Factors Associated with Administration Route When Using Midazolam for Pediatric Conscious Sedation 4/2/10

Department of Pediatric Dentistry
Resident’s Name: Murphy Program: Lutheran Medical Center - Providence

Article title: Factors Associated with Administration Route When Using Midazolam for Pediatric Conscious Sedation

Author(s): Primosch, Robert DDS. Fara Bender, DDS
Journal: Journal of Dentistry for Children
Year. Volume (number). Page #’s: 2001, July-August, 233-238
Major topic: Different ways to admin. Midazolam in the pediatric dental office
Overview of method of research: Retrospective chart study of 222 charts, containing 257 sedations. The children ranged from 15-82 months old. Children were either given intranasal or oral Midazolam, assessed pre-op, intra-op, and post op.

Findings: Midazolam (MD) is a benzodiazepine that possesses hypnotic, anticonvulsant, muscle relaxant, ante grade amnesia, and anxiolytic activity. It has been used in both medicine and dentistry for years. MD can be administered via IV, IM, and submucosal, intranasal, oral, and rectal routes, with each having it’s own advantages and limitations. IV administration is the best, however this can be quite hard to achieve due to lack of patient compliance. IV, IM and submucosal are painful to the child, and rectal is….well it’s rectal. Who wants to do that? Not this guy. Therefore the nasal and oral methods are the more commonly used delivery systems in dentistry. This article basically breaks down which route is better, intranasal or oral, and if preoperative behavior can be correlated with intra-operative behavior. Both have their pros and cons. Intranasal is easily administered (.18-.4 mg/kg), fast acting (10 minutes), and was associated with shorter treatment time than oral. Admin. However, 97% of the children who had the intranasal route were frightened, and described the experience of taking the MD as “horrible”. Also, children receiving intranasal MD were more combative, leading to more children being papoosed.
For oral admin, it’s easy to administer (.25-.75 mg/kg, mixed w/ 15mg ibuprofen or 1.5mg/kg vistaril), is relatively fast acting (20-30 min), and is usually better tolerated than the intranasal route. A con of oral admin is that it has an extremely bitter taste of the solution, even when mixed with other liquids.
The study found that compliance to oral drug admin did not correlate with cooperative behavior during treatment. This could be due to the psychotropic effects of MD, altering the child’s ability to cooperate, thus resulting in undesirable behavior. MD can cause dis-inhibition, eliminating or reducing the child’s ability to cope. Overall, behavior improved from pre-operative to intraoperative.

Key points/Summary: There were definite differences between each of the two methods of delivery. However, the are a number of variables that must be taken into account, including treatment history of the child, treatment style of the operator just to name a few. More research is needed to determine the predictive value of various parameters affecting pediatric sedation behavior management during dental treatment.

Assessment of Article: Some pertinent information that we all need to be aware of and think of when deciding whether to use MD, and which way to admin. it. Unfortunately, I found the article poorly organized, constantly contradicting itself, and non-committal.