Intravenous Sedation

Enhanced CPD DO C

Hassan Abed

Ali Al-Qarni, Shanon Patel and Abdulaziz Bakhsh

Clinical Tips for Safe and

Effective Root Canal Treatment
under Intravenous Sedation
with Midazolam
Abstract: Intravenous (IV) sedation with midazolam works as an anxiolytic and muscle relaxant agent and has proved successful in
providing safe root canal treatment (RCT) for patients with dental anxiety or special care needs. However, before starting RCT under IV
sedation with midazolam, clinicians should consider obtaining a thorough medical history and written, informed consent including any
significant or unavoidable risks. A responsible adult escort should also accompany the patient to their appointment. The dental team
should also ensure labelling the IV sedation drugs and irrigant solutions, and using a well-sealed rubber dam.
CPD/Clinical Relevance: This article provides clinical recommendations to help provide safe RCT under IV sedation with midazolam.
Dent Update 2023; 50: 695–698

Dental anxiety is considered a significant be used to help reduce the patient’s anxiety out, but during which verbal contact with
barrier to many patients seeking dental while delivering safe dental treatment.5 the patient is maintained throughout the
treatment,1,2 including those who are fit and The Intercollegiate Advisory Committee period of sedation.’6 All conscious sedation
well, medically compromised, or special care for Sedation in Dentistry (IACSD) defines techniques should be administrated by
patients.3 Root canal treatment (RCT) has conscious sedation as a ‘technique in which qualified medical or dental care providers
been reported by patients to cause them the the use of a drug or drugs produces a with an accredited certification to perform
most anxiety,4 which may also increase pain state of depression of the central nervous conscious sedation.6
intensity.4 Conscious sedation techniques can system enabling treatment to be carried In the UK, midazolam is most
commonly administered for intravenous
(IV) sedation by dentists. Midazolam
works as an anxiolytic and muscle relaxant
Hassan Abed, BDS, MSc, Dip RCS(I), MFDS RCPS(Glasg), CAGS, PhD (KCL), Assistant
and attenuates the gag reflex. It helps in
Professor and Consultant of Conscious Sedation and Special Care Dentistry, Department
providing RCT for anxious and special care
of Basic and Clinical Oral Science, Faculty of Dentistry, Umm Al-Qura University, Makkah,
patients.4 However, because patients are
Saudi Arabia. Ali Al-Qarni, BDS, PhD (KCL), Assistant Professor of Oral Medicine,
consciously sedated and their muscles
Department of Oral and Maxillofacial Surgery and Diagnostic Sciences, Faculty of Dentistry,
are relaxed, RCT under IV sedation with
Taif University, Saudi Arabia. Shanon Patel, BDS, MSc, MClinDent, MRD, FDS, FHEA, PhD,
midazolam should be delivered with caution
Professor and Consultant of Endodontics, Department of Conservative Dentistry, Guy’s
in order to provide safe treatment and avoid
and St Thomas’ Foundation Trust, London. Abdulaziz Bakhsh, BDS, MClinDent, M Endo
other complications.
(RCSed), PhD (KCL), Assistant Professor and Consultant of Endodontics, Department of
This article provides clinical tips to
Restorative Dentistry, Faculty of Dentistry, Umm Al-Qura University, Makkah, Saudi Arabia.
help provide safe RCT under IV sedation
email: hhabed@uqu.edu.sa
with midazolam for novice sedationists or

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 Intravenous Sedation

Do not drive or ride a bicycle for 24 hours

Do not operate machinery (i.e. cooker, washing machines, and power tools) for 24 hours
Do not travel alone – the patient should travel with her/his escort, by car, if possible, for
24 hours
Do not sign legal documents for 24 hours
Do not drink alcohol for 24 hours
Do not return to work for 24 hours
Table 1. Patient instructions for conscious sedation. Adapted from Craig and Boyle.7

The purpose of root canal treatment under IV sedation

Type of root canal treatment (surgical versus non-surgical)
Number and type of tooth
Any significant or unavoidable risks related to root canal treatment such as unsuccessful
treatment, the possibility of dental extraction, pain, bleeding, swelling and infection
Dental care provider’s name, position and signature
Figure 1. IV sedation drugs (i.e. midazolam,
Patient’s name and signature flumazenil and saline) should be labelled before
the RCT under IV sedation, including the labelling
Date confirming the planned dental treatment of irrigant solutions (i.e. sodium hypochlorite and
Table 2. Written requirements that should be included in the consent form for root canal treatment EDTA) to prevent injecting irrigant solutions into
under IV sedation. the bloodstream.

