Nitrous Oxide Sedation in Pediatric Dentistry

Mark H. Taylor, D.D.S.

History of N2O
1793 - Joseph Priestly invented N2O Initially used as an anesthetic agent in 1844.
Dr. Horace Wells

N2O Commonly Used (and misused)

88% of Pediatric Dentists use N2O, and about 58% of general dentists use N2O.
Deadheads inhaling N2O from a balloon.

Purpose of Nitrous Oxide Sedation

Reduce fear, apprehension, or anxiety Raise pain reaction threshold Reduce fatigue

Fear Reduction & N2O

One group treated with behavior management only; other group with behavior management and N2O. Dental treatment of highly fearful children is carried out more successfully with N2O during the first few sessions. N2O is thus a valuable aid for making highly fearful children treatable quickly.
Veerkamp, et al, J Dent Child, May-June 1993

Fear Reduction & N2O

When highly anxious children are treated with nitrous oxide for a number of consecutive sessions, their anxiety remains significantly lower during a following control period, even without use of nitrous oxide.
Veerkamp, et al, J Dent Child, Jan-Feb 1995

Fear Reduction and N2O

Increase Pain Reaction Threshold

NO Concentration vs. Pain Threshold and Tolerance
50 40 m Amps 30 20 10 0 15 0 30 45

% Nitrous Oxide

Pain Threshold

Pain Tolerance

Four Stages of Anesthesia

Analgesia
patient is conscious reflexes are intact
The patient is unconscious in Stages 2, 3, and 4.

Delerium Surgical Anesthesia Respiratory Paralysis

Analgesia
In analgesia stage, the patient is conscious, has all vital reflexes intact, can communicate and cooperate with the dentist, and quickly returns to a normal state following a few minutes of oxygenation.

Four Plateaus of Analgesia

Paresthesia - tingling of hands, feet Vasomotor - warm sensations Drift - euphoria, pupils centrally fixed, sensation of floating Dream - eyes closed but will open in response to questions, difficulty in speaking, jaw sags open

N2O Should Be Used To:

Ease fears and anxieties Aid in the treatment of special patients Increase tolerance for longer appointments Raise the pain reaction threshold

N2O Should Not Be Used To:

Control defiant or uncontrolled behavior Control pain by replacing local anesthesia Replace poor techniques of behavior management

Uptake and Saturation of N2O

Lungs Blood Highly Perfused Tissues

Less Uptake N2O from Lungs

PROBLEMS!!!

Effective PP in Brain

Increase Lung N2O Concentration

Tissue Saturation

Signs of Saturation
Reminding child continuously to hold mouth open No response to questions Agitation Monitor Sweating Frequently Nausea Unconsciousness

Reduce N2O Dosage...

with lengthy administration (> 30 min.).

Inhalation Analgesia Permits - State of Nebraska

Portable oxygen tank Delivery system that delivers a maximum of 80% N2O Medical history Physical evaluation ("...vital signs such as pulse, blood pressure, respirations, temperature and weight..." Oral pharyngeal airways available Emergency drugs

Elimination of N2O
Rapid Primarily through the lungs Small amount through skin, sweat glands, urine, and intestinal gas

Diffusion Hypoxia
High outpouring of N2O Dilutes available oxygen in lungs
Ventilate the patient for 3 to 5 minutes to prevent diffusion hypoxia!

Effects on Systems
CNS - primary system effected by N2O Respiratory
respiratory rate increase decrease tidal volume N2O potentiates respiratory depression with concommitant use of narcotics, barbiturates, or other sedatives

Effects on Systems
Cardiovascular
normally, no meaningful changes in heart rate or pressure myocardial depression with cardiac decompensation (congestive heart failure) patients with ischemic heart disease without decompensation may benefit from N2O

Myocardial Depression with N2O Use in CHF Patients

3.6 3.4 3.2 Cardiac 3 Index 2.8 2.6 2.4 2.2 100% O2 50% N2O

Normal LVEDP

Elevated LVEDP

Effects on Systems
Fetal
1967 (Vaisman) - report showing increased incidence of spontaneous abortion among femal Russian anesthesiologists 1980 (Cohen, et al) - report showing increased spontaneous abortion rates (2.3) for DAs and unexposed wives of DDSs who used N2O in their practices; also higher rates of liver, kidney and neurological disease

Effects on Systems
Fetal (cont.)
1992 (Rowland, et al.) - demonstrated reduced fertility among female DAs exposed to ambient levels of unscavenged N2O for longer than five hours per week; the concentration and length of exposure that produce any of these effects remain undocumented.

