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Dental Tribune Middle East & Africa Edition No. 3 2015

Dental Tribune Middle East & Africa Edition | May-June 2015 45pediatric tribune < Page 36 5. A cooperative child undergo- ing a lengthy dental procedure. Contraindications for the use of nitrous oxide/oxygen inha- lation analgesia: Contraindications for use of ni- trous oxide/oxygen inhalation may include: 1. Some chronic obstructive pul- monary disease13 2. Common cold, tonsillitis, na- sal blockage 3. Pre-cooperative children 4. Severe emotional disturbanc- es or drug-related dependen- cies14 5. First trimester of pregnancy15 6. Treatment with bleomycin sulfate16 7. Methylene tetrahydrofolate reductase deficiency17 8. Cobalamin deficiency5 Whenever possible, appropriate medical specialists should be consulted before administering analgesic/anxiolytic agents to patients with significant under- lying medical conditions (eg, severe obstructive pulmonary disease, congestive heart failure, sickle cell disease, acute otitis media, recent tympanic mem- brane graft, and acute severe head injury. Technique of nitrous oxide/ oxygen administration Only appropriately licensed and trained pediatric dentists must administer nitrous oxide/oxy- gen. The practitioner responsi- ble for the treatment of the pa- tient and/or the administration of analgesic/anxiolytic agents must be trained in the use of such agents and techniques and appropriate emergency re- sponse. Selection of an appropriately sized nasal hood is very impor- tant. A flow rate of five to six L/ min generally is appropriate for 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. Intro- duction of 100 percent oxygen for one to two minutes followed by titration of nitrous oxide in 10 percent intervals is recom- mended. During nitrous oxide/ oxygen analgesia/anxiolysis, the concentration of nitrous oxide should not normally exceed 50 percent. Studies have demon- strated that gas concentrations dispensed by the flow meter vary significantly from the end- expired alveolar gas concentra- tions; it is the later that is respon- sible for the clinical effects18 . To achieve sedation, care should be taken that the scavenging vacu- um is not so strong as to prevent adequate ventilation of the lungs with nitrous oxide19 . A review of records of patients undergoing nitrous oxide-ox- ygen inhalation sedation dem- onstrate that the typical patient requires from 30 to 40 percent nitrous oxide to achieve ideal se- dation19 . Nitrous oxide concen- tration may be decreased during easier procedures (eg, resto- rations) and increased during more stimulating ones (eg, ex- traction, injection of local anes- thetic). The use of a dental dam, whenever possible during re- storative procedures is essential to minimize the concentration of needed nitrous and increase the potency of the gas. The prac- titioner should continue with communicative techniques dur- ing the administration of nitrous oxide as patients become highly suggestible. The level of nitrous oxide can be titrated down at subsequent visits due to its con- siderable placebo effect. During treatment, it is important to continue the visual monitor- ing of the patient’s respiratory rate and level of consciousness. The effects of nitrous oxide are largely dependent on psycholog- ical reassurance. Therefore, it is important to continue traditional behavior guidance techniques during treatment. Once the ni- trous oxide flow is terminated, 100 percent oxygen should be delivered for five minutes14 . The patient must return to pretreat- ment responsiveness before dis- charge. Monitoring The response of patients to commands during procedures performed with analgesia/anxi- olysis serves as a guide to their level of consciousness. Clinical observation of the patient must be performed during any den- tal procedure. During nitrous oxide/oxygen analgesia/anxi- olysis, continual clinical obser- vation of the patient’s respon- siveness, color, and respiratory rate and rhythm must be per- formed. Spoken responses pro- vide an indication that the pa- tient is breathing20 . If any other pharma-cologic agent is used in addition to nitrous oxide/oxygen and a local anesthetic, monitor- ing guidelines for the appropri- ate level of sedation must be fol- lowed21 . Adverse effects of nitrous ox- ide/oxygen inhalation Nitrous oxide/oxygen analgesia/ anxiolysis has an excellent safe- ty record. When administered by trained personnel on carefully selected patients with appropri- ate equipment and technique, nitrous oxide is a safe and effec- tive agent for providing pharma- cological guidance of behavior in children. Acute and chronic adverse effects of nitrous oxide on the patient are rare. Nausea and vomiting are the most com- mon adverse effects, occurring in 0.5 percent of patients22 . A higher incidence is noted with longer administration of nitrous oxide/oxygen, fluctuations in ni- trous oxide levels, and increased concentrations of nitrous oxide3 . Typically, if a child appears rest- less during the course of ad- ministration of nitrous oxide/ oxygen, they