Dealing with dental anxiety in children – the evidence on type of sedation

Fear of the dentist may be expressed as unco-operative behaviour in children requiring dental treatment. Behaviour management problems can result in a child’s tooth decay going untreated. While behavioural techniques play an important role in managing children, some children still find it difficult to co-operate with dental treatment and may require sedation. This review examined the effects of drugs to sedate a child whilst keeping them conscious.

What was the research?

A systematic review to find out which drugs used to sedate children during dental treatment were the most effective.

Who conducted the research?

The research was conducted by a team led by Paul Ashley of UCL Eastman Dental Institute, London, UK, on behalf of Cochrane Oral Health. Mohsin Chaudhary and Liege Lourenço-Matharu were also on the team.

What evidence was included in the review?

We included 50 randomised controlled trials, including 3,704 children. Within these studies 34 different sedatives were used, often with inhalational nitrous oxide as well. Dosages and delivery of these drugs varied widely. We grouped studies into those where drugs were compared to a placebo, where drugs were compared to other drugs or where different dosages of drugs were compared. Because all the studies were so different we could only carry out a meta-analysis for studies comparing oral midazolam to a placebo.

What did the evidence say?

Oral midazolam probably improves behaviour of children during dental treatment. We evaluated other sedatives but there is insufficient evidence to draw any conclusions.

Where reported, adverse effects were few and minor.

How good was the evidence?

There is some moderate-certainty evidence that midazolam administered in a drink of juice is effective. There was not enough evidence on other sedatives to decide whether or not they were effective.

What are the implications for dentists and the general public?

There is moderate-certainty evidence from six trials that oral midazolam is an effective agent for sedation of children. Although other sedatives have been evaluated, the range of sedatives, regimens, doses, modes of administration and comparisons included makes it impossible to produce a clear statement of implications for practice regarding other agents.

What should researchers look at in the future?

This is the second update of the Cochrane Review first published in 2005 and previously updated in 2012. It is unfortunate that there has been little improvement in the design, statistical power and reporting of studies carried out since then.The shortfalls of studies reported in this review are many. The principles that researchers should adhere to when designing, carrying out and reporting clinical trials in the future are the CONSORT guidelines. There also needs to be a improvement in reporting of variables like gender, weight, time starved, time of onset of sedation, dropouts, reason for patient failing to complete treatment, etc.


Ashley PF, Chaudhary M, Lourenço‐Matharu L. Sedation of children undergoing dental treatment. Cochrane Database of Systematic Reviews 2018, Issue 12. Art. No.: CD003877. DOI: 10.1002/14651858.CD003877.pub5.

This post is an extended version of the review’s plain language summary, compiled by Anne Littlewood at the Cochrane Oral Health Editorial Base.