Nationwide trends in intravenous sedative and analgesic drug use in Korean dental institutions: a big data analysis using the Narcotics Information Management System from 2020 to 2024

Abstract

Background

Intravenous (IV) sedation is an effective method of alleviating patient anxiety and pain, thereby improving cooperation during dental procedures. In South Korea, most drugs used for IV sedation are classified as psychotropic substances, which require strict management throughout the processes of administration, storage, and disposal. In 2018, all medical institutions in Korea were mandated to report on the manufacture, import, use, administration, and disposal of narcotic and psychotropic drugs to the Narcotics Information Management System (NIMS). Thus, in this study, we aimed to analyze the current status and trends of narcotic and psychotropic drug use in IV sedation performed at domestic dental clinics and hospitals by year, region, sex, and age using the aforementioned big data.

Methods

Data on narcotic and psychotropic drug use reported nationwide by dental clinics and hospitals between January 2020 and December 2024 were collected. The drugs analyzed included midazolam, propofol, ketamine, and remimazolam (used for intravenous sedation), as well as fentanyl, remifentanil, and pethidine (used as analgesic adjuncts). Annual trends, regional distributions, and usage ratios by age and sex were analyzed for these medications.

Results

During the analysis period, the use of intravenous sedatives in domestic dental practice showed a continuous annual increase. As of 2024, midazolam account for the largest share, at approximately 76.5% of the total sedative use, followed by propofol (10.6%), ketamine (9.9%), and remimazolam (2.8%). Notably, ketamine showed the most rapid growth, with its annual usage increasing by approximately 152% in 2023 compared to the previous year. According to the type of medical institution, the volume of sedatives used in dental clinics account for 90.8% of the sedatives in 2024, indicating a higher growth rate in dental clinics than in dental hospitals. The average annual growth rate of sedative use is high among adults. Regionally, usage tends to become increasingly concentrated in the Seoul Metropolitan Area (Seoul and Gyeonggi).

Conclusion

The use of IV sedation in Korean dentistry is consistently increasing. Safe IV sedation methods, primarily involving midazolam, are being widely implemented for adults in dental clinic settings.

INTRODUCTION

Oral health is a fundamental component of healthcare that significantly influences both systemic health and the overall quality of life [1]. Dental caries and periodontal diseases are among the most prevalent chronic conditions worldwide, and their management—encompassing restorative, prosthetic, and surgical interventions—is largely invasive. Although local anesthesia has traditionally served as the cornerstone of pain control in dental practice, it is often insufficient to ensure optimal treatment conditions for certain patient populations [2]. These include pediatric patients experiencing severe anxiety in unfamiliar environments, individuals with disabilities who have limited behavioral control, and patients with pronounced dental phobia [3]. In addition, adjunctive anesthetic techniques such as sedation are frequently required to maintain patient stability during extensive intraoral surgical procedures [4].

Intravenous sedation (IVS), which is characterized by the intravenous administration of sedative agents, is widely used in clinical settings because of its rapid onset and ease of titration [5]. Commonly used agents include midazolam, propofol, ketamine, and remimazolam, often in combination with opioid analgesics, such as fentanyl. Although these pharmacological agents provide effective sedation and anxiolysis, they are associated with adverse effects, particularly respiratory depression. Accordingly, safe implementation of an IVS requires operator proficiency and continuous patient monitoring [6].

In Korea, multiple efforts have been undertaken to improve the safety and efficiency of sedation practices by investigating current sedation methods and drug utilization [7]. These studies include survey-based assessments by dentists [8], analyses of institutional medical records [9], and investigations using national health insurance claims data [4]. However, prior research has predominantly focused on oral and inhalational sedation in pediatric populations, with relatively limited evidence regarding intravenous sedation in adult patients [9,10], and is often restricted to case reports. Furthermore, given that a substantial proportion of adult sedation procedures in Korea are performed as non-reimbursed services, the reliance on national health insurance data presents inherent limitations in accurately capturing real-world clinical practice, particularly with respect to uncovered treatments and foreign patients [4].

In Korea, controlled substances are regulated by the Narcotics Control Act. As most agents used for intravenous sedation fall under this regulatory category, concerns regarding illegal diversion and misuse of medical narcotics have increased [11]. To address these concerns, a revision of the Narcotics Control Act implemented on May 18, 2018, mandated that all handlers report their activities to the Narcotics Information Management System (NIMS) [12].

