Effect of Continuous versus Interrupted Administration of Nitrous Oxide-Oxygen Inhalation on Behavior of Anxious Pediatric Dental Patients: A Pilot Study

The purpose of this study was to determine the effect of interrupted administration of nitrous oxide (N₂O) inhalation, after obtaining profound local anesthesia, on the behavior of mild to moderately anxious pediatric patients during routine restorative dentistry. Study Design: Healthy children, 5 to 8 years old, requiring nitrous oxide/oxygen inhalation sedation and bilateral mandibular restorative treatment performed in two sequential appointments under local anesthesia were recruited for this study. After profoundness of the local anesthesia was confirmed, the subject was randomly assigned to either Protocol A (50% N₂O / 50% O₂ ) or Protocol B (100% O₂ ) and restorative dental care was completed. On the second appointment, the subject was assigned to the alternate protocol. Results: Hemoglobin oxygen saturation remained constant with no episodes of oxygen desaturation recorded. There were no statistically significant differences (P < .05) in pulse rate or behavior change noted between the two protocols. Conclusion: The implication of this pilot study was significant in consideration of the desire to minimize chronic exposure to ambient nitrous oxide and its potential health hazards to the dental team. These findings challenge the traditional practice of N₂O maintenance throughout the dental appointment.

nitrous oxide, inhalation, sedation, behavior management

1. Wilson S. A survey of the American Academy of Pediatric Dentistry membership:  nitrous  oxide  and  sedation.  Pediatr  Dent,  18:  287–293, 1996.

2. Houpt  MI,  Limb  R,  Livingston  RL.  Clinical  effects  of  nitrous  oxide conscious sedation in children. Pediatr Dent, 26: 29–36, 2004.

3. Everett  GB, Allen  GD.  Simultaneous  evaluation  of  cardiorespiratory and  analgesic  effects  of  nitrous  oxide-oxygen  inhalation  analgesia.  J Am Dent Assoc, 83: 129–133, 1971.

4. Hammond N, Full C. Nitrous oxide analgesia in children’s perception of pain. Pediatr Dent, 6: 238–242, 1984.

5. Nathan  JE,  Venham  LL,  West  MS,  Werboff  J.  The  effect  of  nitrous oxide  on  anxious  young  pediatric  patients  across  sequential  visits:  a double blind study. J Dent Child, 55: 220–30, 1988.

6. Nakai Y, Milgrom P, Mancl L, Coldwell SE, Domoto PK, Ramsay DS. Effectiveness  of  local  anesthesia  in  pediatric  dental  practice.  JADA, 131: 1699–1705, 2000.

7. Clark M, Brunick A. Technique for nitrous oxide/oxygen administra-tion  (Chapter  13),  In  Handbook  of  Nitrous  Oxide  and  Oxygen Sedation. St. Louis: CV Mosby; 127–145, 1999.

8. Primosch  RE,  Buzzi  IM,  Jerrell  G.  Effects  of  nitrous  oxide-oxygen inhalation with scavenging on behavioral and physiological parameters during pediatric dental treatment. Pediatr Dent, 21: 417–420, 1999.

9. Henry RJ, Primosch RE, Courts FJ. The effects of various dental pro-cedures and patient behaviors upon nitrous oxide scavenger effective-ness. Pediatr Dent,14: 19–25, 1992.

10. Primosch RE: Nitrous oxide-oxygen inhalation. In: Mathewson RJ and Primosch  RE.  Fundamentals  of  Pediatric  Dentistry.  3rd  ed.  Chicago: Quintessence Publishing Co.; 186–196, 1995.

11. Dock M, Creedon RL. Pharmacologic management of patient behavior. In:  McDonald  RE, Avery  DR,  Dean  JA.  Dentistry  for  the  Child  and Adolescent. 8th ed. St. Louis: CV Mosby, 285–311, 2004.

12. Wilson  S,  Vann  WF,  Dilley  DC.  Pain  reaction  control:  sedation.  In: Pinkham JR, Casamassimo PS, Fields HW, McTigue DJ, Nowak AJ. Pediatric Dentistry: Infancy Through Adolescence. 4th ed. St. Louis: Elsevier Saunders; 116–129, 2005.

13. Clark  M,  Brunick A.  Potential  biohazards  for  health  personnel  with chronic  exposure  to  nitrous  oxide  (Chapter  17),  In  Handbook  of Nitrous Oxide and Oxygen Sedation. St. Louis: CV Mosby; 169–182, 1999.

14. Howard WR. Nitrous oxide in the dental environment: assessing the risk, reducing the exposure. J Am Dent Assoc 128:356-60, 1997.

