Original Article
Comparison of oral midazolam with a
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combination of oral midazolam and nitrous
oxide-oxygen inhalation in the effectiveness of
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dental sedation for young children
Abstract
Aim: To compare the effectiveness of 0.6 mg/kg oral
midazolam sedation alone and a combination of 0.6 mg/
kg oral midazolam plus nitrous oxide-oxygen inhalation
sedation, in controlling the behavior of uncooperative
children during dental treatment. Study Design: The study
had a crossover design where the same patient received two
different sedation regimens, that is, oral midazolam 0.6 mg/
kg and oral midazolam 0.6 mg/kg with nitrous oxide-oxygen
inhalation during two dental treatment visits. Materials and
Methods: Thirty children (17 males and 13 females) were
randomly selected for the study, with a mean age of 55.07 (±
9.29) months, ranging from 48 - 72 months. A scoring system
suggested by Houpt et al. (1985) was utilized for assessment
of the children’s behavior. Results: There was no significant (p
> 0.05) difference in the overall behavior assessment between
the two sedation regimens, that is, oral midazolam alone
and oral midazolam plus nitrous oxide-oxygen. However,
the combination of midazolam and nitrous oxide-oxygen
showed significantly (p < 0.05) superior results as compared
to midazolam alone, in terms of controlling movement and
crying during local anesthesia administration and restorative
procedures. Conclusion: Compared to oral midazolam
alone, a combination of oral midazolam and nitrous oxide
inhalation sedation appears to provide more comfort to
pediatric dental patients and operators during critical stages
of dental treatment.
Key words
Nitrous oxide-oxygen, oral midazolam, sedation
DOI: 10.4103/0970-4388.50810
J Indian Soc Pedod Prevent Dent | Jan - Mar 2009 | Issue 1 | Vol 27 |
Al-Zahrani AM1, Wyne AH2, Sheta SA3
Specialist Pediatric Dentist, Security Forces Hospital, Makkah
1
Al-Mukarrama, Saudi Arabia, 2Associate Professor/Consultant,
Pediatric Dentistry, King Saud University College of Dentistry,
Riyadh, Saudi Arabia, 3Associate Professor/Consultant,
Anesthesiology, King Saud University College of Dentistry,
Riyadh, Saudi Arabia
Correspondence:
Dr. Amjad H Wyne, PO Box 60169, Riyadh 11545, Saudi
Arabia. E-mail:ahwyne@ksu.edu.sa
Introduction
Dental treatment of pediatric patients with
behavioral problems is an extremely challenging task.
Psychological behavior management techniques alone
are not always adequate for soliciting the patients’
cooperation. Therefore, a definite need remains for
pharmacological remedies for the problem. A variety
of oral sedative agents have been used for managing
uncooperative young dental patients.[1] Midazolam,
one such agent, is a relatively newer generation
benzodiazepine, with a wide toxic/therapeutic ratio
and safety margin.[2,3] It does not produce prolonged
sedation that is associated with other benzodiazepines,
such as, diazepam.[2] When taken orally, midazolam
is rapidly absorbed in the gastrointestinal tract
and produces its peak effects in a relatively shorter
time of about 30 minutes, with a half-life of about
1.75 hours.[2] When administered in doses between
0.5 to 0.75 mg/kg of body weight, oral midazolam
has been found to be a useful sedative agent for
9
 Al-Zahrani et al.: Oral midazolam and nitrous oxide-oxygen inhalation sedation
pediatric dental patients.[4,5] Midazolam has also been
shown to enhance anterograde amnesia when used
preoperatively in pediatric patients. [5,6] However,
Midazolam is a short-acting anxiolytic agent[7] with
a short duration of action,[8-10] which makes its use
limited for shorter and simpler dental procedures
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only. Hence, it is desirable to find a second agent,
which in combination with midazolam, can add its
own desirable effects (sedation and analgesia) to the
clinical situation.
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Sedation by inhalation of nitrous oxide with oxygen
has become increasingly popular, pioneered principally
by Langa.[11] Inhaled nitrous oxide also produces
anxiolytic and mild analgesic effects.[12] However,
inhalation sedation used alone may prove difficult or