endodontists who perform RCT only, albeit
under IV sedation.
Pre-operative instructions
for dental treatment under
IV sedation
Anxious patients are sometimes unable
to retain pre-operative verbal instructions
related to pain management or dental
treatment owing to their anxiety levels.7
Therefore, it is important to follow current
guidance and undertake a separate
assessment visit. In some cases, it is not
possible to assess whether the tooth is
restorable or if it needs to be extracted
until the existing restoration and/or caries
have been removed. However, this is
difficult to discuss with patients when they
are receiving dental treatment under IV
sedation, thus the written consent form
should include all treatment outcomes as
well as significant or unavoidable risks, such
as swelling, infection, pain, discomfort, and
the possibility of dental extraction for an
unrestorable tooth.
On the day of the dental procedure under
IV sedation, the written consent form should
be signed by the patient and dentist. The
patient should also bring a family member
or friend for support and to help with the
consent process, and for the journey home.
Patients must sign the consent form when
they can understand, weigh up and retain
the information long enough to make the
decision, and then articulate the decision
about the dental treatment.8
Pre-IV sedation measures
The patient’s baseline blood pressure,
heart rate and oxygen saturation should be
measured during the sedation suitability
assessment. The patient should also be
asked when they last ate, which is important
for preventing any hypoglycaemic
event. When a patient has not eaten, it is
suggested that they be given a glucose
drink, as conscious sedation masks signs
of a hypoglycaemic episode.9 Fit and well
patients should be instructed to have a light
breakfast before a morning appointment
or a light lunch before an afternoon
appointment. Patients should be advised to
avoid a heavy meal before having treatment
under IV sedation to reduce risk of reflux
and inhalation of gastric contents.
Moreover, it is important to check that
the patient takes their normal medication
as treatment under IV sedation does not
routinely require stopping any medication.
A responsible adult escort should also
accompany the patient receiving dental
treatment under IV sedation to their
appointment to ensure safe discharge.7 It
is also crucial to make sure that the patient
does not do any of the activities listed
in Table 1.
No dental treatment, such as RCT,
should be started under IV sedation unless
the patient has provided written, informed
consent.7 The consent form should include
the dental treatment plan (e.g. number and
type of tooth), the purpose of RCT under IV
sedation (e.g. dental anxiety and to deliver
effective and safe RCT), any significant or
unavoidable risks (e.g. unsuccessful RCT
and the possibility of dental extraction,
pain, discomfort, bleeding, swelling, and
infection), costs of the treatment, dental care
provider’s name, position and signature,
patient’s name and signature and date
confirming the planned dental treatment.
This is important because no decision or
change to the treatment plan (e.g. RCT versus
dental extraction) can be made once RCT
has commenced under IV sedation (Table
2). This is because Mental Capacity Act
necessitates that the patients should fulfil the
four criteria of having the mental capacity
(e.g. understand, weigh up and retain the
information and be able to communicate),
and these are altered temporarily with
IV sedation.8