15. American  Dental Association,  Council  on  Scientific Affairs.  Nitrous oxide in the dental office. J Am Dent Assoc, 128: 364–65, 1997.

16. American Academy of Pediatric Dentistry. Policy on minimizing occu-pational  health  hazards  associated  with  nitrous  oxide.  Reference Manual, 32: 65–66, 2010.

17. American Academy of Pediatric Dentistry. Guidelines on use of nitrous oxide  for  pediatric  dental  patients.  Reference  Manual,  32:  163–166, 2010.

18. Houpt MI, Koenigsberg SR, Weiss NJ, Desjardins PJ. Comparison of chloral hydrate with and without promethazine in the sedation of young children. Pediatr Dent, 7: 41–46, 1985.

19. Houpt  MI,  Sheskin  RB,  Koenigsberg  SR,  Desjardins  PJ,  Shey  Z. Assessing chloral hydrate dosage for young children. J Dent Child, 52: 364–369, 1985.

20. Houpt MI, Kupietzky A, Tofky NS, Koenigsberg SR. Effect of nitrous oxide  on  diazepam  sedation  of  young  children.  Pediatr  Dent,  18: 236–241, 1996.

21. McCann W, Wilson S, Larsen P, Stehle B: The effects of nitrous oxide on  behavior  and  physiological  parameters  during  conscious  sedation with a moderate dose of chloral hydrate and hydroxyzine. Pediatr Dent, 18: 35–41, 1996.

22. Ellis RK, Berg JH, Raj PP. Subjective signs of efficacious inferior alve-olar nerve block in children. J Dent Child, 57: 361–5, 1990

23. Langa  H.  Relative Analgesia  in  Dental  Practice.  W.B.  Saunders  Co; Philadelphia, 1968.

24. Carnow R. An analysis of the patient reaction under N2O + O2 anal-gesia. J Oregon Dent Assoc, 38: 13–16, 1969.

25. Verwest TM, Primosch RE, Courts FJ: Variables influencing hemoglo-bin oxygen desaturation in children during routine restorative dentistry. Pediatr Dent, 15: 25–29, 1993.

26. Rohlfing GK, Dilley DC, Lucas WJ, Vann WF: The effect of supple-mental oxygen on apnea and oxygen saturation during pediatric con-scious sedation. Pediatr Dent, 1: 8–16, 1998.

27. Henry  RJ,  Vaikuntam  J,  Jones  DJ:  The  influence  of  midazolam  and nitrous oxide on respiratory depression in laboratory rats. Pediatr Dent, 18: 281–86, 1996.

28. Anderson J, Vann WF: Respiratory monitoring during pediatric seda-tion: pulse oximetry and capnography. Pediatr Dent, 10: 94–101, 1988.

29. Whitehead G, Durr D, Adair S, Proskin H: Monitoring sedated pedi-atric dental patients. J Dent Child, 55: 329–33, 1988.

30. Hasty  MF, Vann WF,  Dilley  DC, Anderson  J:  Conscious  sedation  of pediatric dental patients: an investigation of chloral hydrate, hydrox-yzine  pamoate,  and  meperidine  vs.  chloral  hydrate  and  hydroxyzine pamoate. Pediatr Dent, 13: 10–19, 1991.

31. Litman RS, Kottra JA, Berkowitz RJ, Ward DS: Upper air way obstruc-tion during midazolam/nitrous oxide sedation in children with enlarged tonsils. Pediatr Dent, 20: 318–320, 1998.

32. Litman  RS,  Kotta  JA,  Verga  KA,  Berkowitz  RJ,  Ward  DS:  Chloral hydrate  sedation:  the  additive  sedative  and  respiratory  depressant effects of nitrous oxide. Anesth Analg, 86: 724–728, 1998.

33. Annequin  D,  Carbajal  R,  Chauvin  P,  Gall  O, Tourniaire  B,  Murat  I. Fixed  50%  nitrous  oxide  oxygen  mixture  for  painful  procedures:  a French survey. Pediatrics, 105: e47, 2000.

34. Faddy SC, Garlick SR. A systematic review of the safety of analgesia with 50% nitrous oxide: can lay responders use analgesic gases in the prehospital setting? Emerg Med J, 22: 901–906, 2005.

35. Litman RS, Berkowitz RJ, Ward DS: Level of consciousness and ven-tilatory parameters in young children during sedation with oral mida-zolam  and  nitrous  oxide. Arch  Pediatr Adolesc  Med,  150:  671–675, 1996.