impossible in the treatment of very fearful children
because of their refusal to accept the nasal mask.[12,13]
Several studies have reported the efficacy and safety of
using nitrous oxide in combination with other sedative
drugs in uncooperative children.[14-20] Nitrous oxide has
also been reported to potentiate the sedative effects of
benzodiazepines.[17,18] However, the effectiveness of
nitrous oxide on oral midazolam sedation, and safety
of combining oral midazolam and nitrous oxide-oxygen
have rarely been studied. The aim of the present
study is to compare the effectiveness of 0.6 mg/kg
oral midazolam sedation alone with a combination of
0.6 mg/kg oral midazolam and nitrous oxide-oxygen
inhalation in controlling the behavior of uncooperative
children during restorative dental treatment.
Materials and Methods
The study protocol was reviewed and approved by
the Ethics Committee of the College of Dentistry
Research Center, and then the College of Graduate
Studies, King Saud University. The study had a
crossover design where the same patient received two
different regimens that is, oral midazolam 0.6 mg/
kg and oral midazolam 0.6 mg/kg with nitrous oxide
inhalation during the two dental treatment visits. The
dental treatment was provided by the same operator
during the two visits.
Sample selection
Thirty patients were randomly selected through
screening of the sedation waiting list of dental patients
in the pediatric dentistry clinics of the King Saud
University College of Dentistry, Riyadh, Saudi Arabia.
10
The inclusion criteria are given below:
• Age between four and six years
• ASA - I Category[21]
• Child’s weight within the normal range
• No previous dental treatment
• Behavior category: Frankl[22] Scale #2 (negative:
reluctant to accept treatment and some evidence
of negative attitude, not profound)
• Needing bilateral restorative treatment in lower
arch
• No cognitive impairment
Following were the exclusion criteria:
• Those who needed pulp therapy or extractions
• Patients who had recently used medications such as
erythromycin or anticonvulsants that may interfere
with the pharmacokinetics of midazolam[2]
• Children with any condition that predisposes
them to airway obstruction or difficulties (such
as, adenoid hyperplasia, nasal septum problems,
enlarged turbinates or nasal polyp)
The selected children were called for further assessment
of medical and dental history, clinical/radiographic
examination, and confirmation of behavior category.
Verbal and written explanations of the procedures
were provided to the parents of the selected children.
A written consent was obtained from the parent for
participation of their child in the study. Preoperative
written instructions (with verbal reinforcement) were
given to the parents, including emphasis on nothing
per mouth at least 6 hours before the appointment. The
parents were advised to call for cancellation of sedation
appointment if the child got unwell.
Medications
Midazolam was prepared in syrup form in King
Saud University College of Pharmacy. The syrup
was prepared in a concentration of 2 mg/ml, with a
stability of 30 days, if kept refrigerated. The syrup
consisted of intravenous midazolam (ampoules of
Dormicum@ 15 mg/3 ml, F. Hoffinan - La Roche
Ltd, Basel, Switzerland) and a dye-free flavored
diluent. The diluent consisted of sorbitol 45 g,
sucrose 15 g, saccharine 0.2 g, sodium benzoate 0.15
g, citric acid 2 g, and distilled water 100 ml. Then,
45 ml of the diluents and 30 ml of intravenous
midazolam were mixed to obtain a final preparation,
which had the strength of midazolam as 2 mg/ml.
The nitrous oxide and oxygen source was a relative
analgesia unit (Matrx Digital Quantiflex, MDM,
New York, USA).
J Indian Soc Pedod Prevent Dent | Jan - Mar 2009 | Issue 1 | Vol 27 |
 Al-Zahrani et al.: Oral midazolam and nitrous oxide-oxygen inhalation sedation
Sedation protocol
All the patients were examined by the anesthetist
(SAS), on the day of sedation, for medical clearance.
The patients with upper respiratory tract infection
and/or nasal discharge on the day of sedation were
postponed. Subsequently, the patient’s body weight
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was taken with the help of an electronic weighing
scale. Baseline blood pressure, heart rate, and oxygen
