Midazolam in Pediatric Dentistry

Foreword
Preface
Contents
1: The Practical Role of Midazolam in Pediatric Dentistry
	1.1	 Overview
	1.2	 Background and Objective
	1.3	 Need for Pharmacological Management in Children
	1.4	 The Role of Inhalation Sedation and Other Sedative Drugs
	1.5	 The Benzodiazepines
		1.5.1	 Classification of Benzodiazepines and their Clinical Applications
	1.6	 Midazolam
		1.6.1	 Desirable Characteristics of Midazolam
		1.6.2	 Midazolam: A Minimal and Moderate Sedation Drug
		1.6.3	 Deep Sedation with Midazolam
	References
2: Understanding Midazolam: The Key to Its Safe Clinical Use
	2.1	 Overview
	2.2	 Background and Objective
	2.3	 Chemistry
		2.3.1	 Importance of Understanding the Chemistry of Midazolam
		2.3.2	 The Basic Chemical Structure of Midazolam
		2.3.3	 Water Solubility of Midazolam Related to its Chemical Structure
		2.3.4	 The Clinical Advantages of the Water Solubility of Midazolam
		2.3.5	 The Chemical Structure of Midazolam Influencing its Quick Onset and Short Duration of Clinical Action
	2.4	 Pharmacokinetics
		2.4.1	 Lipophilicity of Midazolam
		2.4.2	 Midazolam’s Quick Onset of Clinical Action
		2.4.3	 Understanding Basics of Drug Metabolism
		2.4.4	 The Short Duration of Clinical Action of Midazolam
		2.4.5	 Other Clinically Relevant Information Related to Midazolam Metabolism in the Liver
		2.4.6	 Alpha and Beta Half-Life of Midazolam
		2.4.7	 Brief Note on Excretion
	2.5	 Pharmacodynamics
		2.5.1	 Difference Between Sedation, Hypnosis, and Anxiolysis
		2.5.2	 GABA
		2.5.3	 The GABA Receptors
		2.5.4	 Reason for the High Therapeutic Index and Safety Profile of Benzodiazepines
		2.5.5	 Sedative-Hypnotic, Amnestic, and Anticonvulsive Effects of Midazolam
		2.5.6	 Anxiolytic and Muscle Relaxant Effects of Midazolam
		2.5.7	 The Low Incidence of Benzodiazepine-Associated Respiratory Depression
		2.5.8	 Anterograde Amnestic Property of Midazolam and its Clinical Relevance
		2.5.9	 Paradoxical Reactions
	References
3: Pre-operative Assessment: The Key to Safe Sedation Outcomes
	3.1	 Overview
	3.2	 Background and Objective
	3.3	 ASA Classification and its Importance in Sedation
	3.4	 Steps to Arrive at an ASA Category for the Child
		3.4.1	 Structured Medical History
		3.4.2	 Evaluation of Vital Signs
			3.4.2.1	 The Pulse Rhythm, Rate, and Force
			3.4.2.2	 The Respiratory Rate and Quality of Breath Sounds
			3.4.2.3	 Oxygen Saturation
			3.4.2.4	 Blood Pressure
		3.4.3	 Body Mass Index (BMI)-for-Age Percentiles
			3.4.3.1	 Clinical Importance of Body Mass Index (BMI)-for-Age Percentiles for Sedation in Pediatric Dentistry
		3.4.4	 Tonsil Size and Extra-Oral Anatomic Abnormalities
			3.4.4.1	 Method of Examination [2]
		3.4.5	 Mallampati Classification [6, 7]
		3.4.6	 Recent History of Upper Respiratory Tract Infection (URTI) [8]
			3.4.6.1	 Moderate Sedation with Midazolam and URTI
		3.4.7	 Auscultation of the Heart and the Lungs
			3.4.7.1	 Needs and Challenges of Auscultation in a Pediatric Dental Setup
			3.4.7.2	 Understanding the Stethoscope
			3.4.7.3	 Identification of the Second Intercostal Space
			3.4.7.4	 Cardiac Auscultation
				Basics of Blood Flow Inside the Heart [22]
				Sequence and Landmarks to Listening Heart Sounds [22]
