Guideline:
Clinical guideline on appropriate use of nitrous oxide for pediatric dental patients
Bibliographic Source(s)
- American Academy of Pediatric Dentistry (AAPD). Clinical guideline on appropriate use of nitrous oxide for pediatric dental patients. Chicago (IL): American Academy of Pediatric Dentistry (AAPD); 2005. 4 p. [16 references]
Guideline Status
This is the current release of the guideline.
Guideline Category
Management
Treatment
Intended Users
Dentists
Guideline Objective(s)
To assist the dental profession in developing appropriate practices in the use of nitrous oxide/oxygen analgesia/anxiolysis for pediatric patients
Target Population
Infants children adolescents and persons with special health care needs
Interventions and Practices Considered
Clinical Assessment
- Patient selection
- Review of medical history
- Specialist consultation
Management
- Technique of nitrous oxide/oxygen administration
- Patient monitoring during procedure (patient's responsiveness color respiratory rate and rhythm spoken responses)
- Documentation
- Informed consent
- Provision of instructions to the parent (regarding pre-treatment dietary precautions)
- Recording of indication dose flow procedure duration post treatment oxygenation procedure
Facilities/Personnel/Equipment
- Proper gas delivery and fail-safe function
- Appropriate oxygen concentration
- Training and certification in basic life support (BLS) for all clinical personnel
- Periodic review of safety procedures (the office's emergency protocol the emergency drug cart and simulated exercises to assure proper emergency management response)
Major Outcomes Considered
Side effects of nitrous oxide
Methods Used to Collect/Select Evidence
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
A MEDLINE search was conducted using the terms "nitrous oxide" "analgesia" "anxiolysis" "behavior management" and "dental treatment."
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Not stated
Rating Scheme for the Strength of the Evidence
Not applicable
Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence
Not stated
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
The oral health policies and clinical guidelines of the American Academy of Pediatric Dentistry (AAPD) are developed under the direction of the Board of Trustees utilizing the resources and expertise of its membership operating through the Council on Clinical Affairs (CCA).
Proposals to develop or modify policies and guidelines may originate from 4 sources:
- The officers or trustees acting at any meeting of the Board of Trustees
- A council committee or task force in its report to the Board of Trustees
- Any member of the AAPD acting through the Reference Committee hearing of the General Assembly at the Annual Session
- Officers trustees council and committee chairs or other participants at the AAPD's Annual Strategic Planning Session
Regardless of the source proposals are considered carefully and those deemed sufficiently meritorious by a majority vote of the Board of Trustees are referred to the CCA for development or review/revision.
Once a charge (directive from the Board of Trustees) for development or review/revision of an oral health policy or clinical guideline is sent to the CCA it is assigned to 1 or more members of the CCA for completion. CCA members are instructed to follow the specified format for a policy or guideline. All oral health policies and clinical guidelines are based on 2 sources of evidence: (1) the scientific literature; and (2) experts in the field. Members may call upon any expert as a consultant to the council to provide expert opinion. The Council on Scientific Affairs provides input as to the scientific validity of a policy or guideline.
The CCA meets on an interim basis (midwinter) to discuss proposed oral health policies and clinical guidelines. Each new or reviewed/revised policy and guideline is reviewed discussed and confirmed by the entire council.
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation
Once developed by the Council on Clinical Affairs (CCA) the proposed policy or guideline is submitted for the consideration of the Board of Trustees. While the board may request revision in which case it is returned to the council for modification once accepted by majority vote of the board it is referred for Reference Committee hearing at the upcoming Annual Session. At the Reference Committee hearing the membership may provide comment or suggestion for alteration of the document before presentation to the General Assembly. The final document then is presented for ratification by a majority vote of the membership present and voting at the General Assembly. If accepted by the General Assembly either as proposed or as amended by that body the document then becomes the official American Academy of Pediatric Dentistry (AAPD) oral health policy or clinical guideline for publication in the AAPD's Reference Manual and on the AAPD's Web site.
Major Recommendations
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.
Clinical Algorithm(s)
None provided
Type of Evidence supporting the Recommendations
All oral health policies and clinical guidelines are based on 2 sources of evidence: (1) the scientific literature; and (2) experts in the field.
Potential Benefits
- Reduction or elimination of anxiety
- Reduction of untoward movement and reaction to dental treatment
- Enhancement of communication and patient cooperation
- Raising of the pain reaction threshold
- Increasing the tolerance for longer appointments
- Aiding in the treatment of the mentally/physically disabled or medically compromised patient
- Reduction of gagging
- Potentiate the effect of other sedatives
Potential Harms
- For some patients the feeling of "losing control" with nitrous oxide may be troubling and claustrophobic patients may find the nasal hood confining and unpleasant.
- Side effects of nitrous oxide include nausea vomiting headache and disorientation.
- Lack of potency of nitrous oxide/oxygen inhalation
- Interference of the nasal hood with injection to anterior maxillary region
- Nitrous oxide pollution and potential occupational exposure health hazards
Contraindications
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
Description of Implementation Strategy
An implementation strategy was not provided.
Implementation Tools
Chart Documentation/Checklists/Forms
Resources
For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.
IOM Care Need
Staying Healthy
IOM Domain
Effectiveness
Safety
Bibliographic Source(s)
- American Academy of Pediatric Dentistry (AAPD). Clinical guideline on appropriate use of nitrous oxide for pediatric dental patients. Chicago (IL): American Academy of Pediatric Dentistry (AAPD); 2005. 4 p. [16 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
American Academy of Pediatric Dentistry
Guideline Committee
Council on Clinical Affairs
Composition of Group that Authored the Guideline
Not stated
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
This is the current release of the guideline.
Guideline Availability
Electronic copies: Available from the American Academy of Pediatric Dentistry Web site.
Print copies: Available from the American Academy of Pediatric Dentistry 211 East Chicago Avenue Suite 700 Chicago Illinois 60611
Availability of Companion Documents
Information about the American Academy of Pediatric Dentistry (AAPD) mission and guideline development process is available on the AAPD Web site.
The following implementation tools are available for download from the AAPD Web site:
- Dental growth and development chart
- American Academy of Pediatric Dentistry Caries-Risk Assessment Tool (CAT)
Patient Resources
None available
NGC STATUS
This NGC summary was completed by ECRI on August 19 2005.
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This summary is based on the original guideline which is subject to the guideline developer's copyright restrictions.
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