The NIMS is a centralized electronic reporting system that enables narcotics handlers, including medical institutions, pharmacies, and distributors, to record all aspects of controlled substance handling, including manufacturing, importation, storage, use, administration, and disposal. Reporting is mandatory, and the system allows for the accurate quantification of actual drug utilization. Moreover, it enables a comprehensive analysis of usage patterns stratified by institution type, geographic region, year, age, and sex, thereby providing valuable resources for policy development, misuse prevention, and academic research [12].

To overcome the limitations of existing data sources, this study utilized nationwide big data from the NIMS provided by the Korea Institute of Drug Safety and Risk Management. Unlike conventional datasets, the NIMS captures all administrations of controlled substances, regardless of insurance coverage status, and includes records of foreign patients identified via passport numbers, enabling a comprehensive population-level analysis. This study aimed to evaluate the utilization patterns of major intravenous sedatives and analgesics in dental clinics and hospitals across Korea from January 2020 to December 2024, using analyses stratified by year and region. The findings of this study provide important evidence for enhancing the clinical safety of intravenous sedation, establishing standardized clinical guidelines, and developing policy strategies to prevent drug misuse.

METHODS

1. Acquisition of medical narcotics big data and research materials

This study was approved by the Institutional Review Board (IRB) of our institution (approval no. ERI25001). The data used in this study were obtained from the Big Data Repository of the Narcotics Information Management System (NIMS) operated by the Korea Institute of Drug Safety and Risk Management (KIDS) under the Ministry of Food and Drug Safety. To access these data, an application for data use was submitted through the “Medical Narcotics Safety Doum-e” website (https://data.nims.or.kr/). We requested data from July 2019, when NIMS officially began operations, to December 2024. Data from January 2020 to December 2024 were analyzed.

As of 2024, the NIMS permits data applications for 51 drugs across nine ingredient groups. We requested data on drugs used for intravenous sedation, specifically injectable midazolam, propofol, ketamine, remifentanil, injectable fentanyl, remimazolam, and pethidine.

In accordance with Article 11-5 of the Narcotics Control Act of the Republic of Korea, the data provided to researchers exclude personal information and are processed such that individuals, corporations, and organizations cannot be identified. The monthly dataset included identifiable reporting categories corresponding to 17 metropolitan cities and provinces of South Korea: Gangwon-do, Gyeonggi-do, Gyeongsangnam-do, Gyeongsangbuk-do, Jeollanam-do, Jeollabuk-do, Chungcheongnam-do, Chungcheongbuk-do, Seoul, Sejong, Gwangju, Daegu, Daejeon, Busan, Ulsan, Incheon, and Jeju. With respect to the institution type, data applications can be submitted for general hospitals, hospitals, long-term care hospitals, clinics, dental hospitals, dental clinics, Korean medicine hospitals, animal hospitals, and public health centers. For demographic variables, data were requested for both male and female patients, and age was categorized into 10-year intervals: under 10 years, 10s, 20s, 30s, 40s, 50s, 60s, 70s, and 80 years or older.

As this study aimed to investigate the current status of intravenous sedation in dentistry, we specifically requested data from dental hospitals and clinics. The received data were organized according to identifiable reporting categories, and monthly drug usage volumes had already been calculated in the provided dataset (Fig. 1).

Fig. 1. Format of the dataset provided by the Narcotics Information Management System (NIMS). The dataset was provided in a tabulated format and included the following variables: number, year/month, sex, age group, prescribing institution type, prescribing institution location, narcotic/psychotropic classification, efficacy ingredient, drug name, total quantity, and unit. The data were organized into identifiable reporting categories, and monthly drug usage volumes were provided as total quantities with corresponding units for each drug.

2. Analysis of medical narcotics big data

Descriptive statistical analyses were performed to evaluate the drug use patterns. First, the total use of each drug from 2020 to 2024 was calculated, and the proportion of each drug among all included drugs was determined. This analysis was used to identify the most frequently used intravenous sedatives and analgesics in dental practice during the study period.

Monthly drug use was analyzed to assess temporal trends. The monthly quantity of each drug from January 2020 to December 2024 was plotted. These analyses were used to determine whether each drug showed a steady increase, sudden increase after a specific time point, decrease, or fluctuation over time.