saturation were recorded. The dose of midazolam was
calculated for the child and the appropriate quantity
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was given in a cup. The degree of drug acceptability
was recorded. The treatment was to be postponed, if
a child expectorated all or part of the drug (actually
no such case occurred). After administration of
midazolam, the child waited in a quiet room with
his/her parents and signs of onset of sedation were
observed and recorded every 5 minutes. The following
sedation onset signs[5] were observed:
• Glazed look
• Delayed eye movement
• Lack of muscle coordination
• Slurred speech
• Sleep
After 30 minutes of drug administration, the patient
was moved to a sedation room, carried by his/her
parent, with the guidance of a trained clinical assistant.
Before starting the dental procedure, the child was
asked to select and name one of the three pictures
(cat, car or a flower), for the purpose of evaluating the
amnesic action of the drug. Next, a pulse oximeter
(Vitalmax 800 Monitoring Equipment: Pace Tech. Inc.,
Clearwater, FL 34615) clip was attached to the child’s
big toe of the right foot. The blood pressure cuff was
wrapped to the left arm by a trained assistant. The
patient was immobilized using a papoose board with
pedi-wrap (Olympic, Medical Group, Seattle, WA). One
of the parents remained present in the sedation room,
but was instructed to be passive.
First appointment
A mouth prop (Molt) was placed and topical
anesthesia (Benzocaine 20%) was applied for 2
minutes followed by local anesthesia (2% lidocaine
with epinephrine 1:100,000) in one of the lower
quadrants. Local anesthesia was administered
once, not exceeding the maximum recommended
dosage (4.4 mg/kg). Rubber dam was applied and
the required restorative treatment accomplished.
The required procedures such as class I, II, III, IV,
V restorations, preventive resin restorations and
J Indian Soc Pedod Prevent Dent | Jan - Mar 2009 | Issue 1 | Vol 27 |
fissure sealants were completed using glass ionomers,
compomers, composite resins or amalgam.
Second appointment
The same protocol, as on the first visit, was followed
for treatment on the other side, but with addition
of nitrous oxide inhalation. First, 100% oxygen was
delivered via a flavored nasal mask, and then nitrous
oxide was gradually added, up to 30-50%, titrated to
the patient’s need. The required restorative treatment
was accomplished. At the end of the dental procedure,
100% oxygen was given for 3 minutes before removal
of the nasal mask. The time interval between the
appointments was one week.
All the hemodynamic parameters were monitored
continuously during the course of the treatment. The
hemodynamic parameters were also recorded at the
beginning of the procedure, for every 10 minutes,
during the course of the treatment, end of the
treatment, in the recovery room, and before discharge.
At the end of the dental procedure, the child was
transferred to a quiet room and monitored for recovery.
The child was discharged when he/she fulfilled the
discharge criteria (ability to maintain a standing
posture, absence of dizziness or disorientation, and
acceptable vital signs). Before discharge, the patient
was asked about the picture he/she had selected. Post-
sedation instructions were given to the parents. Parents
were instructed to give clear liquids slowly and juice
only after 2 hours from discharge to avoid vomiting.
Parents were advised to observe the child for the rest
of the day. They were advised not to allow the child
to play with sharp objects or walk on the stairs alone.
The parents were provided with a telephone number
in case of any query.
Measurements
Amnesia Test[23]: The child was shown pictures of
three familiar objects (cat, car, and a flower) and asked
to select one of the pictures before starting the dental
procedure. At the time of discharge, the child was asked
which picture he/she had selected. The child was asked
again about it after 24 hours, at the time of the follow-
up phone call to the parents.
Assessment of the Sedation: A scoring system
suggested by Houpt et al.[24] was utilized for this
purpose. The system included the following scales:
• Sleep Scale
• Crying Scale
11
 Al-Zahrani et al.: Oral midazolam and nitrous oxide-oxygen inhalation sedation

