Characteristics and selection of the sedative agents and clinical strategies of intravenous moderate sedation during dental treatment

Abstract

As reported in the previous review, midazolam, propofol and their combination are common choices for intravenous moderate sedation of dental outpatients in Japan. In the “Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018”, midazolam and dexmedetomidine are recommended for “sedative/analgesic medications not intended for general anesthesia”, that is moderate sedation. The aim of this review is to introduce modern view of the sedative agents’ characteristics and to present the clinical strategies of intravenous moderate sedation during dental treatment. Practitioners should select the sedative agent or its combination depending on the patient’s condition and coexisting diseases. Suppression of hemodynamic fluctuation is important in the dental treatment of medically compromised patients such as patients with cardiovascular diseases including hypertension and/or ischemic heart disease. Intravenous moderate sedation has stronger sedative effects than inhalation sedation with nitrous oxide (Minimal sedation: Anxiolysis). Both midazolam and propofol are commonly used in phobic and medically compromised patients. In contrast, propofol is a good candidate for patients with gag reflex and receiving prolonged treatment. Patients with acute closed angle glaucoma and myasthenia gravis, and taking HIV protease inhibitor are contraindications of benzodiazepines including midazolam. Systemic condition of the patient should be evaluated before sedation. Practitioners should consult the family doctor and obtain medical information including laboratory data and regular medications. During sedation basic monitoring items include consciousness, oxygenation, ventilation and circulation such as heart rate and blood pressure. In addition, electrocardiography, capnography and bispectra index monitoring may be appended in some patients with coexisting cardiorespiratory diseases or during deep sedation. Airway protective reflex may be to some degree suppressed during moderate sedation. Airway protective reflex may be to some degree suppressed during moderate sedation. Conclusion. Intravenous moderate sedation has wide range of indications and practitioners can propose safe and comfortable dentistry to the patients.