Practical Advanced Periodontal Surgery, 2nd Edition

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Ziedonis (Zie) Skobe, PhD

29 April 1941–5 August 2018

Known as a “gentle giant” who had “a remarkable life and

career,” Zie guided and supported hundreds of projects
and grants, and countless young scientists, during his 40
plus years career at the former Forsyth Dental Institute.

Always proud of his immigrant background, he arrived in

the USA from Latvia as a refugee during World War II, over-
coming language barriers while learning English then
working in the construction industry as a laborer while
studying for his PhD

Throughout his long career, he always had a welcoming

smile and encouraging words for the young scientists
whom he mentored. His early experience with learning
English prepared him to enthusiastically help those for
whom English was not a first language. He is remembered
by all those whose lives he touched for being a great
friend, scientist, and mentor with a kind and generous
heart. You will not be forgotten, Zie. Rest In Peace.
Contents

List of Contributors xi Post‐Operative Care 41

Contraindications for Piezocision 42
Acknowledgments xiii Potential Complications 42

About the Companion Website xv 5. The Contribution of Periodontics to Endodontic

Therapy: The Surgical Management
Introduction 1 of Periradicular Periodontitis 43
Thomas Van Dyke Mani Moulazadeh
History and Evolution 43
1 Conscious IV Sedation Utilizing Midazolam 3 Tooth Conservation Versus Implants 43
Jess Liu Treatment of Failed Root Canal Therapy 44
Introduction 3 Rationale for Endodontic Surgery 44
Midazolam (Versed) 3 Indications for Endodontic Surgery 44
Armamentarium 4 Contraindications for Endodontic Surgery 46
Steps in IV Sedation 4 Types of Endodontic Surgery 48
Periradicular Surgery 51
2. Bone Physiology and Metabolism 11
Phases of Apicoectomy and Surgical
Jean‐Pierre Dibart
Technique 52
Bone Composition 11
Recall 60
Bone Types 11
Bone Formation 11 6. The Contribution of Periodontics
Bone Density Measuring Techniques 14 to Prosthodontics: Treatment Planning
Implications for Dental Treatments 15 of Patients Requiring Combined Periodontal
and Prosthodontic Care 61
3. Anatomy of the Dental/Alveolar Structures
Haneen N. Bokhadoor, Nawaf J. Al‐Dousari,
and Wound Healing 19
and Steven Morgano
Albert Price
Introduction 61
Anatomic Review (Emphasis on Vascular
Diagnostic Phase (Data Collection) 61
Supply) 19
Treatment-Planning Phase 63
Vascular Supply: Macro and Micro 19
Final Prognosis 63
Blood Supply Within the Alveolar and Basal Bone
Conclusion 105
of the Dental Arches 21
Microarchitecture of the Bone/Tooth
Relationship and the Interface of Soft and Hard 7. The Contribution of Periodontics
Connective Tissues 21 to the Correction of Vertical Alveolar
Anatomy and Vascular Supply of the Ridge Deficiencies 107
Investing Soft Connective Tissues 25 Serge Dibart
Cementum 28 Alveolar Distraction Osteogenesis
Antatomy and Vascular Supply of the Epithelial Surgery 107
Structures 28
The Wound‐Healing Process 29 8. Papillary Construction After Dental
Implant Therapy 117
4. PiezocisionTM Assisted Orthodontics in Peyman Shahidi, Serge Dibart, and
Everyday Practice 35 Yun Po Zhang
Serge Dibart, Elif Keser, and Donald Nelson History 117
Introduction 35 Indications 117
The Technique 35 Contraindications 117
Computer Guided Piezocision‐Orthodontics 35 Armamentarium 117
Dynamically Guided Piezocision 37 Technique 117
Piezocision Assisted Orthodontics With Postoperative Instructions 119
Clear Aligners 38 Surgical Indexing 119
Incorporating Piezocision in Multidisciplinary Possible Complications 119
Treatment 39 Healing 119