			3.4.7.5	 Pulmonary Auscultation
				Broad Outline of Pulmonary Auscultation [23]
				Auscultation of the Anterior Chest Wall (Fig. 3.17a, b)
				Auscultation of the Posterior Chest Wall (Fig. 3.18a, b)
				Normal Breath Sounds
		3.4.8	 The Sedation Plan Based on the ASA Category
	References
4: Basic and Advanced Behavior Guidance Templates Based on the Frankl Behavior Rating Scale
	4.1	 Overview
	4.2	 Background and Objective
	4.3	 Frankl Behavioral Rating Scale
	4.4	 Traits of the Frankl Behavior Rating Categories and their Suggested Behavior Guidance Templates
		4.4.1	 Rating 4: Definitely Positive
		4.4.2	 Rating 3: Positive
			4.4.2.1	 Traits of Frankl Positive Behavior
			4.4.2.2	 Behavior Guidance Template for Frankl Positive Behavior
		4.4.3	 Rating 2: Negative
			4.4.3.1	 Traits of Frankl Negative Behavior
			4.4.3.2	 Behavior Guidance Template for Frankl Negative Behavior
		4.4.4	 Rating 1: Definitely Negative
			4.4.4.1	 Subcategorization of Frankl Definitely Negative Behavior
			4.4.4.2	 Frankl Definitely Negative Behavior - - 1
				Traits of Frankl Definitely Negative Behavior - - 1
				Behavior Guidance Template for Frankl Definitely Negative Behavior - - 1
					Voice Modulation
					Parents Not Consenting to the Voice Modulation Technique
					Pharmacological Management Plan for Frankl Definitely Negative behavior - - 1
			4.4.4.3	 Frankl Definitely Negative Behavior - - 2
				Traits of Frankl Definitely Negative Behavior - - 2
				Behavior Guidance Template for Frankl Definitely Negative Behavior - - 2
			4.4.4.4	 Frankl Definitely Negative Behavior - - 3
				Traits of Frankl Definitely Negative Behavior - - 3
				Behavior Guidance Template for Frankl Definitely Negative Behavior - - 3
					Pharmacological Management Plan for Emergency Procedures in Children Displaying - - 3 Behavior
					Pharmacological Management Plan for Elective Procedures in  Children Displaying - - 3 Behavior
	4.5	 Indications of Midazolam in a Nutshell
	References
5: Routes of Midazolam Administration
	5.1	 Overview
	5.2	 Background and Objective
	5.3	 Where Should the Sedative Drug Be Administered?
	5.4	 Volume of Drug Distribution and Midazolam Dosage
	5.5	 Intravenous Route of Midazolam Administration
		5.5.1	 The Practical Role of Intravenous Midazolam in Pediatric Dentistry
		5.5.2	 Advantages [3]
		5.5.3	 Disadvantages
		5.5.4	 Equipment for Intravenous Infusion [4]
			5.5.4.1	 Intravenous Infusion Solution (Fig. 5.2)
			5.5.4.2	 Intravenous Tubing (Fig. 5.3a)
			5.5.4.3	 Intravenous Cannula
			5.5.4.4	 Other Equipment and Materials
			5.5.4.5	 Readying the IV Infusion Solution Bag and the IV Tubing
		5.5.5	 Administration
			5.5.5.1	 Site of Administration [6]
			5.5.5.2	 Venipuncture [7, 8]
			5.5.5.3	 Dosage
			5.5.5.4	 Technique of Administration [10]
		5.5.6	 Onset of Action
	5.6	 The Concept of “Titration by Appointment” for Other Routes
	5.7	 The Oral Route of Midazolam Administration
		5.7.1	 The NPO and the Oral Route
		5.7.2	 Advantages
		5.7.3	 Disadvantages
		5.7.4	 Dosage
		5.7.5	 Administration
			5.7.5.1	 Preparation of the Oral Midazolam Solution
			5.7.5.2	 Technique of Administration
		5.7.6	 Onset of Action
