The use of intranasal midazolam in the treatment of paediatric dental patients

Abstract

We wish to congratulate Gilchrist et al. for their recent publication [1]. We agree on the efficacy and safety of midazolam in children having procedures who may otherwise have required a general anaesthetic. However in recent recommendations [2], intranasal midazolam administration in patients under the age of 12 years, is classified in the category of ‘alternative techniques’. It is important to appreciate then, that the apparent simplicity of intranasal sedation belies the potential for undesirable effects so that monitoring, discharge and supervision requirements should be the same as those for intravenous sedation [2-4]. This technique must be limited to skilled hospital personnel and it must be stressed that premature discharge to an unmonitored setting remains the weakest link in this setting [3, 4]. Indeed, the use of sedation is still a limited practice among European dentists: in Italy sedation is provided mainly by anaesthetists (94%), seldom by dentists (6%) [5]. Education is largely theoretical, and practice on patients is lacking in the majority of the European Dental Schools [6]. If the teacher of dental anaesthesia is an anaesthetist, they must be able to transfer specialist professional skills and competences to dentists, who, in turn, will gain greater autonomy. Without this autonomy, the dental profession will remain subject to the anaesthetist’s will and, consequently, deep sedation/general anaesthesia techniques will be preferred to conscious sedation techniques. This situation increases risks for patients and the expenditure for dental care, with the teaching of inappropriate competencies leading to individuals considering they are able to practice in areas that they have not been truly appropriately taught [7]. This situation has arisen in Europe, but we have the opportunity to change it, with a greater autonomy for the dentists. It is necessary to establish a clear definition of objectives, competences and limits for the modern dentist, in order to get a common professional profile and legal framework, produced by European Union Authorities [8-10]. It is impossible currently to say which is the most effective sedation technique for anxious children [11] and this absence of evidence to support current practice is indeed alarming. However, we must remember that the cornerstone of management in dentistry remains an empathic approach to the patient supported by behaviour management techniques.