Institutional type-specific analyses were conducted to compare drug use between dental hospitals and clinics. These analyses were performed to determine whether certain drugs were used mainly in dental hospitals or more frequently in dental clinics. As drugs used for sedation, anesthesia assistance, or analgesia may show different patterns depending on the clinical setting, institution type was considered an important stratification variable.

Sex-specific analyses compared drug use between males and females by year and month. These analyses examined whether sex-related differences were consistently observed, whether they were limited to specific drugs, and whether overall temporal trends were similar between males and females.

Age-group-specific analyses compared annual drug use across age categories. These analyses were used to evaluate the differences in drug use among children, adolescents, adults, and older adults. Changes from 2020 to 2024 were also examined to determine whether increases in specific drugs would be more prominent in particular age groups.

Regional analyses were performed on 17 metropolitan cities and provinces in the Republic of Korea. First, the total drug use was compared across regions to identify areas with concentrated use. Drug use per dental institution was calculated to improve comparability across regions with different numbers of dental institutions. The regional drug use was visualized using maps to show the geographic distribution of each drug.

Population statistics by administrative region and age group in South Korea for 2024 were obtained from the resident registration population statistics provided by the Ministry of the Interior and Safety (https://jumin.mois.go.kr/). Data on the number of dental institutions and dentists were obtained from the publicly available data provided by the Health Insurance Review and Assessment Service (https://www.hira.or.kr/).

3. Statistical analysis

The raw data set was organized and summarized using pivot tables in Microsoft Excel for Microsoft 365 (Microsoft Corporation, Redmond, WA, USA). Pivot tables were used to aggregate drug quantities by year, month, drug ingredients, sex, age group, type of dental institution, and province. The annual totals, cumulative totals from 2020 to 2024, and proportions of each drug among the total use of the seven included drugs were calculated from the summarized datasets. Data visualization was performed using the R software version 4.6.0 (R Foundation for Statistical Computing, Vienna, Austria). Line graphs, bar graphs, multipanel plots, and regional maps were generated to present temporal trends, demographic distributions, institution-type differences, and geographic variations in drug use. As this study used nationwide aggregated data, the analysis was primarily descriptive. Drug use was summarized as counts, totals, and percentages; patient-level regression or causal inference analysis was not performed.

RESULTS

1. Overall trends in intravenous sedative and analgesic drug use

From January 2020 to December 2024, the use of intravenous sedatives and analgesics in dental institutions steadily increased in Korea. Among the seven drugs analyzed, midazolam was the most frequently used throughout the study period. Propofol was the second most commonly used drug. This was followed by ketamine, fentanyl, remifentanil, remimazolam, and pethidine (Table 1).

Table 1. Annual distribution of intravenous sedative and analgesic drug use in dental institutions from 2020 to 2024.

Drugs	Type of institution	2020	2021	2022	2023	2024	Total
		No of Drugs (%)	No of Drugs (%)	No of Drugs (%)	No of Drugs (%)	No of Drugs (%)	No of Drugs (%)
Midazolam	Dental hospital	6,737	7,312	8,224	10,677	11,804	44,754
	Dental clinic	68,620	80,990	96,838	122,246	147,138	515,831
	Total	75,358 (77.2 %)	88,301	105,062 (78.3 %)	132, 923 (78.3 %)	158,942 (73.8 %)	560,585 (76.9 %)
Propofol	Dental hospital	4,823	4,442	5,386	5,383	4,804	24,838
	Dental clinic	6,512	8,336	8,626	11,110	17,286	51,870
	Total	11,335 (11.6 %)	12,778 (11.4 %)	14,012 (10.4 %)	16,493 (9.7 %)	22,090 (10.3 %)	76,708 (10.5 %)
Ketamine	Dental hospital	122	100	91	508	1,102	1,923
	Dental clinic	913	1,584	3,398	8,309	19,491	33,695
	Total	1,035 (1.1 %)	1,684 (1.5 %)	3,489 (2.6 %)	8,816 (5.2 %)	20,593 (9.6 %)	35,617 (4.9 %)
Remimazolam	Dental hospital	0	10	1,503	1,666	1,180	4,359
	Dental clinic	0	0	7	1,250	4,721	5,978
	Total	0 (0 %)	10 (0 %)	1,510 (1.1 %)	2,916 (1.7 %)	5,901 (2.7 %)	10,337 (1.4 %)
Fentanyl	Dental hospital	6,313	5,957	5,326	3,419	3,288	24,303
	Dental clinic	176	133	265	311	952	1,837
	Total	6,489 (6.6 %)	6,090 (5.4 %)	5,591 (4.2 %)	3,730 (2.2 %)	4,240 (2 %)	26,140 (3.6 %)
Pethidine	Dental hospital	556	603	523	544	667	2,893
	Dental clinic	3	153	369	751	363	1,639
	Total	559 (0.6 %)	756 (0.7 %)	892 (0.7 %)	1,295 (0.8 %)	1,030 (0.5 %)	4,532 (0.6 %)
Remifentanil	Dental hospital	2,053	1,544	2,323	2,404	1,362	9,686
	Dental clinic	825	805	1,232	1,266	1,092	5,219
	Total	2,878 (2.9 %)	2,349 (2.1 %)	3,555 (2.7 %)	3,670 (2.2 %)	2,454 (1.1 %)	14,905 (2 %)