vii
 9. Dental Implant Placement Including Squamous Cell Carcinoma 150
the Use of Short Implants 121 Verrucous Carcinoma 151
Albert Price and Ming Fang Su Metastatic Disease 151
History 121 Infections 152
Indications 123 Herpes 152
Surgical Technique 123 HIV‐Associated Gingivitis 152
Implant Placement 125 Oral Soft Tissue Biopsy Techniques 153
Site Preparation 125 Armamentarium 153
The Fixture (Implant) Installation 130 Incisional Scalpel Biopsy 153
Possible Problems and Complications 130 Excisional Scalpel Biopsy 154
Biopsy Data Sheet 154
10. Periodontal Medicine Including Biopsy
Techniques 137 11. Sinus Augmentation Using
Vikki Noonan and Sadru Kabani Tissue‐Engineered Bone 159
Gingival Nodules 137 Ulrike Schulze‐Späte, Luigi Montesani,
Parulis 137 and Lorenzo Montesani
Fibroma 137 History 159
Peripheral Ossifying Fibroma 137 Indications 159
Pyogenic Granuloma 138 Contraindications 160
Peripheral Giant Cell Granuloma 138 Armamentarium 160
Diagnosis and Treatment of Reactive Gingival Sinus Augmentation Using Tissue-Engineered
Nodules 139 Bone Discs 160
Gingival Cyst of the Adult 139 Transplant Implantation Surgery (Sinus
Mucocele 139 Augmentation Procedure Using Tissue-
Desquamative Gingivitis 140 Engineered Bone Discs) 161
Lichen Planus 140 Sinus Lift Using Autogenous Mesenchymal Cells
Pemphigus Vulgaris 141 Processed Chairside 165
Mucous Membrane (Cicatricial)
Pemphigoid 141 12. Extraction Site Management in the Esthetic
Diagnosis and Treatment of Desquamative Zone: Hard and Soft Tissue Reconstruction 169
Gingival Lesions 142 Sherif Said
Plasma Cell Gingivitis 142 Introduction 169
Erythema Multiforme 143 The Influence of Tissue Volume on
Gingival Enlargement 144 the Peri‐Implant “Pink” Esthetics 169
Epulis Fissuratum 144 Tissue Volume Availability and
Medication‐Induced Gingival Overgrowth 144 Requirements 169
Hyperplastic Gingivitis 144 Pre‐Operative Implant Site
Leukemia 145 Assessment 172
Gingival Fibromatosis 145 Tissue Augmentation at the Time of Tooth
Ligneous Gingivitis and Conjunctivitis 145 Extraction 175
Wegener’s Granulomatosis 146 Management of Class I Sockets 177
Pigmented Lesions 146 Armamentarium 177
Physiologic Pigmentation 146 Three‐Dimensional Implant
Medication‐Induced Pigmentation 146 Positioning 179
Smoker’s Melanosis 147 Selection of the Bone Graft Material 180
Amalgam Tattoo 147 Rationale 181
Melanotic Macule 148 Socket Seal 183
Oral Melanoacanthoma (Melanoacanthosis) 148 Autogenous Tissue for Concomitant Buccal
Oral Melanocytic Nevus 148 Volume Augmentation and Socket Seal
Oral Melanoma 149 Procedures 186
Sanguinaria‐Induced Leukoplakia 149 Sub‐Epithelial Connective Tissue Graft 186
Proliferative Verrucous Leukoplakia 149 Compromised Sockets 192
Malignant Neoplasia 150 Flapless Ridge Preservation 192

viii Contents
Ridge Preservation Utilizing 13. Digital Technologies in Clinical Restorative
Barrier Membranes 193 Dentistry 213
Esthetic Ridge Augmentation 194 Vygandas Rutkū nas, Rokas Borusevičius,
Open Flap Approach for Extraction Site Agnė Geč iauskaite,̇ and Justinas Pletkus
Management 197 From Conventional to Digital Technologies 213
Site Analysis and Classification 197 Digital Solutions for Planning and Manufacturing
Surgical Phase 198 of Teeth‐Supported Restorations 214
Suturing of the Graft 203 Digital Solutions for Planning and Manufacturing
Stabilization of the Graft 205 of Implant‐Supported Restorations 223
Closure 205 Future Perspectives 227
Managing Implant Tissue Deficiencies 206
Conclusion 210 Index 233

Contents ix
List of Contributors

Nawaf J. Al‐Dousari, DDS, MSD Jess Liu, DDS, MSD

Practice Limited to Prosthodontics Clinical Assistant Professor
Armed Forces Hospital Department of Periodontology
Ministry of Defense Boston University School of Dental Medicine
Shamiya, Kuwait City, Kuwait Boston, MA, USA

