Considerations for Satisfactory Sedation during Dental Implant Surgery

Abstract

Implant surgery is a lengthy dental procedure, and sedation is often used to reduce discomfort. The effectiveness of sedation has traditionally been evaluated in terms of patient and surgeon satisfaction, but the most important goal is not to induce a deep sleep in the patient, but rather to ensure that the surgery is performed safely and as planned. Additionally, adequate pain control is a necessary requirement for patient and surgeon satisfaction. Most patients undergoing implant surgery are middle-aged or older, and a relatively large number of them have cardiovascular disease. Infiltration anesthesia using articaine or lidocaine in combination with adrenaline is widely used, but its use in patients with cardiovascular disease is limited because of adrenaline’s effects on the cardiovascular system. The use of long-acting local anesthetics and the potential efficacy of ultrasound-guided jaw nerve block have been investigated to enhance analgesia without resorting to adrenaline. Midazolam and propofol are usually used for sedation, but dexmedetomidine, which causes less respiratory depression, and the ultrashort-acting benzodiazepine remimazolam are emerging as potential alternatives. Monitoring of anesthetic depth using electroencephalography is effective in maintaining a constant level of sedation. In addition, sedation promotes the stabilization of heart rate and blood pressure, reducing the risks associated with adrenaline and allowing for safer management.

Remimazolam for Procedural Sedation in Older Patients: A Systematic Review and Meta-Analysis with Trial Sequential Analysis

“…Full texts of the remaining 15 studies were reviewed in detail. Of these, eight studies were further excluded because seven studies did not include older patients [ 23 , 24 , 25 , 26 , 27 , 28 , 29 ] and one study was a review [ 30 ]. The kappa value for the articles selected by the two investigators was 0.875.…”

Efficacy and safety of remimazolam besilate for sedation in outpatients undergoing impacted third molar extraction: a prospective exploratory study

“…However, few reports exist on procedural sedation using continuous intravenous administration of remimazolam. As a mild-to-moderate level of sedation allowing for some degree of consciousness is deemed appropriate for dental procedures [ 41 , 42 ], in this study, we determined the dose of remimazolam administration based on the findings of Schüttler et al, who reported that a remimazolam Ce of 0.34 µg/mL corresponded to a MOAA/S score of 4 (indicating a lethargic response of the patient to their name spoken in a normal tone) [ 27 ]. We adopted Masui’s pharmacokinetics model [ 13 , 14 ] and set the initial remimazolam loading dose to 0.05 mg/kg, followed by an initial continuous infusion rate of 0.35 mg/kg/h, aiming to maintain a simulated remimazolam Ce of approximately 0.34 µg/mL during the maintenance phase of anesthesia.…”

“…The MOAA/S score was used to clinically assess the depth of sedation. In dental procedures, moderate sedation is often the desired level, where patients can respond purposefully to verbal commands, corresponding to a MOAA/S score of 3 [ 22 , 41 , 42 ]. Therefore, in this study, remimazolam dosing was adjusted to achieve a MOAA/S score of 2–4.…”