	5.8	 Intranasal Route of Midazolam Administration
		5.8.1	 Advantages Over the Oral Route
		5.8.2	 Disadvantages
		5.8.3	 Dosage
		5.8.4	 Administration
			5.8.4.1	 Different Modes of Intranasal Midazolam Administration
			5.8.4.2	 Technique of Administration
		5.8.5	 Onset of Action
	5.9	 Intramuscular Route of Midazolam Administration
		5.9.1	 Advantages
		5.9.2	 Disadvantages
		5.9.3	 Dosage
		5.9.4	 Administration
			5.9.4.1	 Site of Administration
			5.9.4.2	 Technique of Administration
		5.9.5	 Onset of Action
	5.10	 Rectal Route of Midazolam Administration
		5.10.1	 Advantages
		5.10.2	 Disadvantages
		5.10.3	 Dosage
		5.10.4	 Technique of Administration
		5.10.5	 Onset of Action
	5.11	 Oral Mucosal Route of Midazolam Administration
		5.11.1	 Advantages
		5.11.2	 Disadvantages
		5.11.3	 Dosage
		5.11.4	 Technique of Administration
		5.11.5	 Onset of Action
	References
6: Local Anesthetic Techniques in Children
	6.1	 Overview
	6.2	 Background and Objective
	6.3	 The Philosophy of Local Anesthesia in Children
	6.4	 Are “Painless” Intraoral Injections Possible?
	6.5	 The Process
		6.5.1	 Establishing Two-Way Communication
		6.5.2	 Use of Euphemisms
		6.5.3	 Instructions to the Parents
		6.5.4	 Applying the Topical Anesthetic
		6.5.5	 Needle Selection and Assembling the Syringe
		6.5.6	 Keeping the Syringe Out of the Child’s Line of Sight
		6.5.7	 Needle Insertion
		6.5.8	 Slow Deposition of the Local Anesthetic Solution
		6.5.9	 Use of Distraction, Verbal Positive/Negative Reinforcement, and Voice Modulation During the Injection Process
	6.6	 Local Anesthetic Techniques in Children
		6.6.1	 The Buccal/Labial Supraperiosteal Injection
			6.6.1.1	 Difference Between a Supraperiosteal Injection and an Infiltration
			6.6.1.2	 Shorter Syringes for Children
			6.6.1.3	 The Supraperiosteal Injection Technique
		6.6.2	 Palatal Anesthesia with the Intra-papillary Technique [21]
		6.6.3	 The Modified Two-Stage Inferior Alveolar Nerve Block (IANB) Technique
			6.6.3.1	 The Conventional Two-Stage IANB
			6.6.3.2	 The Modified Two-Stage IANB
				The First Stage of the Modified Two-Stage IANB
				The Second Stage of the Modified Two-Stage IANB
	6.7	 Additional Considerations for Local Anesthesia in Children
		6.7.1	 Injection in the Maxillary Second Primary/First Permanent Molar Region
		6.7.2	 Maximum Recommended Dosage (MRD)
			6.7.2.1	 Calculation of MRD
		6.7.3	 Effectiveness of Mandibular Molar Supraperiosteal Injections in Children
		6.7.4	 Buffering the Local Anesthetic Solution [32, 33]
			6.7.4.1	 The Rationale of Buffering
			6.7.4.2	 The Buffering Process
	References
7: Midazolam: A Step-by-Step Clinical Protocol
	7.1	 Overview
	7.2	 Background and Objective
	7.3	 The Objective Signs of Sedation
	7.4	 Parental Presence Inside the Operatory
	7.5	 “Settling” the Child
	7.6	 Nitrous Oxide and Oxygen
	7.7	 Protective Stabilization
	7.8	 Personnel and Monitoring
		7.8.1	 Personnel
		7.8.2	 Types and Frequency of Monitoring
		7.8.3	 Level of Consciousness
		7.8.4	 Monitoring Equipment
			7.8.4.1	 Precordial Stethoscope
			7.8.4.2	 Bluetooth Stethoscope
			7.8.4.3	 The Pulse Oximeter
			7.8.4.4	 The Sphygmomanometer
			7.8.4.5	 Capnography
	7.9	 Administration of Local Anesthesia