Haneen N. Bokhadoor, DDS, MSD Lorenzo Montesani, DDS

Practice Limited to Periodontics and Dental Implants Practice Limited to Prosthodontics and
Bneid Al Gar Specialty Dental Center Implant Dentistry
Ministry of Health Rome, Italy
Shamiya, Kuwait City, Kuwait
Luigi Montesani, MD, DDS
Rokas Borusevičius, DDS
Practice Limited to Periodontology, Prosthodontics,
Division of Periodontology, Institute of Odontology
and Implant Dentistry
Faculty of Medicine
Rome, Italy
Vilnius University, Vilnius, Lithuania

Jean‐Pierre Dibart, MD Steven Morgano, DMD

Rheumatology and Sport Medicine Professor and Chair
Marseilles, France Department of Restorative Dentistry
Rutgers University School of Dental Medicine
Serge Dibart, DMD Newark, NJ, USA
Professor and Chair
Department of Periodontology Mani Moulazadeh, DMD
Director Advanced Specialty Program in Periodontics Assistant Clinical Professor
Boston University Henry M. Goldman School of Department of Endodontics
Dental Medicine Boston University School of Dental Medicine
Boston, MA, USA Boston, MA, USA

Thomas Van Dyke, DDS, PhD Donald Nelson, DMD

Vice President and Senior Member of Staff Assistant Clinical Professor
Forsyth Institute Department of Orthodontics
Professor of Oral Medicine, Infection and Immunity Harvard School of Dental Medicine
Faculty of Medicine, Harvard University Boston, MA, USA
Boston, MA, USA
Vikki Noonan, DMD, DMSc
Agnė Gečiauskaitė, DDS
Director and Associate Professor, Division of Oral
Division of Prosthodontics, Institute of Odontology,
Pathology
Faculty of Medicine
Boston University Henry M. Goldman School
Vilnius University, Vilnius, Lithuania
of Dental Medicine
Sadru Kabani, DMD, MS Boston, MA, USA
Co‐Director of Oral Pathology
STRATADX Justinas Pletkus, DDS
Lexington, MA, USA Division of Prosthodontics, Institute of Odontology
Faculty of Medicine
Elif Keser, DDS, PhD Vilnius University, Vilnius, Lithuania
Private Practice, London, UK
Adjunct Assistant Professor, Department of Albert Price, DMD, MS
Orthodontics & Dentofacial Orthopedics Clinical Professor
Boston University Henry M. Goldman School of Department of Periodontology and Oral Biology
Dental Medicine Boston University School of Dental Medicine
Boston, MA, USA Boston, MA, USA

xi
Vygandas Rutkūnas, DDS, PhD Peyman Shahidi, DDS, MScD
Associate Professor Practice Limited to Periodontology and
Division of Prosthodontics, Institute of Odontology Implant Dentistry
Faculty of Medicine Toronto, Ontario, Canada
Vilnius University, Vilnius, Lithuania
ProDentum Clinic, Vilnius, Lithuania Ming Fang Su, DMD, MS
Clinical Professor
Sherif Said, DDS, MSD Department of Periodontology and Oral Biology
Clinical Assistant Professor Boston University School of Dental Medicine
Department of Periodontology Boston, MA, USA
Boston University School of Dental Medicine
Boston, MA, USA Yun Po Zhang, PhD, DDS(hon)
Director
Ulrike Schulze‐Späte, DMD, PhD Clinical Dental Research
Diplomate, American Board of Periodontology Colgate‐Palmolive Company
Director, Section of Geriodontics Piscataway, NJ, USA
Department of Conservative Dentistry
and Periodontology
Center of Dental Medicine
University Hospital Jena
Jena, Germany

xii List of Contributors

Acknowledgments

I would like to thank my colleagues and students of Boston I would also like to thank Ms. Samantha Rose Burke for her
University Henry M. School of Dental Medicine for their invaluable help in formatting this manuscript, Mary Malin
invaluable help. I would also like to thank Ms. Leila Joy for copyediting and to the team at Wiley for bringing the
Rosenthal for drawing Figures 7.32 and 7.33, Dr. Alessia book to Production.
De Vit Dr. Trevor Fujinaka for the video on Piezocision and
Dr. Galip Gurel.

xiii
About the Companion Website

This book is accompanied by a companion website:

www.wiley.com/go/dibart/advanced

The website includes 2 videos from Chapter 4.

