Clinical Outcomes of Low-Dose Intranasal Midazolam for Severe Gag Reflex in Endodontic Patients: A Retrospective Case Series Study

OBJECTIVE: The severe gag reflex (SGR) is an involuntary protective response to foreign substances. SGR presents a significant obstacle to the provision of standard dental care. This retrospective case series study evaluates the clinical outcomes and the feasibility of low-dose (2.5 mg) intranasal midazolam administration on SGR control in uncooperative patients with Gagging Severity Index 5. MATERIAL AND METHODS: This retrospective study includes patients who could not receive endodontic treatment due to the severe gag reflex and were referred for general anesthesia. Data from 13 adult patients, one of whom had an intellectual disability, were used. A fixed low-dose (2.5 mg) of intranasal midazolam was administered under the control of an anesthesiologist. Clinical monitoring (vital signs) focused on respiratory effort, skin color, and the maintenance of verbal commands. Endodontic treatment was started with local anesthesia approximately 10 minutes after 2.5 mg midazolam administration, averaging 40 minutes per session. RESULTS: All patients remained conscious, responsive to verbal commands, and cooperative during treatment. One patient received intranasal saline as an ad-hoc clinical observation, but midazolam was later administered due to persistent gagging. SGR was effectively managed in all patients during initial and ongoing sessions of endodontic treatment without side effects. All necessary dental procedures, including root canal treatment and restorations, were performed comfortably. CONCLUSION: A conservative 2.5 mg dose of intranasal midazolam can safely control severe gag reflex in adult patients during long and complex dental procedures, such as endodontic treatment. Also, it is a practical, less invasive alternative to general anesthesia.