Remimazolam, which was approved by the Korean Ministry of Food and Drug Safety in 2021, showed no recorded use in 2020 and only 10 cases in 2021. Its use subsequently increased after 2022, reaching 5,901 cases by 2024. In contrast, fentanyl use decreased from 6,489 in 2020 to 4,240 in 2024. Pethidine and remifentanil showed relatively low and fluctuating use compared to midazolam, propofol, and ketamine (Table 1, Fig. 2).

Fig. 2. Monthly trends in the use of intravenous sedative and analgesic drugs in dental practice from January 2020 to December 2024.

2. Drug use according to dental institution type

When drug use was analyzed according to institution, clear differences were observed between dental hospitals and clinics. Midazolam use was substantially higher in the dental clinics than in the hospitals (Table 1 and Fig. 3). Similar patterns were observed for propofol and ketamine. Remimazolam use was slightly higher in the dental clinics than in the hospitals (Table 1).

Fig. 3. Monthly trends in intravenous sedative and analgesic drug use by dental institution type from January 2020 to December 2024.

In contrast, fentanyl is predominantly administered in dental hospitals. Pethidine and remifentanil also showed relatively higher use in dental hospitals than in clinics, although their overall use was lower than that of midazolam and propofol (Fig. 3).

3. Drug use according to sex

Sex-stratified monthly analysis revealed that midazolam use increased over time in both males and females. Although midazolam use tended to be slightly higher in males during the study period, the overall temporal pattern was similar between sexes. For other drugs, sex-related differences were less consistent and varied by drug and year. Overall, the increase in drug use over time appeared to reflect a general increase across both male and female patients rather than a pattern confined to one sex (Fig. 4).

Fig. 4. Monthly trends in intravenous sedative and analgesic drug use by sex from January 2020 to December 2024.

4. Drug use according to age group

Age-stratified analysis showed that the distribution of drug use varied according to the drug type. Midazolam was the most frequently used drug in all age groups and years. The highest use of midazolam in 2020 was observed in patients aged < 10 years; however, use among middle-aged groups increased markedly over time. By 2024, the highest use was observed in patients in their 50s, followed by those in their 40s, 60s, 10s, and 30s. (Table 2, Fig. 5).

Table 2. Annual distribution of intravenous sedative and analgesic drug use by age group in dental institutions from 2020 to 2024.