xv
Introduction
Thomas Van Dyke

As reflected in this Second Edition, the surgical techniques IV sedation by Dr. Jess Liu, Digital Technologies in Clinical
that span the scope of dentistry have continued to evolve. Restorative Dentistry by Dr. Vygandas Rutkūnas and
Predictable implant placement and bone augmentation colleagues, and Extraction Site Management in the
techniques have become a common part of the repertoire of Esthetic Zone: Hard and Soft Tissue Reconstruction by
the periodontist. Importantly, these technical developments Dr. Sherif Said. The final five chapters of the book are
and the research on which they are based have impacted devoted to exploring the specialized needs of complex
other specialties, including orthodontics, endodontics, oral cases. The problems of inadequate vertical bone height
and maxillofacial surgery, and prosthodontics. and soft tissue defects can now be predictably addressed
in most cases. In ­particular, the esthetic issues of lack of
In Practical Advanced Periodontal Surgery, Second papillary redevelopment between adjacent implants are
Edition, Dr. Serge Dibart has updated, expanded, and addressed by established investigators in the field.
improved on the landmark First Edition with a team of Distraction osteogenesis and papilla regeneration tech­
experts who have played a major role in the development niques now provide a means to enhance the esthetics of
of these concepts, in some cases, and their implementa­ the most complicated cases.
tion, in all cases. It is arranged into 13 chapters that range
from a review of the science leading up to new technolo­ Periodontal medicine has its roots in oral pathology/oral
gies to their implementation and the evidence backing medicine. The forefathers of periodontics, physicians such
their veracity. The contribution of periodontal concepts to as Gottlieb, Orban, and Goldman, were oral pathologists
orthodontics and endodontics is just an example of how first. No book of advanced periodontal techniques would
modern periodontology adds to the armamentarium of all be complete without a review of the most common oral
aspects of the dental profession. lesions that face the periodontist and their treatment, along
with proper biopsy techniques.
The focus of this book is bone – the biology of bone and
how an understanding of the basic principles of biology The look to the future has also changed between the First
can be used to enhance treatment. The book begins with and Second Editions. The future of periodontology is
a review of bone biology and current understanding of bright; we are provided an exciting glimpse of what is next.
wound healing. The discovery that surgically injured bone
becomes rapidly osteopenic followed by increased turn­ Dr. Dibart has again brought together the subject, the
over has been updated to include new clinical techniques team, and the expertise to produce a most valuable com­
for rapid tooth movement through Piezocision. pilation of advanced techniques of modern periodontics.
The content is based in science and is well‐balanced, pro­
Notably, there are three new chapters in the Second viding a reference work and guide for the practitioner of
Edition. The topics are vital to modern practice, including advanced dentistry.

Practical Advanced Periodontal Surgery, Second Edition. Edited by Serge Dibart.

© 2020 John Wiley & Sons, Inc. Published 2020 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/dibart/advanced

1
Chapter 1 Conscious IV Sedation Utilizing Midazolam
Jess Liu

INTRODUCTION Training in Intravenous Conscious Sedation

Dental fear and anxiety are the common reasons why While IV conscious sedation is relatively safe to practice,
patients avoid seeking proper dental care. A survey con- only a qualified and well‐trained healthcare provider who is
ducted in the US has reported up to 30.5% of both US able to manage emergency complications should perform
adults and adolescents experience a moderate to high the practice. Dentists who practice IV conscious sedation
dental fear (Gatchel 1989). Therefore, it is important for are mandated by all states to be certified by an approved
dentists to understand the management of dental fear and continuing education program. Furthermore, each state is
anxiety as an integral component of the overall treatment. governed by its own rules and regulations for the adminis-
tration of conscious sedation, therefore it is important to
As defined by the American Society of Anesthesiologists verify with the individual state dental board for the proper
(see Table 1.1), the continuums of depth of sedation are: requirements to obtain a permit to practice IV conscious
sedation.
• Minimal Sedation: Normal response to verbal
stimulation. MIDAZOLAM (VERSED)
• Moderate Sedation: Purposeful response to verbal or Midazolam is a water soluble, short acting benzodiaze-
tactile stimulation. pine central nervous system (CNS) depressant.
Pharmacologically, it produces anxiolytic, hypnotic,
• Deep Sedation: Purposeful response following repeated
­anterograde amnestic, muscle relaxation, and anticon-
or painful stimulation.
vulsant effects (Reves et al. 1985). Metabolized in the liver
• General Anesthesia: Unarousable even with painful by cytochrome P450 enzymes, its mechanism of action is
stimulus. through binding of the GABAA receptors, (causing an
influx of chloride ion which causes hyperpolarization
According to the American Society of Anesthesiologists of the neuron’s membrane potential) creating a neural
moderate sedation is also known as “Conscious Sedation,” inhibition effect.
and by definition, conscious sedation is “a drug‐induced
depression of consciousness during which patients The onset of intravenous administration of midazolam is
respond purposefully to verbal commands, either alone or relatively fast with a short acting duration. Intravenous
accompanied by light tactile stimulation. No interventions administration of 5 mg of midazolam in healthy adults has
are required to maintain a patent airway, and spontaneous shown to take effect one to two minutes after administra-
ventilation is adequate. Cardiovascular function is usually tion and has a half‐life of approximately one to three hours
maintained.” (Smith et al. 1981).

