondary Care only, not to used in primary care.

So in summary, to offer the best care, the drug of choice for sedation should be simple, safe and dictated by the clinical needs of the patient, not by the needs of the practitioner or sedationist. It should be able to deliver sedation for short and longer procedures and be easy to reverse in case of incidents.

What if I’m used to working under Propofol?

In our experience, patients who have previously undergone more advanced sedation techniques respond extremely well to Midazolam led sedation, which does call into question the need for advanced techniques in the first place. Often the dentists have low expectations and these get transferred to the patients, leading them to believe they will receive an inferior level of anxiety management.

In practice, this does not happen and patients report a high level of satisfaction (including one patient who said “oo, I like that drug!”. Often patients report that they felt more “out of it” and of course the amnesia effect can carry out well after the treatment is finished.

Every week, advanced dentistry like full arch fixed implants, bone augmentation, sinus lifting and zygomatic implants are carried out successfully with Midazolam with high degrees of satisfaction and patient cooperation.

With good all round management, including effective local anaesthesia, behavioural management and a good protocol for incremental tops ups from an experienced practitioner, dentists, teams and patients can be reassured that treatment can still be carried out more safely with a high degree of compliance and comfort, safe in the knowledge that everything is being done to comply with current guidelines.