Year	Age group	Midazolam	Propofol	Ketamine	Remimazolam	Fentanyl	Pethidine	Remifentanil
2020	Under 10	1,156	742	63	0	699	43	301
	10s	29,854	481	418	0	741	0	199
	20s	5,850	4,437	170	0	1,387	226	1,204
	30s	7,238	2,629	117	0	674	86	521
	40s	8,872	1,463	94	0	655	44	278
	50s	11,945	844	92	0	861	60	171
	60s	7,781	523	61	0	846	59	136
	70s	2,346	148	15	0	463	32	49
	80s	316	69	4	0	163	11	21
	Total	75,358	11,335	1,035	0	6,489	559	2,878
2021	Under 10	1,128	644	57	1	694	45	250
	10s	30,302	263	438	0	941	0	12
	20s	7,132	4,325	275	2	1,238	203	931
	30s	9,443	3,212	225	0	527	115	520
	40s	11,605	2,235	193	3	548	102	304
	50s	14,940	1,148	236	3	676	112	178
	60s	10,350	689	178	1	882	103	123
	70s	2,920	228	71	0	464	54	26
	80s	482	34	11	0	120	22	7
	Total	88,301	12,778	1,684	10	6,090	756	2,349
2022	Under 10	1,528	852	84	61	623	55	453
	10s	31,438	258	291	0	728	0	274
	20s	7,803	4,066	502	459	1,305	222	1,292
	30s	11,866	3,632	680	340	550	146	584
	40s	15,512	2,360	685	242	583	155	385
	50s	19,214	1,568	691	173	566	125	245
	60s	13,436	869	427	183	685	117	207
	70s	3,674	310	108	41	373	55	75
	80s	591	98	21	11	178	17	41
	Total	105,062	14,012	3,489	1,510	5,591	892	3,555
2023	Under 10	2,230	1,096	181	108	261	55	543
	10s	29,490	382	107	3	185	0	232
	20s	10,741	4,280	1,129	616	820	318	1,218
	30s	16,490	4,026	1,613	594	410	252	667
	40s	22,068	3,153	1,907	588	374	250	386
	50s	26,602	2,215	2,139	591	541	174	300
	60s	18,963	935	1,353	321	547	149	193
	70s	5,477	291	333	87	413	70	89
	80s	860	114	54	8	179	27	44	Population of Republec of Korea (December 2024)
	Total	132,923	16,493	8,816	2,916	3,730	1,295	3,670	Female	Male	Total
2024	Under 10	2,844	1,025	287	148	290	30	287	1,531,058	1,609,060	3,140,118
	10s	24,152	418	82	5	226	0	6	2,245,507	2,373,758	4,619,265
	20s	13,322	4,648	2,437	1,003	772	165	1,043	2,855,132	3,100,524	5,955,656
	30s	22,329	5,064	3,777	1,275	486	167	529	3,166,585	3,457,978	6,624,563
	40s	28,473	4,447	4,654	1,406	499	146	288	3,796,703	3,926,120	7,722,823
	50s	34,236	3,898	5,155	1,200	669	195	185	4,315,099	4,391,271	8,706,370
	60s	24,629	1,984	3,281	660	601	148	70	3,968,224	3,850,559	7,818,783
	70s	7,674	492	819	179	475	130	33	2,254,795	1,931,802	4,186,597
	80s	1,283	114	100	25	222	49	12	1,585,794	857,252	2,443,046
	Total	158,942	22,090	20,593	5,901	4,240	1,030	2,454	25,718,897	25,498,324	51,217,221

Fig. 5. Monthly trends in intravenous sedative and analgesic drug use by age group from January 2020 to December 2024.

Propofol use was concentrated mainly in the adult age groups. By 2024, the highest propofol use was observed in patients in their 30s. Ketamine use increased markedly in the adult and older adult groups during the later years of the study period (Table 2; Figs. 5 and 6).

Fig. 6. Annual distribution of intravenous sedative and analgesic drug use by age group and sex from 2020 to 2024.

Remimazolam also showed increasing use after 2022, particularly in adult age groups. In 2024, remimazolam use was highest in patients in their 40s. Fentanyl, pethidine, and remifentanil showed lower overall use and more variable age-group distributions. Overall, the age-stratified findings suggest that midazolam is broadly used across age groups, whereas propofol, ketamine, and remimazolam are mainly used in adult patients (Figs. 5 and 6).

Fig. 7 shows the annual distribution of drug use in dental hospitals and clinics according to age groups from 2020 to 2024. Overall, the use of sedative and analgesic agents was substantially higher in dental clinics than in dental hospitals for most drugs, particularly midazolam, propofol, ketamine, and remimazolam. In contrast, use of fentanyl and remifentanil was higher in dental hospitals than in dental clinics across most years and age groups, suggesting that opioid analgesics may be more commonly used in hospital-based dental settings.

Fig. 7. Annual distribution of intravenous sedative and analgesic drug use by age group and dental institution type from 2020 to 2024.

5. Regional distribution of drug use

Regional analyses have demonstrated substantial geographic variations in drug use. During the cumulative period from 2020 to 2024, Seoul showed the highest use of most drugs (Table 3).

Table 3. Regional distribution of intravenous sedative and analgesic drug use in dental institutions by province.

