Enhancing Patient Safety and Access: The role of intravenous sedation in adolescent dental care 

The growing demand for paediatric dental treatment, combined with significant delays in access to general anaesthetic (GA) services, has created a pressing need to expand alternative, safe, and effective sedation pathways for adolescents aged 12 to 16. Traditionally, inhalation sedation has been the primary modality for paediatric conscious sedation; however, intravenous (IV) sedation using midazolam is an alternative that could help address growing concerns around access, safety, and service provision in both primary and secondary care. 

In England alone, there were 49,112 episodes of tooth extractions in NHS hospitals for 0 to 19 year olds in 2024, costing the NHS an estimated £74.8 million (1).  While this figure may include some procedures not conducted under general anaesthesia due to coding limitations, the majority are presumed to be GA cases.   These high volumes contribute directly to prolonged waiting times for surgery, which in turn increase the risk of preventable complications such as dental infections and sepsis (2). Against this backdrop, IV sedation offers a timely and effective alternative, particularly for patients for whom inhalation sedation has proven ineffective or is clinically unsuitable. By enabling earlier intervention in less resource-intensive settings, IV sedation has the potential to enhance both patient outcomes and service efficiency. 

Intravenous sedation with midazolam has a well-established safety profile and is widely used in adult dental care (3). While its use in adolescents has traditionally been limited by training opportunities, shifts in national guidance and growing clinical experience suggest that this modality can be effectively and safely extended to the adolescent cohort (4). Importantly, IV sedation is not only less resource-intensive than GA but also provides significant advantages in terms of patient flow and access. Treatment can be delivered in outpatient settings without the logistical and staffing demands of operating theatres, thereby alleviating pressure on hospital services (5). 

From a patient safety perspective, conscious dental sedation reduces the risks associated with GA, particularly in patients with complex medical histories (6). Moreover, in adolescents with urgent dental conditions (e.g. those presenting with abscesses), or in those with special care needs where pain may manifest as behavioural distress, conscious sedation can provide a quick and efficient route to care. 

At the Royal London Dental Hospital, collaborative efforts between paediatric and sedation teams have led to the successful integration of IV sedation into adolescent care pathways. Training paediatric specialists and dental registrars in IV sedation not only upskills the workforce but also promotes resilience and flexibility within teams. Embedding this skillset into paediatric training pathways will be crucial in sustainably expanding the availability of IV services. 

An emerging agent of interest is remimazolam, an ultra-short-acting benzodiazepine. It combines the desirable sedative properties of midazolam with a faster recovery time due to its rapid metabolism by tissue esterases. Our preliminary data using remimazolam  in adults has been positive, particularly in improving recovery among patients with learning disabilities. Faster post-operative recovery has reduced the risk of falls and injury, as well as minimised the need for elective reversal with flumazenil. Early studies regarding its use in paediatric procedural sedation have also highlighted its potential (7) but while these results are promising, remimazolam remains unlicensed for use in patients under 18, and large-scale clinical trials are needed before it can be formally integrated into national sedation protocols 

The future of paediatric sedation should be rooted in interprofessional collaboration. By fostering partnerships between dentists routinely providing care for paediatric patients and sedation-trained clinicians, we can create robust, scalable models that prioritise patient safety and equity of access. Ultimately, the ideal outcome would see IV sedation for adolescents available in both secondary and primary care settings, ensuring that patients with additional complexities are prioritised for GA, thus improving resource allocation and patient outcomes. 

Strategic integration of IV sedation into adolescent dental care represents a critical step forward in addressing unmet need. With appropriate training, governance, and collaboration, IV sedation can serve as a safe, accessible, and patient-centred alternative to GA, aligning with national priorities to reduce waiting times, improve outcomes, and uphold the highest standards of care. 

References