• Movement Scale Amnesia

• Overall Scale
An experienced observer (AHW) assessed and
recorded all the behavioral and hemodynamic
parameters. The evaluations were carried out at the
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Most of the children were not able to recall the selected
picture. For first visit, 23 (76.7%) patients, and for the
second visit, 24 (80%) patients were unable to recall
the selected picture, with no significant difference in
amnesia between the two visits (P = 0.56).

following times:
• During placement in the Papoose Board
• At mouth prop insertion
• During administration of local anesthesia
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Working time
The mean working time (the time from bringing the
patient to the operating room until the planned dental

• During treatment in the selected quadrant procedures were completed) was 33.3 (±5.5) minutes
for the first visit and 33.2 (± 5.9) minutes for the second
Data analysis visit. The difference was not statistically significant
All the data were entered into the computer and (P = 0.97).
analyzed using the Statistical Program for Social
Sciences (SPSS, Version 12). Frequency tables and Sleep scale
cross tabulations were generated. The effectiveness Only one patient reached deep sleep on both visits and
of sedation (sleep, movement, crying, and overall that occurred only in the beginning of dental treatment
behavior) of the two regimens was compared using
the Wilcoxon signed ranks test. The same test was also Table 1: The mean onset times for midazolam sedation signs
used to compare amnesia between the two regimens. during the two visits
The paired t test was used to compare the working time Sedation Signs Onset Times (Minutes)
of the two regimens. First visit Second visit
Mean (SD) Mean (SD)
Glazed look 10.3 ± 1.3 10.5 ± 1.5
Results Delayed eye movement 13.0 ± 3.4 13.3 ± 3.5
Lack of muscle coordination 17.5 ± 4.3 19.0 ± 4.6
Patients’ demographics Slurred speech 23.3 ± 3.7 24.0 ± 4.2
Thirty children (17 males and 13 females) were Sleep 27.5 ± 4.2 28.2 ± 3.2
selected for the study, with a mean age of 55.07
(±9.29) months. The age ranged from 48 - 72 months. Table 2: Sleep (drowsiness) assessment on first and second
The body weight of the children ranged from 13 - visits during various phases of dental treatment
24 kilograms with a mean weight of 17.45 (±3.46) Dental Sleep Rating Scale P value
kilograms. procedure
Fully Drowsy Asleep Deep
awake N (%) (easily sleep
N (%) aroused) N (%)
Drug acceptance N (%)
Most of the children accepted oral midazolam readily Beginning of treatment
both during the first visit (86.7%) and the second (1st visit) 3 (10.0) 25 (83.3) 1 (3.3) 1 (3.3)
visit (83.3%), with others accepting it with only some (2nd visit) 4 (13.3) 21 (70) 4 (13.3) 1 (3.3) 0.62
hesitation. There was no case of drug rejection. Nitrous MP
oxide was administered in concentrations ranging (1st visit) 4 (13.3) 24 (80) 2 (6.7) 0
from 30 to 50% according to the patient’s need. The (2nd visit) 4 (13.3) 22 (73.3) 4 (13.3) 0 0.56
LA
mean concentration of nitrous oxide used was 37.8%
(1st visit) 11 (36.7) 19 (63.3) 0 0
(±4.29). There were no problems in acceptance of the
(2nd visit) 5 (16.7) 23 (76.7) 2 (6.7) 0 0.05
nasal mask.
RD
(1st visit) 9 (30) 21 (70) 0 0
Sedation onset (2nd visit) 5 (16.7) 23 (76.7) 2 (6.7) 0 0.13
In all children, on both visits, dental treatment was Restoration
started after 30 minutes of midazolam administration. (1st visit) 9 (30) 20 (66.7) 1 (3.3) 0
The mean onset times for various sedation markers (2nd visit) 3 (10) 24 (80) 3 (10) 0 0.05
during both visits are shown in Table 1. MP: Mouth prop, LA: Local anesthesia, RD: Rubber dam

12 J Indian Soc Pedod Prevent Dent | Jan - Mar 2009 | Issue 1 | Vol 27 |
 Al-Zahrani et al.: Oral midazolam and nitrous oxide-oxygen inhalation sedation

[Table 2]. During local anesthesia administration, Crying scale

the percentage of children who were fully awake was
more (36.7%) with oral midazolam alone as compared
to oral midazolam plus nitrous oxide (16.7%). During
the restorative treatment 30% of the children were
fully awake with midazolam as compared to 10% with
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The scores of crying in most of the children on both
visits were either intermittent crying or no crying
[Table 4]. The percentage of children with “no crying”
was higher on the second visit compared to the first
visit, but significant difference (p = 0.05) was only

midazolam plus nitrous oxide. Most of the children
were drowsy on both visits during various phases of
dental treatment. There was a significant difference
during the local anesthesia administration stage (p =
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observed during administration of local anesthesia.
On both visits, there was no hysterical crying during
various phases of dental treatment.

0.05) and during the restorative procedures (p = 0.05), Evaluation of overall behavior
where midazolam plus nitrous oxide showed more sleep Only one (3.3%) child was labeled as having behavior
(drowsiness) than midazolam alone. score “excellent” with midazolam alone compared
to seven (23.3%) with midazolam plus nitrous oxide
Movement scale sedation [Table 5]. Most of the patients showed good
In most of the patients, movement did not interrupt or very good behavior in both groups; with no poor
dental treatment on both visits [Table 3]. However,
a significant (p < 0.05) difference was observed Table 4: Crying scale during first and second visits during
between the two visits during local anesthesia various phases of dental treatment
administration and restorative procedures. During Dental Crying Rating Scale P value
local anesthesia administration the children sedated procedure Hysterical Continuous Intermittent No crying
with oral midazolam alone exhibited significantly N (%) N (%) N (%) N (%)
more (p = 0.02) movement than those sedated Beginning of treatment
with oral midazolam plus nitrous oxide. Similarly, (1st visit) 0 2 (6.7) 13 (43.3) 15 (50)
during restorative procedures, children during oral (2nd visit) 0 3 (10) 6 (20) 21 (70) 0.19
midazolam alone exhibited significantly more (p = MP
0.02) movement than oral midazolam plus nitrous (1st visit) 0 4 (13.3) 14 (46.7) 12 (40)
oxide sedation. Violent movements were rare (3.3%) (2nd visit) 0 3 (10) 9 (30) 18 (60) 0.10
and occurred only with oral midazolam alone. LA
(1st visit) 0 11 (36.7) 11 (36.7) 8 (26.7)
(2nd visit) 0 5 (16.7) 13 (43.7) 12 (40) 0.05
Table 3: Movement scale during first and second visits during RD
various phases of dental treatment (1st visit) 0 8 (26.7) 14 (46.7) 8 (26.7)
Dental Movement Rating Scale P value (2nd visit) 0 5 (16.7) 12 (40) 13 (43.7) 0.11

