Patient Selection
Indications for use of nitrous oxide/oxygen analgesia/anxiolysis include:
- A fearful, anxious, or obstreperous patient
- Certain mentally, physically, or medically compromised patients
- A patient whose gag reflex interferes with dental care
- A patient for whom profound local anesthesia cannot be obtained
- A cooperative child undergoing a lengthy dental procedure
Review of the patient's medical history should be performed prior to the decision to use nitrous oxide/oxygen analgesia/anxiolysis. This assessment should include:
- Allergies and previous allergic or adverse drug reactions
- Current medications including dose, time, route, and site of administration
- Diseases, disorders, or physical abnormalities and pregnancy status
- Previous hospitalization to include the date and purpose
Contraindications for use of nitrous oxide/oxygen inhalation may include:
- Some chronic obstructive pulmonary diseases
- Severe emotional disturbances or drug-related dependencies
- First trimester of pregnancy
- Treatment with bleomycin sulfate
Whenever possible, appropriate medical specialists should be consulted before administering analgesic/anxiolytic agents to patients with significant underlying medical conditions (e.g., severe obstructive pulmonary disease, congestive heart failure, sickle cell disease, acute otitis media, or recent tympanic membrane graft).
Technique of Nitrous Oxide/Oxygen Administration
Nitrous oxide/oxygen must be administered only by appropriately licensed individuals, or under the direct supervision thereof, according to state law. The practitioner responsible for the treatment of the patient and/or the administration of analgesic/anxiolytic agents must be trained in the use of such agents and techniques and appropriate emergency response.
Selection of an appropriately-sized nasal hood should be made. A flow rate of 5 to 6 liters/minute generally is acceptable to most patients. The flow rate can be adjusted after observation of the reservoir bag. The bag should pulsate gently with each breath and should not be either over- or underinflated. Introduction of 100% oxygen for 1 to 2 minutes followed by titration of nitrous oxide in 10% intervals is recommended. During nitrous oxide/oxygen analgesia/anxiolysis, the concentration of nitrous oxide should not routinely exceed 50%. Nitrous oxide concentration may be decreased during easier procedures (e.g., restorations) and increased during more stimulating ones (e.g., extraction, injection of local anesthetic). During treatment, it is important to continue the visual monitoring of the patient's respiratory rate and level of consciousness. The effects of nitrous oxide largely are dependent on psychological reassurance. Therefore, it is important to continue traditional behavior guidance techniques during treatment. Once the nitrous oxide flow is terminated, 100% oxygen should be delivered for 3 to 5 minutes. The patient must return to pre-treatment responsiveness before discharge.
Monitoring
The response of patients to commands during procedures performed with anxiolysis/analgesia serves as a guide to their level of consciousness. Clinical observation of the patient must be done during any dental procedure. During nitrous oxide/oxygen analgesia/anxiolysis, continual clinical observation of the patient's responsiveness, color, and respiratory rate and rhythm must be performed. Spoken responses provide an indication that the patient is breathing. If any other pharmacologic agent is used in addition to nitrous oxide/oxygen and a local anesthetic, monitoring guidelines for the appropriate level of sedation must be followed.
Adverse Effects of Nitrous Oxide/Oxygen Inhalation
Nitrous oxide/oxygen analgesia/anxiolysis has an excellent safety record. When administered by trained personnel on carefully selected patients with appropriate equipment and technique, nitrous oxide is a safe and effective agent for providing pharmacological guidance of behavior in children. Acute and chronic adverse effects of nitrous oxide on the patient are rare. Nausea and vomiting are the most common adverse effects, occurring in 1 to 10% of patients. A higher incidence is noted with longer administration of nitrous oxide/oxygen, fluctuations in nitrous oxide levels, and increased concentrations of nitrous oxide. Fasting is not required for patients undergoing nitrous oxide analgesia/anxiolysis. However, the practitioner may recommend that only a light meal be consumed in the 2 hours prior to the administration of nitrous oxide. Diffusion hypoxia can occur as a result of rapid release of nitrous oxide from the blood stream into the alveoli, diluting the concentration of oxygen. This may lead to headache and disorientation and can be avoided by administering 100% oxygen after nitrous oxide has been discontinued.
Documentation
Informed consent must be obtained from the parent and documented in the patient's record prior to administration of nitrous oxide/oxygen. The practitioner should provide instructions to the parent regarding pre-treatment dietary precautions, if indicated. In addition, the patient's record must include indication for use of nitrous oxide/oxygen inhalation, nitrous oxide dosage (i.e., percent nitrous oxide/oxygen and/or flow rate), duration of the procedure, and post-treatment oxygenation procedure.
Facilities/Personnel/Equipment
All newly installed facilities for delivering nitrous oxide/oxygen must be checked for proper gas delivery and fail-safe function prior to use. Inhalation equipment must have the capacity for delivering 100%, and never less than 30%, oxygen concentration at a flow rate appropriate to the child's size, and must have a fail-safe system that is checked and calibrated regularly according to the practitioner's state laws and regulations. If nitrous oxide/oxygen delivery equipment capable of delivering more than 70% nitrous oxide and less than 30% oxygen is used, an in-line oxygen analyzer must be used. The equipment must have an appropriate scavenging system.
The practitioner who utilizes nitrous oxide/oxygen analgesia/anxiolysis for a pediatric dental patient shall possess appropriate training and skills and have available the proper facilities, personnel, and equipment to manage any reasonably foreseeable emergency. Training and certification in basic life support (BLS) are required for all clinical personnel. These individuals should participate in periodic review of the office's emergency protocol, the emergency drug cart, and simulated exercises to assure proper emergency management response.
An emergency cart (kit) must be readily accessible. Emergency equipment must be able to accommodate children of all ages and sizes. It should include equipment to resuscitate a non-breathing, unconscious patient and provide continuous support until trained emergency personnel arrive. A positive pressure oxygen delivery system capable of administering >90% oxygen at a 10 liters/minute flow for at least 60 minutes (650 liters, "E" cylinder) must be available. When a self-inflating bag valve mask device is used for delivering positive pressure oxygen, a 15 liters/minute flow is recommended. There should be documentation that all emergency equipment and drugs are checked and maintained on a regularly scheduled basis. Where state law mandates equipment and facilities, such statutes should supersede this guideline.
Occupational Safety
In an effort to reduce occupational health hazards associated with nitrous oxide, the American Academy of Pediatric Dentistry (AAPD) recommends exposure to ambient nitrous oxide be minimized through use of effective scavenging systems and periodic evaluation and maintenance of the delivery and scavenging systems.