Chronic Exposure to N2O

Long-term (chronic) exposure to nitrous oxide in sufficient concentrations can produce irreversible, toxic changes, and should be a concern for dental personnel working in environments in which nitrous oxide is administered to patients.

Howard, JADA, March 1997

Chronic Exposure Disorders

Reproductive Hematologic Immunological Neurological Liver Kidney

Neurological Symptoms of Chronic Exposure

Loss of concentration Numbness and paresthesia Ataxia Impotence Loss of bladder control Loss of bowel sphincter control

Safe Concentrations of N2O

OSHA - not established NIOSH - recommended exposure limit (REL) 25ppm during administrations ACGIH (American Conference of Governmental Industrial Hygienists) 50 ppm threshold limit value (TLV) over 8 hour TWA (time weighted average)

Safe Concentrations of N2O

Nitrous Oxide Guidance
ADA met with OSHA's second in command, Deputy Assistant Secretary James Stanley, Sept. 18 after learning that a draft OSHA "technical guidance" document on anesthetic gases apparently imposes on dental offices a nitrous oxide level of 25 ppm, a level technologically out of reach and far below that associated with adverse health effects. ADA pointed out that the Association's expert panel, which met Sept. 12 and 13 and included an OSHA engineer, agreed the 25 ppm level is unjustified by scientific data. ADA will submit written comments on the OSHA draft by the end of October. (September 26)

Safe Concentrations of N2O

ADA - has not proposed a permissible exposure limit, but emphasizes the routine use of scavenging equipment

N2O Scavenging
Developed out of a concern regarding possible health consequences and psychomotor influences ADA states that scavenging equipment should be:
used to reduce ambient N2O effective regardless of heating and air conditioning system in use able to achieve N2O standards recommended by NIOSH and OSHA

Controlling N2O in the Operatory

Monitoring N2O concentration
Air samples from two areas
room air - infrared spectrophotometer worker breathing zone - passive dosimeter

Howard, JADA, March 1997

Controlling N2O in the Operatory

Engineering controls
Inspection
equipment for wear, cracks, tears test connections

Scavenging system
no system currently accepted by ADA flow rate of 45 L/min vacuum rate

Howard, JADA, March 1997

Controlling N2O in the Operatory

Ventilation
Fresh air inlets - ceiling Return air vents - floor level Location of ventilation system exhaust Air exchange rate (>10/hr)

Howard, JADA, March 1997

Controlling N2O in the Operatory

Work Practices
Inspect equipment every day Use scavenging system Instruct patient to refrain from mouth breathing and talking Bag should collapse and expand as the patient breathes After administration, flush the system 100% O2.
Howard, JADA, March 1997

Controlling N2O in the Operatory

Maintenance
Inspect and test for leaks (soap) Document results of tests and actions taken All repairs done by authorized dealers

Howard, JADA, March 1997

N2O Scavenging
Factors of scavenging effectiveness
auxilliary evacuation rate of evacuation of scavenging device operatory ventilation use of air sweep fans reduced concentration of delivered N2O poor patient behavior certain procedures (local anesthesia) improper administration loose connections

N2O Scavenging - Device

Preparation of Patient
Patient in reclined position Use TSD Describe sensations in advance

This is how its gonna be, kid...

Administration of N2O
Medical history & vital signs 5 - 6 liters O2 Increase N2O gradually; watch for stages of analgesia Maintenance about 20 - 40% Reduce N2O with long procedures Record N2O levels in the chart 3 - 5 minute O2 flush Rapid induction (surge) technique

Administration of N2O

Complications/Precautions
Vomiting - due to:
overdosage prolonged administration pre-existing GI infection, influenza history of motion sickness or vomiting (use antiemetic) impurities in the delivery system (rare)

If vomiting occurs, turn patient to the side and use HVE Prevent vomiting by close observation of patient

Hallucinations
Complications/Precautions

Always have an assistant present!

Complications/Precautions
Mild rhinitis or colds are not absolute contraindications Contraindicated in patients with a depressed respiratory system
chronic emphysema tuberculosis multiple sclerosis remember, N2O will potentiate drugs that depress the respiratory system

Complications/Precautions
Contraindicated in patients with blocked eustachian tube, pneumothorax, pneumoperitoneum, and pneumopericardium Contraindicated in the first trimester of pregnancy

Complications/Precautions
Other possible contraindications:
severe cardiac disease hyperthyroidism uncontrolled diabetes sickle cell anemia severe asthmatic conditions

See Ya Next Time.