procedure
Violent Continuous Controllable No Restoration
N (%) N(%) N (%) movement (1st visit) 0 8 (26.7) 15 (50) 7 (23.3)
N (%) (2nd visit) 0 5 (16.7) 14 (46.7) 11 (36.7) 0.14
Beginning of treatment MP: Mouth prop, LA: Local anesthesia, RD: Rubber dam

(1st visit) 0 3 (10) 13 (43.3) 14 (46.7)

(2nd visit) 0 3 (10) 9 (30) 18 (60) 0.31
Table 5: Overall behavior rating for sedation with oral
midazolam alone and oral midazolam plus nitrous oxide
MP
(1st visit) 1 (3.3) 3 (10) 15 (50) 11 (36.7)
Behavior Overall Behavior Sedation Regimen
(2nd visit) 0 3 (10) 11 (36.7) 16 (53.3) 0.12 Category Ratings Midazolam Midazolam +
N (%) Nitrous Oxide
LA
N (%)
(1st visit) 1 (3.3) 9 (30) 14 (46.7) 6 (20)
Acceptable Excellent 1 (3.3) 7 (23.3)
(2 visit)
nd
0 5 (16.7) 14 (46.7) 11 (36.7) 0.02
Behavior Very Good 12 (40) 10 (33.3)
RD
Good 10 (33.3) 7 (23.3)
(1st visit) 1 (3.3) 7 (23.3) 14 (46.7) 8 (26.7)
Total 23 (76.6) 24 (79.9)
(2nd visit) 0 5 (16.7) 12 (40) 13 (43.3) 0.10
Unacceptable Fair 7 (23.3) 6 (20.0)
Restoration
Behavior Poor - -
(1 visit)
st
1 (3.3) 8 (26.7) 15 (50) 6 (20)
Aborted - -
(2 visit)
nd
0 5(16.7) 13 (43.3) 12 (40) 0.02
Total 7 (23.3) 6 (20.0)
MP: Mouth prop, LA: Local anesthesia, RD: Rubber dam