Year	Province	Midazolam	Propofol	Ketamine	Remimazolam	Fentanyl	Pethidine	Remifentanil
Total from 2020 to 2024	Total	592,869	81,991	35,985	10,337	29,536	4,809	16,684
	Seoul	213,910	54,747	15,314	5,133	19,905	3,907	10,287
	Busan	13,832	557	427	164	222	20	0
	Daegu	46,709	1,620	1,090	40	0	0	1,458
	Incheon	30,931	13	958	343	0	0	0
	Gwangju	11,169	4,656	742	11	297	0	0
	Daejeon	22,532	2,678	970	30	4,054	408	1,292
	Ulsan	5,669	41	456	2	0	0	0
	Sejong	6,243	0	0	0	0	0	0
	Gyeonggi-do	141,995	6,231	7,139	765	261	389	23
	Gangwon-do	1,129	0	4	8	0	0	0
	Chungcheongbuk-do	24,705	3,204	2,605	113	941	0	0
	Chungcheongnam-do	14,904	4,794	265	398	1,225	85	145
	Jeollabuk-do	25,555	439	702	1,027	0	0	0
	Jeollanam-do	5,936	0	79	38	0	0	0
	Gyeongsangbuk-do	16,446	45	4,526	798	0	0	0
	Gyeongsangnam-do	11,203	2,966	708	1,467	2,631	0	3,479	National statistics (December 2024)
	Jeju-do	0	0	0	0	0	0	0	Population	Dental hospital	Dental clinic	Dentist
2024	Total	158,942	22,090	20,593	5,901	4,240	1,030	2,454	51,217,221	242	19,121	28,836
	Seoul	61,108	12,440	9,001	2,691	2,098	848	1,980	9,331,828	56	4,867	7,484
	Busan	2,069	48	223	159	0	0	0	3,266,598	25	1,332	1,872
	Daegu	13,945	248	704	34	0	0	234	2,363,629	13	946	1,439
	Incheon	6,622	13	486	339	0	0	0	3,021,010	13	1,006	1,444
	Gwangju	3,168	782	325	11	23	0	0	1,408,422	13	643	1,091
	Daejeon	4,142	701	388	30	936	168	212	1,439,157	7	552	865
	Ulsan	1,606	0	95	0	0	0	0	1,098,049	4	384	521
	Sejong	1,261	0	0	0	0	0	0	390,685	1	100	146
	Gyeonggi-do	38,250	2,616	4,395	638	124	14	15	13,694,685	46	4,737	6,788
	Gangwon-do	0	0	0	0	0	0	0	1,517,766	4	441	773
	Chungcheongbuk-do	6,385	2,564	565	109	820	0	0	1,591,177	4	474	717
	Chungcheongnam-do	4,033	2,305	212	94	239	0	13	2,136,574	12	622	1,039
	Jeollabuk-do	4,859	211	609	946	0	0	0	1,738,690	3	606	997
	Jeollanam-do	2,217	0	79	38	0	0	0	1,788,819	7	515	812
	Gyeongsangbuk-do	6,514	14	3,147	534	0	0	0	2,531,384	11	693	997
	Gyeongsangnam-do	2,762	148	364	278	0	0	0	3,228,380	22	956	1,529
	Jeju-do	0	0	0	0	0	0	0	670,368	1	247	322

Regional map analyses showed that midazolam and propofol use were mainly concentrated in the Seoul metropolitan area (Fig. 8, Supplementary file). Because regional differences in total drug use may partly reflect differences in population size and number of dental institutions, additional regional comparisons were performed using drug use normalized by the number of dental hospitals and clinics. These institution-adjusted analyses allowed the comparison of regional drug use after accounting for differences in the regional dental healthcare infrastructure (Fig. 8, Supplementary figures).

Fig. 8. Regional distribution of midazolam use in Korea from 2020 to 2024. (A) Annual regional distribution of the total amount of midazolam used in dental institutions in Korea. The color intensity represents the total number of midazolam ampules used in each region, with darker red indicating higher use. Overall midazolam use increased over time, with the highest usage consistently observed in the Seoul metropolitan area. (B) Annual regional distribution of midazolam use normalized by the number of dental institutions, calculated as midazolam use divided by the total number of dental hospitals and dental clinics in each region.

