Sir, we were interested to read the letter entitled Sedation in Europe1 commenting on our paper concerned with the use of intranasal and intravenous sedation for the treatment of adults with learning disability.2 This letter also refers to a paper by McKenna and Manton on fasting for intravenous conscious sedation.3 Whilst we do not wish to respond to their comments on this publication we would agree that the provision of conscious sedation does not routinely require a starving regimen advised for the provision of general anaesthesia. However, varying opinions may still be held on this matter and the paper by McKenna and Manton based on an examination of the literature is helpful in airing this issue.

With regard to the use of intranasal midazolam, Zanette, Facco and Manini refer to two aspects of its use. For the sedation of children as referred to in a paper by Gilchrist et al.4 this may be regarded as an advanced technique and therefore subject to the guidelines set out in the report by the Standing Dental Advisory Committee.5 However, these guidelines clearly state that the use of intranasal followed by intravenous midazolam conscious sedation for adults is a standard technique and evidence from our paper supports its safety and efficacy. The comments in this part of their letter (ie 'or adult patients') are therefore incorrect and misleading. The guidelines quoted state on page 11 that 'the pharmacokinetic characteristics of midazolam make it the preferred choice' [for oral and transmucosal sedation] and it is our experience that the preparation concentrated at 40 mg/ml is particularly useful for both intranasal and oral use.

The GDC clearly state that dentists have a duty and responsibility to make provision for the management of pain and anxiety in their patients and the use of basic conscious sedation has been shown to be safe and effective. In addition, the use of operator sedationist techniques by the general dental practitioner within primary care enables a wide availability of such techniques. Their performance almost solely by anaesthesiologists, as in Italy, may lead to a limitation of the availability of conscious sedation in primary care and perpetuate the well documented inequalities in oral health for adults with severe disability. The Dental Sedation Teachers Group (DSTG 2008) have recently published a proposal for a standard core postgraduate sedation programme for UK dentists. Perhaps this approach could be adopted by European schools so that the same benefits are available to these patients across Europe?

P.S. There was a slight confusion in the referencing system of their letter, however, this did not distract from the overall thrust of their comment!