Pediatric dentistry

THE USE
OF NITROUS OXIDE INHALATION SEDATION
FOR DENTAL TREATMENT IN AGITATED
CHILDREN

:Presented by
b4 ‫محمود علي حسين‬
:Supervised by
Dr. Wissam Mohammed
INTRODUCTION
Young, fearful, and uncooperative pediatric dental patients
should be managed with behavioral techniques. Although
behavioral techniques could be useful
in reducing anxiety, there is a part of the pediatric
patients that are not able to tolerate dental procedures
and may require alternative approaches, such as the use of
sedative agents (Propofol , Etomidate , Midazolam , Ketamine ,
or Dexmedetomidine), or the use of analgesic agents (Opioids,
Fentanyl, or Ketamine). Howevere, the application of conscious
sedation with nitrous oxide and oxygen or general anesthesia
were more favored to be used by European dentists.
Child anxiety about dental treatment is a well recognized
problem, with several studies demonstrating that fear of invasive
procedures, such as injections and the ‘drill’, is the cause of
dental anxiety amongst children. The use of conscious sedation
as a safe alternative to general anaesthesia for dental care in
anxious patients. Nitrous oxide inhalation sedation is the standard
technique for managing pediatric patients with dental anxiety.
Dental fear, anxiety, and low pain tolerance are
associated with increased levels of caries. In fact, fear
of the dentist can result in untreated dental caries.

A recent study, investigating the prevalence of

clinical consequences of untreated dental caries and
its relation to dental fear, showed that children with
high dental fear had 2 times the risk of untreated
caries as compared to children with low fear.
Pain and suffering due to untreated diseases can lead
to problems in eating and speaking.
 Indications
1. Extraction of first permanent molar teeth for
children aged from 8-12 years.
2. Soft tissue laceration repair
3. Reduction and fixation of fracture
4. Draining abscess
5. during various dental procedures
6. certain imaging or minor procedures where
the patient is unable (or unwilling)
 Contraindications
There are no reasons that immediately disqualify a patient from
receiving inhalation sedation. However, serious medical
condition such as severe obstructive pulmonary disease;
severe emotional disturbances or drug-related dependencies;
acute otitis media; and recent tympanic drainage are absolute
contraindication.
General anesthesia is the most common modality for managing
uncooperative children.

General anaethesia vs conscious sedation nitrous oxide

1. The morbidity and mortality risks associated with general

anesthesia are considerably higher compared with conscious
sedation.
2. The discomfort produced and the inconvenience of a
prolonged time of no oral feeding make general anesthesia a no
longer recommended.
3. Costs for conscious sedation are estimated to be cheaper by
about a third comparedwith general anesthesia.
Nitrous oxide (N2O) is a colorless and virtually odorless gas with
a faint, sweet smell. It is an effective analgesic/anxiolytic agent
causing central nervous system (CNS) depression and euphoria
with little effect on the respiratory system.

Inhalation sedation technique

The uses of sub anesthetic concentrations of nitrous oxide
delivered with oxygen from dedicated machinery via a nasal
mask. Nitrous oxide is poorly soluble with a high minimum
alveolar concentration; rapid onset of action is therefore coupled
with a rapid recovery period; the duration of the sedation is
controlled and the patient can quickly return to normal activities.
The level of sedation must be such that the patient remains
conscious, retains protective reflexes, and is able to understand
and to respond to verbal commands. It may be considered as the
first level in the sedation process.
Patients were asked not to eat for at least 2 hours before
conscious sedation treatment.
Heart rate, oxygen saturation, and blood pressure were monitored
at the beginning of the dental treatment, every 10 minutes during
the procedure, and at the end of the treatment.
Parents were invited to be present in the room throughout the
dental procedure performed with the aid of conscious sedation.
At the start, 100% oxygen was delivered via a flavored
nasal mask for 1 to 2 minutes and then nitrous oxide, from
a concentration of 30%, was titrated in 5–10 % increments to
the maximum desired level for each patient by appropriately
trained and experienced dentists with the aid of dental nurses,
until adequate sedation was achieved (patients should be
quiet and nearly motionless but able to understand and to
respond to verbal commands). A flow rate of 4 to 9 L/min was
generally used.
After an induction period of 8 minutes, dental treatment was
carried out according to a predetermined treatment plan, while
verbal contact with the patient was maintained.
All pediatric patients were responsive to verbal command
throughout the duration of the treatment. During the procedure,
the patients were reminded to breathe through the nose in order
for the gas to work. At the end of the treatment, 100%
oxygen was administered for 3–5min.
The patient’s physical status and alertness were assessed
before discharge.
 References

1. Galeotti A, Garret Bernardin A, D’Antò V, Fabrizio Ferrazzano G, Gentile

T, Viarani V, Cassabgi G, and Cantile T. 2016. Inhalation Conscious Sedation
with Nitrous Oxide and Oxygen as Alternative to General Anesthesia in
Precooperative, Fearful, and Disabled Pediatric Dental Patients: A Large
Survey on 688 Working Sessions. BioMed Res Internat. Volume 2016. Article
ID 7289310, 6 pages. https://doi.org/10.1155/2016/7289310.
2. Foley J. 2005. A prospective study of the use of nitrous oxide inhalation
sedation for dental treatment in anxious children. Europ J Paediatric Dent.
3/2005.