	7.10	 Rubber Dam Application for Restorative Procedures
	7.11	 Discharge Criteria
	7.12	 Post-Operative Instructions to Parents
	References
8: SAFE: Sedation Attitudes to Forestall Emergencies
	8.1	 Overview
	8.2	 Background and Objective
	8.3	 Ground Rules Governing the Safe Practice of Sedation in Pediatric Dentistry
		8.3.1	 A Meticulous Pre-operative Assessment
		8.3.2	 Strict “Nil per Oral” (NPO) Compliance
			8.3.2.1	 The NPO Protocol
			8.3.2.2	 Practical NPO for Minimal/Moderate Sedation
			8.3.2.3	 Clear Fluids
		8.3.3	 “Single Drug-Single Dose”
			8.3.3.1	 A “Single” Drug
			8.3.3.2	 A “Single” Dose
				Titration by Appointment
				Expectoration of the Drug by the Child
		8.3.4	 Understanding Deep Sedation/General Anesthesia and Moderate Sedation
			8.3.4.1	 Deep Sedation
			8.3.4.2	 The Induction of General Anesthesia with Intravenous Drugs
			8.3.4.3	 Airway Management in General Anesthesia
			8.3.4.4	 Airway Management for Dental Restorative Procedures Under Deep Sedation/General Anesthesia
			8.3.4.5	 Understanding the Implications of the Loss of Muscle Tone in Deep Sedation/General Anesthesia
			8.3.4.6	 Differentiating Deep Sedation/General Anesthesia from Moderate Sedation
		8.3.5	 Following the Recommended Monitoring, Personnel, and Infrastructure Protocols for the Planned Level of Sedation
		8.3.6	 Following the Recovery and Discharge Protocols
	8.4	 Management of Sedation-Related Emergencies
		8.4.1	 The Two Potential Complications of Moderate Sedation
		8.4.2	 Basic Management of Desaturation in a Deeply Sedated Child
		8.4.3	 Diagnosing the Complication and Management in a Continued Desaturation Scenario
		8.4.4	 Assisted Positive Pressure Ventilation
		8.4.5	 The Oropharyngeal Airway
		8.4.6	 The Use of a Laryngeal Mask Airway
		8.4.7	 The Administration of Flumazenil
		8.4.8	 The Administration of Adrenaline
		8.4.9	 The Initiation of Cardiac Compressions
		8.4.10	 Management of Intraoperative Vomiting
		8.4.11	 List of Emergency Drugs and Equipments
	References
9: Documentation
	9.1	 Overview
	9.2	 Background and Objective
	9.3	 Drug Procurement
	9.4	 Pre-operative Documentation
		9.4.1	 Pre-operative Assessment Records
		9.4.2	 Informed Consent
		9.4.3	 Pre-operative Parent Instructions
	9.5	 Intraoperative Documentation
	9.6	 Post-operative Documentation
		9.6.1	 Discharge Criteria
		9.6.2	 Post-operative Parent Instructions and Discharge Summary
	Annexure 1: Pre-operative Assessment
		Medical Questionnaire
		Pre-operative Vital Signs
		Examination of the Tonsil Size
		The Mallampati Score
		History of Active Upper Respiratory Tract Infection (URTI) in the Last 4 Weeks
		BMI-for-Age Percentiles to Check for Obesity
		Auscultation of the Lungs and Heart
		ASA Score (Based on Information Above)
	Annexure 2: Informed Consent Form for Midazolam Sedation
		Recommended Treatment
		Treatment Alternatives
		Risks and Complications
	Annexure 3: Pre-operative Parent Instructions
	Annexure 4: Intraoperative Documentation
		Sedation Appointment Checklist
		Midazolam Dosage Calculation (Example Below)
		Time-Based Record
		Clinical Notes
	Annexure 5: Discharge Criteria
	Annexure 6: Post-operative Parent Instructions and Discharge Summary
	References