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Introduction
Patient anxiety has always been a major issue in dental offices. Practitioners have jumped at any potential tool that could be used to help alleviate this anxiety. Less patient anxiety leads to greater treatment acceptance and, in the long term, more business. With the plethora of pharmaceutical options available these days, dentists have more choices than ever. Many of these choices require specialized training of the dentist and staff as well as specialized safety equipment (pulse oxymeter). Due to its relative safety and efficacy, nitrous oxide remains the leading anxiolytic used in dental offices today.
As previously stated, nitrous oxide is used in the dental office for its calming effects. It enables patients to better tolerate lengthy dental procedures and makes the overall experience more of a positive one. Many practitioners will tell you that it can be a tremendous practice builder. Nitrous is generally administered in a 25-50% mixture with oxygen. It is administered through a small mask that covers the patient's nose. Some patients may feel uncomfortable having their nose covered so the dentist should closely monitor the patient for the first few minutes of use. Likewise, patients who have trouble breathing through their nose may be better off abstaining from nitrous use. Some patients only require nitrous to overcome their anxiety and fear of receiving an intraoral injection. Good communication with the patient should bring any problems to light early in the procedure.
Nitrous Oxide Propellant Canisters |
When a patient is receiving nitrous oxide for the first time, the dentist or assistant should explain to the patient what the experience would feel like. This discussion should include what to look for in the instance that the patient is receiving too high a dose of the gas. At a proper therapeutic dose, the patient will |
| experience tingling in the hands and feet. They will feel a slight "floating" sensation and a general disconnectedness to what is occurring around them. At a correct therapeutic level, the experience will be very positive for most patients. If the level of nitrous administered is too high, the patient will begin to experience slight to severe nausea, uncontrollable giggling (hence the nickname "laughing gas") and may even experience a greater sense of anxiety than they would have had without the nitrous. Communication with the patient is instrumental in ensuring the patient is receiving the correct dose. It is generally recommended that the patient be started on 25% nitrous with the percentage being increased if the desired effect is not being achieved. |
 Modern nitrous oxide delivery systems employ "fail-safe" mechanisms that allow a minimum of 30% oxygen to be delivered at any given time. When you consider that the atmosphere we breathe everyday is made up of around 21% oxygen, this fail-safe mechanism ensures that the body is never oxygen starved during the administration of nitrous oxide. Modern nitrous machines also ensure that if at any point during sedation the office supply of bottled oxygen runs out, the nitrous oxide will be automatically shut off. This guarantees that the patient will not at any point be breathing 100% N2O. Both the flow meter delivery system and the tanks from which the gasses are dispensed uses the universal color-coding for both nitrous oxide (blue) and oxygen (green). The flow meter balls are calibrated so that when the ratio of nitrous to oxygen is 50/50, the balls are floating at the same level. If a practitioner were to adjust only the oxygen level, the nitrous level would adjust to keep this ratio the same. In order to increase or decrease the percentage of nitrous oxide being administered, the nitrous oxide lever must be adjusted. Next to this lever is typically a listing of percentages for ease of adjustment. The tanks that these gasses are dispensed from follow also follow the same color code. The pressure of gas inside the tanks is an indication of the amount left. This can be monitored using the nitrous oxide manifold that is typically located near the tanks.
It is important that administration of nitrous oxide in a dental setting be closely monitored. Long term, chronic exposure to nitrous can cause serious health problems. With this in mind, a very important part of the nitrous oxide armamentarium is the scavenger system. This system employs a vacuum to remove any gas exhaled through the patient's nostrils or escaping from the nosepiece. The nosepiece is also provided with a plurality of holes in the underside to scavenge gas exhaled through the patient's mouth. This helps minimize gas leakage into the environment and potential exposure to health care workers.
Nitrous Oxide Delivery Masks
The dangers associated with nitrous use in the dental office are few but potentially very serious. Women who are known to be pregnant or think they may be pregnant should not use nitrous. N2O has shown teratogenic properties in rodents. While the few studies involving humans have been inconclusive, it is prudent to refrain from administering N2O to pregnant women. Nitrous oxide itself is not a flammable gas. However, since it is administered with oxygen (which is flammable), the mixture is flammable and can pose a problem in select situations. The use of a diamond bur on titanium or other metals can cause sparking and may lead to ignition of the oxygen being administered. This may sound far-fetched but cases of this have occurred and it is a legitimate concern. Always use carbide burs to cut titanium in the presence of flammable gas.
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Nitrous Oxide Use