J Indian Soc Pedod Prevent Dent | Jan - Mar 2009 | Issue 1 | Vol 27 | 13
 Al-Zahrani et al.: Oral midazolam and nitrous oxide-oxygen inhalation sedation
behavior or treatment aborted. The overall behavior
of the children was divided into two categories:
acceptable behavior (excellent behavior, very good, and
good behavior) or unacceptable behavior (fair behavior,
poor behavior, and where treatment had to be aborted)
[Table 5]. Overall, acceptable behavior was observed
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in 76.6% children sedated with oral midazolam alone
and in 79.9% children sedated with oral midazolam
plus nitrous oxide. However, the difference was not
significant (p = 0.13). When the behavior score of
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each child was compared, between the two visits, the
behavior improved in 56.7% of the cases; remained the
same in 16.7% of the cases, and deteriorated in 26.6%
of the cases. It was noted that the improvement and
deterioration, however, remained limited within the
same overall categories, that is, acceptable behavior and
unacceptable behavior.
Discussion
The present study has attempted to test the efficacy of
combining oral midazolam with nitrous oxide - oxygen
inhalation in controlling the behavior of uncooperative
children during dental treatment. Oral midazolam (0.6
mg/kg) alone and in combination with nitrous oxide –
oxygen inhalation seems to be an effective and suitable
sedative agent for young dental patients who need
minimal restorative treatment (The safety aspects of
combining oral midazolam and nitrous oxide are being
published separately).
The Houpt[24] Sedation Rating Scale was used to assess
the efficacy of sedation because of its demonstrated
reliability, simplicity in data interpretation, and frequent
successful previous use by various studies.[24-30] The
lower arch was used for the purpose of standardization
and to administer local anesthesia, for reducing
repeated stressful situations during dental treatment.
Midazolam has a disagreeable taste that is difficult
to mask.[31] Children may refuse to swallow the drug
or may expectorate some of it. The clinician then
becomes uncertain about how much of the drug
has actually been ingested by the child. Various
homemade preparations to mask the bad taste have been
suggested.[31-33] The present study utilized a special
preparation of midazolam sweetened with sorbitol,
sucrose, and saccharine, which made it palatable for
children; with no case of drug expectoration during
the study.
Previous studies have reported a sedation onset time
14
ranging from 15 - 40 minutes for oral midazolam.
McMillan et al.,[34] in1992, in their dose-related study,
reported that time taken to reach maximum sedation
when using midazolam 0.5 mg/kg was 15 - 30 minutes.
Silver et al., in 1994, found that the length of time
between administering the oral midazolam and starting
treatment varied from 15 minutes to 40 minutes.[4] The
present study utilized “30 minutes” waiting time before
starting treatment. However, the mean times of onset
of various sedation signs in the present study indicated
that a shorter waiting time of 20 - 25 minutes could be
utilized for clinical purposes.
Amnesia after sedation is considered a positive side
effect of sedative agents, especially in uncooperative
patients, because memory of any unpleasant aspects
of the dental procedures is lost. The results of the
present study indicated a strong amnesic affect of
oral midazolam on most of the children. However,
the amnesic affect was not enhanced by the addition
of nitrous oxide - oxygen to midazolam. The results
of the present study are in agreement with previous
studies, which reported amnesia in 50 - 80% of the
children after medical or dental procedures, under oral
midazolam sedation.[35-38]
The sleep scale in the present study indicated that
most of the children were drowsy on both visits
during various phases of dental treatment. However,
a combination of oral midazolam and nitrous oxide
seemed to work better during administration of local
anesthesia and restoration. A study of comparison
between midazolam/N2O and diazepam/N2O in autistic
children showed that midazolam/N 2O was more
effective during local anesthesia administration.[30]
Undesirable body movements did not reach the level
of interrupting dental treatment during both visits.
However, there were significantly less movements with
the midazolam/N2O combination than with midazolam
alone during local anesthesia administration and
restorative procedures. In addition, violent movement,
although rare, occurred only with oral midazolam
alone. The study in autistic children also showed that
midazolam/N2O combination was more effective in
controlling movements during dental treatment.[30]
There was no case of hysterical crying in both visits.
The crying level was generally higher in midazolam-
alone visits as compared to midazolam/N2O visits.
However, the difference reached a significant level (p
< 0.05) only during local anesthesia administration.
J Indian Soc Pedod Prevent Dent | Jan - Mar 2009 | Issue 1 | Vol 27 |
 Al-Zahrani et al.: Oral midazolam and nitrous oxide-oxygen inhalation sedation
The study of Pisalchaiyong et al.[30] has also reported
that the midazolam/N2O combination showed greater
success in the early phases of treatment when the
patient was exposed to several painful stimuli.
There were no significant differences in the overall
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behavior between oral midazolam alone and oral
midazolam plus nitrous oxide sedation. However,
the midazolam/N2O combination did work better
during stressful situations, such as, local anesthesia
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administration and cavity preparation. It is in agreement
with the previous studies,[30,39] where midazolam/N2O
combination was more effective (than oral midazolam
alone) in regulating patient behavior at the time of
increased stimulation in children.
Conclusions
There was no statistically significant (P> 0.5) difference
in the overall behavior of children (undergoing dental
treatment) who had been administered oral midazolam
(0.6 mg/kg) alone and oral midazolam (0.6 mg/kg) plus
nitrous oxide - oxygen sedation.
However, sleep (drowsiness) scores were significantly
(P < 0.05) higher when the oral midazolam plus nitrous
oxide combination was used as compared to midazolam
alone, during local anesthesia administration and
restorative procedures.
Patients’ movements were significantly (P < 0.05)
less when oral midazolam plus nitrous oxide was
administered as compared to midazolam alone,
especially during local anesthesia administration and
restorative treatment.
Crying was also significantly (P < 0.05) less when
oral midazolam plus nitrous oxide was administered as
compared to midazolam alone during local anesthesia
administration.
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Source of Support: Nil, Conflict of Interest: Nil

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