Conscious sedation can be achieved by different routes of It is important to understand that the use of midazolam is
administration such as enteral or parenteral administration. to produce conscious sedative effects and does not
For the purpose of this chapter, parenteral administration replace the need for proper local anesthesia. Therefore
of conscious sedation limited to intravenous administration proper anesthetic should be administered prior to the
of Midazolam (Versed) will be reviewed. starting of the dental procedure.

Practical Advanced Periodontal Surgery, Second Edition. Edited by Serge Dibart.

© 2020 John Wiley & Sons, Inc. Published 2020 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/dibart/advanced

3
Table 1.1 Continuum of sedation: definition and levels (2004).

Continuum of depth of sedation: definition of general anesthesia and levels of sedation/analgesia

Minimal sedation Moderate sedation/analgesia

(Anxiolysis) (Conscious sedation) Deep sedation/Analgesia General anesthesia

Responsiveness Normal response to Purposefula response to verbal Purposefula response following Unarousable even with painful
verbal stimulation stimulation repeated or painful stimulation stimulus
Airway Unaffected No intervention required Intervention may be required Intervention often required
Spontaneous Unaffected Adequate May be inadequate Frequently inadequate
Ventilation
Cardiovascular Unaffected Usually maintained Usually maintained May be impaired
Function
a
Reflex withdrawal from a painful stimulus is NOT considered a purposeful response.

ARMAMENTARIUM STEPS IN IV SEDATION

Monitoring equipment for: Patient pre‐op evaluation: As with all dental procedures,
a thorough review of the patient’s medical history is essen-
• Non‐invasive Blood Pressure (NIBP)
tial to ensure safe and successful treatment. Review of
• Electrocardiogram (EKG) the patient’s medical history with complete review of the
­system, current medications, as well as drug allergies will
• Pulse Oximetry
provide you the necessary information to assess the
• Capnography patient utilizing the ASA Physical Status Classification
IV Supplies: System (see Table 1.2). The authors recommend limiting
the administration of conscious sedation with patients with
• 0.9% Sodium Chloride Injection 250 ml bag ASA Physical status of 2 or less to reduce the chance of
• Primary IV set (100″) medical emergencies.

• 22 Gauge × 1″ Introcan Safety® IV Catheter Contraindication:

• 24 Gauge × ¾″ Introcan Safety IV Catheter • Hypersensitivity
Basic Supplies: • Acute narrow‐angle glaucoma
• 1 ml Insulin Syringe • Hypotension
• Blunt Plastic Cannula • Pregnancy
• Nasal Cannula • Renal disease
• Supplemental Oxygen • Critically ill patients
• 1″ Latex free Tourniquet Pre‐op instructions
• 3M Tegaderm Film Transparent Film Dressing • No food or drinks eight hours prior to procedure.
• 3M Transpore Tape • Please wear comfortable loose‐fitting clothing with short
• Gauze sleeves to allow for monitoring of your blood pressure.

• Band‐Aids • Must be accompanied by a person of legal age to escort

you home.
• Alcohol Wipes
• No sedatives for 24 hours before appointment.
Basic Medications:
Day of Procedure:
• Midazolam 5 mg/1 cc
• Seat the patient
• Flumazenil 5 cc
• Review medical history. If patient has medical history of
• ACLS Emergency Medical Kit (HealthFirst)
asthma instruct patient to take two puffs of asthma
Please see Figure 1.1. inhaler prior to starting of procedure.

4 Practical Advanced Periodontal Surgery

Figure 1.1 Armamentarium needed to provide sedation: monitor, drug, IV sedation set.