might be ready to vomit or they might be entering into a deeper stage of sedation. Fasting is not required for pa- tients undergoing nitrous oxide analgesia/anxiolysis. The practi- tioner, however, may advise that only a light meal be consumed in the two 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, thereby diluting the concentration of oxygen. This may lead to headache and diso- rientation and can be avoided by administering 100 percent oxy- gen after nitrous oxide has been discontinued3 . Documentation Informed consent must be ob- tained from the parent and doc- umented in the patient’s record prior to administration of nitrous oxide/oxygen. An explanation of the sedation technique proposed and of appropriate alternative methods of pain and anxiety controlmustbegivenInadvance of the procedure, the child and their parent or guardian must be given clear and comprehensive pre- and postoperative instruc- tions in writing. The practitioner should provide instructions to the parent regarding pretreat- ment dietary precautions, if in- dicated. In addition, the patient’s record should include indication for use of nitrous oxide/oxygen inhalation, nitrous oxide dosage (ie, percent nitrous oxide/oxy- gen and/or flow rate), duration of the procedure, and post treat- ment oxygenation procedure. The record should also include documentation of the patient’s response to the use of nitrous and the postoperative instruc- tions. Any adverse effects of the procedure should be also docu- mented. Facilities/personnel/equip- ment All newly installed facilities for delivering nitrous oxide/oxygen must be checked for proper gas delivery and fail-safe function prior to use. Inhalation equip- ment must have the capacity for delivering 100 percent, and nev- er less than 30 percent, oxygen concentration at a flow rate ap- propriate to the child’s size. Ad- ditionally, inhalation equipment must have a fail-safe system that is checked and calibrated regu- larly. If nitrous oxide/oxygen delivery equipment capable of delivering more than 70 percent nitrous oxide and less than 30 percent oxygen is used, an inline oxygen analyzer must be used. The equipment must have an appropriate scavenging system to minimize room air contami- nation and occupational risk. A thorough check of the equip- ment should be carried out in advance by the dental personnel any time nitrous oxide/oxygen analgesia is to be used. The practitioner who utilizes ni- trous oxide/oxygen analgesia/ anxiolysis for a pediatric dental patient shall possess appropri- ate training and skills and have available the proper facilities, personnel, and equipment to manage any reasonably foresee- able emergency. Training and certification in basic life sup- port are required for all clinical ManalAlHalabiBDSMS Associate Professor & Programme Director, MSc Programme in Pae- diatricDentistry Hamdan Bin Mohammed College ofDentalMedicine DubaiHealthcareCity P.O.Box 505097DubaiUAE T:97144248602|F:97144248687 E:manal.halabi@hbmcdm.ac.ae Contact Information 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 man- agement response. An emergency cart (kit) must be readily accessible. Emer- gency 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 person- nel arrive. A positive-pressure oxygen delivery system capable of administering greater than 90 percent oxygen at a 10 L/ min flow for at least 60 minutes (650 L, “E” cylinder) must be available. When a self-inflating bag valve mask device is used for delivering positive pressure oxygen, a 15 L/min flow is rec- ommended. There should be documentation that all emer- gency equipment and drugs are checked and maintained on a regularly scheduled basis22 . Occupational safety In the medical literature, long- term exposure to nitrous oxide used as a general anesthetic has been linked to bone marrow suppression and reproductive system disturbances5 . Exposure to nitrous oxide can result in depression of vitamin B12 ac- tivity resulting in impaired syn- thesis of RNA. Dental surgeons and their staff are particularly at risk as they are exposed to high concentrations in the con- fined space of a dental surgery, especially if scavenging is inad- equate24 . In an effort to reduce occupational health hazards as- sociated with nitrous oxide, it is recommended that exposure to ambient nitrous oxide be mini- mized through the use of effec- tive scavenging systems and periodic evaluation and mainte- nance of the delivery and scav- enging systems25 . References 1. AAPD Reference Manual. Guideline on Use of nitrous ox- ide for pediatric dental patients. http://www.aapd.org/media/ Policies_Guidelines/G_Nitrous. pdf 2. American Dental Association. Guideline for the use of seda- tion and general anesthesia by dentists. 2007. Available “http:// www.ada.org/sections/about/ pdfs/anesthesia_guidelines.pdf”. 3. Paterson SA, Tahmassebi JF. Pediatric dentistry in the new millennium: Use of inhalation sedation in pediatric dentistry. Dent Update 2003;30(7):350-6, 358. The full list of references is available from the publisher.

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