Although the comparison between dental hospitals and clinics is shown in Fig. 3, we further analyzed whether this difference varied by region, focusing on midazolam, which is the most frequently used drug. Fig. 9 shows monthly midazolam use by region and institution between 2020 and 2024. Overall, midazolam use was higher in dental clinics than in hospitals in most regions, and clinic-based use tended to increase over time.

Fig. 9. Monthly midazolam use by region and dental institution type from January 2020 to December 2024.

DISCUSSION

To the best of our knowledge, this is the first study to analyze dental sedation-related drug use using big data from the NIMS provided by the Korea Institute of Drug Safety and Risk Management under the Ministry of Food and Drug Safety. The present study provides important real-world evidence on the use of intravenous sedatives, including midazolam, propofol, ketamine, and remimazolam, the utilization of which has been difficult to assess in previous studies because these drugs are often used in non-reimbursed dental sedation procedures and are, therefore, not fully captured in health insurance claims data [4].

This nationwide study analyzed the use of major intravenous sedative and analgesic drugs in Korean dental institutions (dental hospitals and dental clinics) from 2020 to 2024 using data from the NIMS. The principal findings were as follows: first, the total use of intravenous sedation-related drugs increased steadily during the study period; second, midazolam was by far the most frequently used drug; third, midazolam, propofol, ketamine, and remimazolam were used predominantly in dental clinics, whereas fentanyl and remifentanil were used more frequently in dental hospitals; fourth, the age distribution of drug use shifted over time, particularly for midazolam, from younger patients to middle-aged adults; and finally, substantial regional variation was observed, with the highest use concentrated in Seoul and Gyeonggi-do.

When compared with previous studies, the study conducted by Bae et al. in 2014, which expanded the study population to include adult patients, reported that patients younger than 7 years accounted for the largest proportion of the age distribution, at 63.2% [8]. This finding is similar to that of our study, in which patients younger than 10 years of age represented the largest proportion of patients during the early study period. In children younger than 10 years, midazolam is often administered through non-intravenous routes, with intramuscular administration being the most commonly used method; intranasal administration has also been reported as an alternative route [9].

In contrast, a 2021 study by Tak et al., which used cohort big data from the National Health Insurance Service, reported that the number of dental treatment cases involving midazolam use in patients younger than 20 years was 105 in 2015 [13]. Although differences in the study period and the use of sample data comprising approximately one million individuals should be considered, this number was substantially lower than the 31,010 units of midazolam administered to patients younger than 20 years in 2020 in our study. Similarly, a 2022 study by Kim et al. investigated the status of sedation using healthcare big data and reported that the total number of cases involving midazolam use in dental clinics and hospitals in 2018 was 7,563 [4]. This also differed markedly from the 75,357 midazolam units used across all age groups in 2020 in this study. These discrepancies suggest that data on IV sedation performed as a non-reimbursed dental procedure may not be fully captured in the national health insurance claims databases.

The steady increase in the use of midazolam, propofol, ketamine, and remimazolam may reflect the growing clinical demand for sedation in dental care. Sedation is increasingly used to manage dental anxiety, phobia, gag reflex, poor cooperation, and invasive oral surgical procedures [5]. The increasing trend observed in this study may, therefore, indicate a broader expansion of sedation-based dental care beyond traditional pediatric or disability-related indications for adult dental procedures.

A notable finding of this study was the marked predominance of midazolam, propofol, ketamine, and remimazolam in dental clinics. This suggests that intravenous sedation in Korea is no longer limited to hospital-based dental settings but is increasingly being performed in outpatient dental clinics. This trend may reflect changes in patient demand, increased availability of sedation techniques, and expansion of private dental services involving implant surgery, third molar extraction, and other invasive procedures. However, these findings have important safety implications. Sedation outside the operating room requires appropriate patient selection, monitoring systems, emergency preparedness, and trained personnel. As sedation depth increases, the risks of respiratory depression and cardiovascular suppression become more serious, making continuous monitoring and standardized protocols essential [14].