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Figure 2. Separate kits for IV drugs are recommended. (A) Saline; (B) midazolam drug and cannulation
tools; (C) RCT instruments and irrigant solutions, including sodium hypochlorite and EDTA.
Labelling the IV sedation drugs
and irrigant solution(s)
IV sedation drugs should be labelled before
any dental treatment under IV sedation,
including labelling the irrigant solutions
(i.e. sodium hypochlorite (NaOCl) and
ethylenediaminetetra-acetic acid (EDTA)) to
prevent injecting the irrigant solutions into
the bloodstream (Figure 1). Therefore, having
two separate kits, one for IV sedation drugs
and another for the RCT irrigant solutions,
helps to avoid such a serious event (Figure
2).10 Different syringe sizes using colour-
coded tips will remind busy clinicians during
treatment about the content of the syringes.
Lastly, it is safe practice to consider treatment
in two different stages: sedation and RCT.
Local anaesthesia under
IV sedation
Various difficulties may be encountered
during treatment after midazolam
administration. Providing local anaesthetic
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pg695-698 Abed.indd 697
can be challenging because the patient’s
muscles are relaxed and they may find
keeping their mouth open difficult.
Additionally, some patients may have a
short window for the midazolam action,
and further midazolam titration is then
required. Local anaesthesia should be given
as soon as the patient starts to relax after
the first increment of the IV sedative drug
because the patient will have minimum
body movement.11 This usually occurs after
5–7 minutes with a dose of 5–7 mg of IV
midazolam, but varies between patients. It
is essential to perform the dental treatment
as quickly and efficiently as possible during
the sedation window to avoid the sedative
wearing off.
The importance of a mouth
prop during IV sedation
Since the patient’s muscles are relaxed
owing to the effect of IV sedation drugs,
there may be frequent closure of the mouth
Intravenous Sedation
Figure 3. (A) All RCT procedures should be
performed using a rubber dam. (B,C) Using high
and low volume suction is crucial. (D) Mouth
prop with a metal chain. (E) Dental dam clamp
secured with a dental floss.
during treatment, thus making treatment
challenging or even impossible. Mouth props
are very useful to overcome this difficulty,
as they help to keep the sedated patient’s
mouth open. It is essential to select the most
appropriately sized mouth prop during IV
sedation to avoid temporomandibular joint
(TMJ) dislocation.12 Moreover, it is advised
to tie the mouth prop with a metal chain
or dental floss for easier retrieval. Use of a
mouth prop during RCT under IV sedation
also helps to improve access and avoid
sudden mouth closure, which could lead
to mishaps, such as perforation during
access cavity preparation or root canal
instrument fracture.13
Rubber dam and the safety of
treatment under IV sedation
All RCT procedures should be performed
using a rubber dam to protect the airway
from instruments, materials or irrigant
solutions and to prevent contamination
of the root canal system with nosocomial
bacteria (Figure 3). The clinician may also
consider the use of gingival barriers such
as caulking or putty material to ensure the
sealing of the rubber dam.14 The patient’s
oropharyngeal reflexes under IV sedation
are reduced to a level that makes the
patient unaware of the treatment stage
or even if the irrigant solution has leaked
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 Intravenous Sedation
into their mouth. Therefore, high-volume
suction should be used, as well as low-
volume suction inside the patient’s mouth,
to avoid saliva accumulation and prevent
airway obstruction.
It is important to understand that
irrigation is considered the most important
step in RCT, as it reduces the friction
between the file and the root canal dentine,
dissolves tissues and, most importantly, has
an antimicrobial effect.15 Therefore, the same
irrigant solution(s) are used for treatment
under IV sedation. For example, sodium
hypochlorite is the gold standard irrigant
solution as it has antimicrobial action, the
ability to dissolve the pulpal remnants and
organic component of dentine and the
ability to neutralize the necrotic tissues.15 A
rubber dam is mandatory when using the
irrigant solution, therefore, if the placement
of a rubber dam is not possible, the RCT
should be contraindicated.16
Single-visit versus multi-visit
RCT under IV sedation
Under IV sedation, the aim of RCT is to
achieve a chemo-mechanically prepared
root canal system. Patients with a short
window under IV sedation might require
RCT with multiple visits, or they may only
require sedative top-ups throughout the
appointment for having a single visit RCT.
However, a systematic review found that
there is no significant difference between
single-visit and multi-visit RCT.17 In the case
of multi-visit RCT, the clinician should discuss
with the patient the number of visits needed
and the availability of an escort for each visit.
The importance of non-
pharmacological techniques
in anxiolysis
Applying non-pharmacological techniques
is important in anxiolysis for successful
dental treatment under IV sedation
with midazolam. In most cases, it is not
enough to rely on IV sedation alone to
reduce the patient’s anxiety and several
non-pharmacological techniques can be
combined.2 For example, giving the patients
information about what will happen
(procedural information), what sensations
they will experience (sensory information),
and how to cope with the situation (coping
information) helps to change their negative
thoughts and beliefs, hence reducing
anxiety.18 Moreover, modifying the clinical
environment can help to reduce patients’
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anxiety, for example, the use of positive
images and relaxing music or the use of
essential oils, such as lavender, in the dental
waiting area.2,19 Lastly, asking the patients to
take a ‘nice, deep breath’ using a moderately
loud voice with a deep tone is effective
to increase patient cooperation and also
enhance the patient’s sense of control.20,21
Post-operative instructions
related to dental treatment
under IV sedation
Verbal and written post-operative instructions
should be given to patients in the presence
of their escorts (Table 1). It is essential to
include written detailed instructions, such as
the type of pain management medication,
doses, and what the patient should do. One of
the consequences of dental treatment under
IV sedation with midazolam is temporary
anterograde amnesia; hence, the patient may
not remember the advice given afterwards.
Patients should only be discharged into the
care of a responsible, adult escort when
their blood pressure, heart rate and oxygen
saturation are within the normal range, they
can walk independently without assistance
and after removing the cannula.
Conclusions
RCT under IV sedation with midazolam
is useful for anxious and special care
patients. However, clinicians should be
knowledgeable and aware of all possible
risks that could be experienced during
dental treatment under IV sedation.
This article provides brief clinical tips for
novice sedationists or endodontists in
delivering successful RCT under IV sedation
with midazolam.
Compliance with Ethical Standards
Conflict of Interest: The authors declare that
they have no conflict of interest.
Informed Consent: Informed consent was
obtained from all individual participants
included in the article.
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