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Nitrous Oxide: The most popular sedative

1426 McPhillips St Winnipeg, MB 888-KIDS. Nitrous Oxide: The most popular sedative. Fadi Kass DMD, Msc, FRCD(c) ‏ November 15, 2008. Some statistics:. United States 89% 1 and 86% 2 of pediatric dentists 35% 3 of general dentists Manitoba 52 out of 610 registered dentists (8.5%) ‏

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Nitrous Oxide: The most popular sedative

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  1. 1426 McPhillips St Winnipeg, MB 888-KIDS • Nitrous Oxide: • The most popular sedative Fadi KassDMD, Msc, FRCD(c)‏ November 15, 2008

  2. Some statistics: • United States • 89%1 and 86%2 of pediatric dentists • 35%3 of general dentists • Manitoba • 52 out of 610 registered dentists (8.5%)‏ • 4 out of 16 Pediatric dentists (25%)‏

  3. MDA stipulates . . . • Have taken a nitrous licensing course • University of Alberta • Dalhousie University • Site audit for the initial setup • Office audit every 3 years to upkeep your initial site audit allowing the use of nitrous

  4. Some history . . . • Discovered in 1772 but primarily used as recreational drug

  5. Pertinent history . . . • In 1884, Horace Wells first dentist to recognize its value • Saw it at a show • Extracted own tooth next day

  6. Benefits of Nitrous • Safe and effective • Increase patient comfort and enjoyment • Visually shields child's eyes from work • Potential practice building tool • Short recovery time • Short duration of onset • Easy to administer

  7. What is it? • N2O • Colorless • Odorless except for faint sweet smell

  8. 4How does it work? • Exact mechanism unknown • Widely accepted that the analgesic effect is mediated through interaction with opioid receptors. • The anxiolytic effect is mediated through interaction with the GABA-A receptors. Closely resembles the effect of ethanol.

  9. 5How it works . . . • Rapidly absorbed upon inhalation • As a result of lower tissue/blood partition coefficients, the equilibration of nitrous oxide in most tissues occurs rapidly • Nitrous oxide is not metabolized in the body. • The blood/gas partition coefficient is low and most of the inhaled nitrous oxide is rapidly eliminated through the lungs, though small amounts diffuse through the skin

  10. Equipment . . . • Need to deliver a mixture of nitrous oxide and oxygen from the the tanks to the child's lungs

  11. Equipment . . . • Modern equipment employ “fail-safe” mechanisms that allow a minimum of 30% oxygen to be used. • By contrast, air we breath is 22% oxygen • Body is never oxygen starved

  12. Equipment . . . • Use of digital delivery units • Digital units deliver pure oxygen during “flush” function instead of simply mixing more nitrous to the bag

  13. 1Monitoring equipment • Clinical observation of the patient’s responsiveness, color, and respiratory rate and rhythem must be performed. • According to the American Academy of Pediatrics, if nitrous is used with any other sedatives, monitoring should be done in accordance to the protocol of deep sedation • According to the American Academy of Pediatric Dentistry, oxygen analyzers use in the office are only a recommendation unless nitrous is used in concentrations greater than 80%.

  14. Does nitrous work?

  15. My experience . . . • Anecdotally, based on case selection, nitrous use seems to assist significantly. • Children under 3 are not candidates for nitrous as they are pre-cooperative • 3-6 yr old patients are only good candidates if you think they will wear the nose piece without panicking • 6 yrs + are ideal candidates as they are capable of understanding instructions given by the clinical team

  16. Biggest benefit for me . . .

  17. Fear reduction using nitrous4 • Study looking at two groups of children • Behavior Management • Behavior Management + Nitrous • Anxiety scores were significantly lower • At semi annual check-ups, Nitrous group did significantly better • Concluded that nitrous helps children lower anxiety levels during a long period after treatment

  18. Ideal flow rate • Range between 5-6 L/min • Look for bag movement with inspiration / expiration

  19. Percentage of Nitrous? • Depending on the patient • Ranges between 25%-50% • The mean alveolar concentration of N2O considered the ED50 for general anesthesia (the dose at which 50% of patients will experience anesthesia) is 105%. • Nitrous alone can not be used to bring on general anesthesia.

  20. 3Normal distribution curve

  21. Prepare the child • When child receives nitrous for first time, the dentist or assistant should explain what they will feel • Tingling of hands and feet • Slight floating sensation • Chest is going to feel funny • General disconnect (“weird”) feeling • THEY ARE ALWAYS IN CONTROL • THEY WILL NOT FALL ASLEEP

  22. At correct therapeutic levels, it will be a positive experience for most patients • If the nitrous levels are too high • Experience slight/severe nausea • Uncontrollable giggling • May even experience a greater sense of anxiety

  23. Sequence . . . • Start with 100% oxygen • Progress to 25% nitrous over 2 mins • Increase by 5% every 30 seconds until ideal levels area reached • Flush oxygen when giving local • Restart back to ideal level for procedure assuming rubber dam use • Finish with 3-5 mins at 100% oxygen

  24. Problems with nitrous use . . .

  25. Diffusion hypoxia • Occurs when the nitrous is discontinued at the end of a procedure which produces a “hang over” type effect • Rapid diffusion of nitrous from the blood back into the alveoli results in displacement of oxygen and a drop in pO2. • This can be easily avoided by breathing 100% O2 for 3-5 mins.

  26. Contraindications • Women who are in the first trimester of pregnancy • Some evidence linking its use to a higher risk of miscarriage in dental assistants • Persons with chronic obstructive pulmonary disease (COPD) • Bronchitis or emphysema related to cigarette smoke • PO2 is their primary stimulant for respiration • Patients undergoing bleomycin sulfate treatment. • Anticancer drug

  27. Thank You

  28. Bibliography • Wilson S. A survey of the American Academy of Pediatric Dentistry membership: nitrous oxide and sedation. Pediatr Dent. 1996 Jul-Aug;18(4):287-93. • Adair SM, Waller JL, Schafer TE, Rockman RA. A survey of members of the American Academy of Pediatric Dentistry on their use of behavior management techniques. Pediatr Dent. 2004 Mar-Apr;26(2):159-66. • Malamed SF, Clark MS. Nitrous oxide-oxygen: a new look at a very old technique. J Calif Dent Assoc. 2003 May;31(5):397-403. Erratum in: J Calif Dent Assoc. 2003 Jun;31(6):458. • Veerkamp JS, Gruythuysen RJ, Hoogstraten J, van Amerongen WE. Anxiety reduction with nitrous oxide: a permanent solution? ASDC J Dent Child. 1995 Jan-Feb;62(1):44-8 • Reynolds JE. Martindale: The Extra Pharmacopoeia. The Pharmaceutical Press: London 1982..

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