However, the greater increase in ketamine use compared with propofol appears to reflect an increase in its independent use rather than an increase in the use of “ketofol” [15]. This finding is consistent with previous studies that have highlighted the sedative and analgesic effects of ketamine in adult patients [16]. The rapid increase in ketamine use observed after 2022 may be partly attributed to the inclusion of ketamine as a sedative agent in the Clinical Practice Guidelines for Sedation during Diagnostic and Therapeutic Procedures published by the Korean Society of Anesthesiologists in 2022 [17]. These guidelines may have contributed to the increased use of ketamine in dental settings. In addition, the increasing trend of ketamine use among adult patients appears to reflect the combined influence of clinicians’ accumulated clinical experience and the practical demand for effective sedation. In patients undergoing painful procedures or in those with severe anxiety, midazolam alone, which lacks analgesic properties, may be insufficient to achieve an adequate depth of sedation. In such cases, the combined use of opioid analgesics or ketamine, which have analgesic effects, may be considered [18].

Remimazolam showed little or no use in the early study period, but increased after 2022, reaching a substantially higher level by 2024. This pattern is clinically plausible because remimazolam is a relatively new benzodiazepine sedative with a rapid onset, short duration, and favorable recovery characteristics. Recent dental sedation literature suggests that remimazolam may provide effective sedation with rapid recovery and relatively limited respiratory and circulatory effects, although evidence in dental procedures remains limited, and further clinical studies are needed [19]. Thus, the increase observed in this study likely reflects the early clinical adoption of remimazolam for dental sedation, but its optimal dosing, safety profile, and comparative effectiveness in real-world dental clinics require further evaluation [20].

The age-stratified findings provide another important perspective. By 2020, midazolam use was highest among patients aged < 10 years, whereas by 2024, the highest use was observed in patients in their 50s. This shift suggests that intravenous sedation in dentistry may be increasingly used for adult and middle-aged patients rather than being concentrated primarily in children. This may reflect the growing use of sedation in adult oral surgery, implant-related procedures, management of dental anxiety, and complex dental treatment. Propofol, ketamine, and remimazolam were also mainly used in the adult age groups, supporting the interpretation that adult dental sedation is expanding in Korea.

Regional analysis showed that drug use was concentrated in Seoul and Gyeonggi-do, which together accounted for a large proportion of the total midazolam use. This concentration is likely related to the population size, dental service density, and concentration of dental institutions in the Seoul metropolitan area. However, the persistence of regional differences, even after considering institution type, suggests that local practice patterns, availability of trained personnel, patient demand, and regional differences in dental service delivery may also contribute. Therefore, future studies should examine regional variations using adjusted indicators, such as drug use per population, per dental institution, or per dentist.

The use of NIMS data is a major strength of the present study. The NIMS is a nationwide electronic reporting system for controlled substances in Korea, and medical institutions and other narcotic handlers are required to report handling processes such as purchasing, dispensing, use, and disposal. Therefore, compared to survey-based studies or insurance claims data, the NIMS provides a more comprehensive source for evaluating the real-world use of controlled sedatives and analgesics in dental institutions [21].

Nevertheless, this study had several limitations. First, because the dataset was aggregated, patient-level information such as diagnosis, procedure type, sedation depth, comorbidities, adverse events, and treatment outcomes could not be analyzed. Second, drug use was measured using ampules or vials rather than the exact administered dose per patient. Therefore, the results do not directly represent the number of sedation cases or patient exposure. Third, the clinical indications for each drug could not be confirmed; for example, opioid use may reflect analgesia, sedation assistance, or perioperative pain control. Fourth, although the NIMS provides comprehensive reporting of controlled substances, the present analysis cannot determine whether the observed increase represents an increase in the number of sedated patients, an increase in drug dose per case, changes in packaging or reporting behavior, or changes in clinical practice. Moreover, in the context of big data analysis, data from only a few reporting institutions may be omitted to prevent the potential identification of specific hospitals or individuals and to minimize the risk of privacy disclosure. This limitation should be considered when interpreting results based on national big data sources.

Despite these limitations, the present study provides important nationwide evidence regarding the use of intravenous sedation-related drugs in Korean dental institutions. These findings suggest that intravenous sedation in dentistry has expanded steadily from 2020 to 2024, with dental clinics playing a central role. In particular, the increasing use of midazolam, ketamine, and remimazolam in clinical settings highlights the need for standardized sedation education, emergency preparedness, monitoring protocols, and periodic surveillance. Future studies linking NIMS data with clinical information, procedure type, adverse event reports, and regional healthcare resources would help clarify whether the increasing use of intravenous sedatives is associated with improved access to dental care, changes in procedural complexity, and potential safety concerns.