Table 1.2 ASA physical status classification (American Society of Anesthesiologists 2015).
ASA physical status classification system
ASA Physical Status 1 A normal healthy patient
ASA Physical Status 2 A patient with mild systemic disease
ASA Physical Status 3 A patient with severe systemic disease
ASA Physical Status 4 A patient with severe systemic disease that is a constant threat to life
ASA Physical Status 5 A moribund patient who is not expected to survive without the operation
ASA Physical Status 6 A declared brain‐dead patient whose organs are being removed for donor purposes

Conscious IV Sedation Utilizing Midazolam 5

Figure 1.2 Pulse oximetry, oxygen cannula, blood pressure cuff.

• Attach patient monitors (See Figure 1.2) for:

Average range
◦◦ Blood pressure
Pulse Rate Adult 60–80 beats/min
◦◦ Electrocardiography (EKG) Respiratory Rate 12–20 breaths/min
◦◦ Pulse oximetry (Oxygen saturation) Oxygen Saturation 95–100%
End tidal CO2 35–45 mm Hg
◦◦ Capnography (CO2 partial pressure) Give earliest
­warning of respiratory distress
• Starting of IV:
• Record pre‐operatory vital signs: Blood pressure, pulse,
respiratory rate, oxygen saturation, end tidal CO2 level. ◦◦ Complete assemble of Primary IV infusion set with
If vital signs not within normal range re‐evaluate patient 0.9% Sodium Chloride Injection bag See Figure 1.3.
for the procedure. ◦◦ Exam and select visible superficial vein for venepunc-
ture: Location: Dorsum of hand/wrist, Ventral Forearm,
Pre‐operative vital signs chart or Antecubital Fossa.
▪▪ Contraindication for venepuncture site are:
Diagnosis Systolic (mm Hg) Diastolic (mm Hg)
• Mastectomy
Normal Less than 120 and Less than 80
• Cannulas
Prehypertension 120–139 or 80–89
Hypertension Stage 1 140–159 or 90–99 • Scarring
Hypertension Stage 2 160 or higher or 100 or higher
• Vein with valves or bifurcations

6 Practical Advanced Periodontal Surgery

 Figure 1.4 IV catheters of various size.

▪▪ Caution: Initially exam the area of venepuncture

after starting IV drip for swelling to ensure proper
venepuncture has been performed
◦◦ Stabilize the catheter with 3M Tegaderm Film
Transparent Film Dressing and 3M Transpore Tape.
See Figure 1.7.
• Dosage and Administration
◦◦ Use the 1 ml Insulin Syringe U‐100 to draw up 1 ml of
5 mg/ml midazolam. See Figure 1.8.

Figure 1.3 Saline bag used for IV sedation. ◦◦ Dosage and administration indicated for the intrave-
nous administration of midazolam as provided by
pharmaceutical company Hospira Inc. is as follows:
▪▪ Methods of venous distension to facilitate
venepuncture. ▪▪ Healthy Adults Below the Age of 60: Titrate slowly to
the desired effect (e.g. the initiation of slurred
• Application of tourniquet 3–4 in. above collection
speech). Some patients may respond to as little as
area with appropriate compression
1 mg. No more than 2.5 mg should be given over a
• Opening and closing of hand period of at least two minutes. Wait an additional two
or more minutes to fully evaluate the sedative effect.
• Hanging of the arm below heart
If further titration is necessary, continue to titrate,
• Light slapping or rubbing of the area with alcohol using small increments, to the appropriate level of
wipe sedation. Wait an additional two or more minutes
after each increment to fully evaluate the sedative
◦◦ Select appropriate Introcan Safety I.V. Catheter (22/24
effect. A total dose greater than 5 mg is not usually
gauge is recommended). See Figures 1.4 and 1.5.
necessary to reach the desired endpoint.
◦◦ Disinfect selected area of venepuncture with 70% iso-
▪▪ Patients Age 60 or Older, and Debilitated or
propyl alcohol wipe
Chronically Ill Patients: Because the danger of
◦◦ Insertion of needle and observe for blood return in the hypoventilation, airway obstruction, or apnea is
flashback chamber greater in elderly patients and those with chronic
disease states or decreased pulmonary reserve,
▪▪ Caution: At no time should venepuncture be per-
and because the peak effect may take longer in
formed on an artery
these patients, increments should be smaller and
◦◦ Remove tourniquet the rate of injection slower. Titrate slowly to the
◦◦ Attach infusion set to catheter adaptor desired effect (e.g. the initiation of slurred speech).
Some patients may respond to as little as 1 mg. No
◦◦ Start IV drip, constant drip should be observed. See more than 1.5 mg should be given over a period of
Figure 1.6. no less than two minutes. Wait an additional two or

Conscious IV Sedation Utilizing Midazolam 7