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Nitrous Oxide

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Dental offices can safely use nitrous oxide to control patient pain and anxiety by adopting some general work practices.1 Here are some recommendations for incorporating nitrous oxide into your practice:

  • Every nitrous oxide delivery system should be equipped with a scavenging system. A flow meter (or equivalent measuring device) should be easy to see and well maintained to ensure accuracy. The system also should have a vacuum pump with the capacity for up to 45 liters of air per minute per workstation. The system also should come with masks in various sizes to ensure a proper fit for individual patients.
  • Vent the vacuum and ventilation exhaust fumes outside (for example, through a vacuum system). Do not place exhaust system in the vicinity of the fresh-air intake vents. Ensure that the general ventilation provides good room-air mixing. Chronic occupational exposure—several hours a week—to unscavenged nitrous oxide has been associated with adverse health effects.2
  • Test the pressure connections for leaks every time the nitrous system is first turned on and each time a gas cylinder is changed. High-pressure line connections can be tested for leaks quarterly. You can use a soap solution applied to the lines and connections to test for leaks. Alternatively, you can purchase a portable infrared spectrophotometer to test these connections.
  • Before the initial use of the system for the day, inspect all of the system components—reservoir bag, tubings, masks, connectors—for wear, cracks, holes or tears. Replace any damaged pieces.
  • Once all of the components have passed inspection, you can connect the mask to the tubing and turn on the vacuum pump. Ensure that the flow rate is correct—up to 45L/minute or according to the manufacturer’s recommendation.
  • The mask should be properly fitted to each patient. Check that the reservoir bag does not over- or underinflate while the patient is breathing oxygen, before the nitrous is administered.
  • Ask the patient to limit talking during administration of the nitrous and to try to breathe through his or her nose—avoid breathing through the mouth if possible.
  • During administration, watch for changes in the tidal volume of the reservoir bag also keep an eye on the vacuum pump flow rate.
  • After the procedure, deliver 100 percent oxygen to the patient for 5 minutes before removing the mask. This will purge the system, and the patient, of any residual nitrous oxide.
  • Periodically, personnel—particularly those who work with the nitrous oxide delivery—can be assessed for exposure. This can be done by asking the staff members to wear personal dosimetry badges or by placing an infrared spectrophotometer in the room.

NIOSH research has shown that controls including system maintenance, proper ventilation and good work practices can effectively reduce N2O concentrations in dental operatories to approximately 25 ppm (45 milligrams per cubic meter) during analgesia administration.3 This is the exposure limit recommended by NIOSH. Nitrous oxide can be a valuable agent in helping you make your patients comfortable. Like any other resource, nitrous oxide can be safely and effectively incorporated into your practice with proper preparation and equipment maintenance.

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Endnotes

  1. Adapted from: ADA Council on Scientific Affairs, Council on Dental Practice. Association Report: Nitrous Oxide in the Dental Office. JADA 1997;128(3):364-5.
  2. Howard WR. Nitrous Oxide in the Dental Environment: Assessing the Risk, Reducing the Exposure. JADA 1997;128(3):356-60.
  3. National Institute for Occupational Safety and Health. NIOSH Alert: Controlling Exposures to Nitrous Oxide During Anesthetic Administration. Accessed 7/17/13.

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Additional Resources

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