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CSPD/WSPD Annual Meeting 2017 “WOW” Session Title: When Laughing Gas Becomes Not So Funny

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CSPD/WSPD Annual Meeting 2017 “WOW” Session Title: When Laughing Gas Becomes Not So Funny 2017 CSPD/WSPD Annual Meeting “WOW” session Program: When laughing gas becomes Not so funny - A blurred line between use and abuse Presenter: Dr. Yawen Peng, DMD Western University of Health Sciences Course objectives Upon completion, the attendance will be able to: • Recall the indications and contraindications of Nitrous Oxide usage from the AAPD guidelines • Describe the anesthetic properties of Nitrous Oxide • Understand the study reports of the potential toxic from Nitrous Oxide • Identify the best practice of Nitrous Oxide usage in pediatric dentistry About the speaker- Dr. Yawen Peng • DMD from Boston University Goldman School of Dental Medicine • Certificate in Pediatric Dentistry from Tufts University • Masters of Arts in Health Professions Education from University of the Pacific • Diplomate, American Board of Pediatric Dentistry • Practice in Los Angeles, California • Faculty for Pre-doctoral education in Pediatric Dentistry at the College of Dental Medicine at Western University of Health Sciences Tell us about yourself! What is Nitrous Oxide? • Colorless and odorless gas with a faint sweet smell • Heavier than air or oxygen o Spilled/wasted gas that is not scavenged from the room ends up on the floor • Anxiolytic agent: o Used to calm a nervous but cooperative patient without inducing the loss of consciousness o Indirectly relax skeletal muscle (relief of anxiety) o CNS mild depression (cerebral cortex) and euphoria Laughing gas! o Decrease the fear for future dental treatment • Analgesic properties o Mild analgesic effect at sub-anesthetic concentrations Local Anesthesia Supplement • Amnestic History of Nitrous Oxide • 1776- Joseph Priestley and Karl Scheele discovered N2O • Early 1800s- Sir Humphrey Davy recommended N2O used as a recreational drug o Excited and euphoric o Loss all inhibitions and laughed “laughing gas” History of Nitrous Oxide • 1844- Dr. Horace Wells (dentist from Connecticut) o Attend demonstration by Dr. Gardner Colton- No pain in the attendance’s injured leg o Explored the use in general and dental surgery Founder of Anesthesia o Extract his own decayed molar under 100% N2O (may become unconscious and hypoxic) (less than 20% oxygen could be fatal) History of Nitrous Oxide • 1868- Dr. Edmund Andrews o Recommend 20% O2 and 80% N2O combo modern dentistry o Paul Bert developed N2O/O2 delivery equipment • 1976 ADA o Adopted standards for the manufacture of inhalation sedation units Mechanism of Action • Inhaled N2O is insoluble in the blood without binding with hemoglobin and diffuse into brain through crossing the Blood Brain Barrier (BBB) • Change membrane protein structure of neurons • Analgesic action: o Neuronal release of endogenous opioid peptides o Produce “relative analgesia” (Langa) • Anxiolytic effect: o Activation of gamma-aminobutyric acid type A receptor through benzodiazepine binding site David, E., Longnecker, M.D., Frank, L., Murphy, M.D., Introduction to Anesthesia. Saunders 1996 Pharmacokinetic properties • Onset o Quick! (A few seconds to 3-5 minutes) o Rapidly diffuse from lungs to blood and cross BBB in brain rapidly • Elimination o Quick! (99% in 5-10 minutes) o Unchanged with exhalation from the lungs o No metabolism in liver or kidneys o Exits faster than traces of nitrogen that replace it • Need 100% O2 to washout the residuals in anatomic dead space How do you use Nitrous Oxide? • Practice type o Solo, group, hospital, academics, etc.. o Urban, suburban, etc.. • N2O/O2 system o Portable vs Central o Removing and monitoring ambient gases o Monitoring system • Patient type o Medicaid, insurance, etc.. o Age group and frequency o Combine with sedation How is Nitrous Oxide used by other pediatric dentists? • Significant difference in the distribution of respondents indicating the percentage of patients requiring N2O as a function of the years in practice (<10 yrs vs. >10 yrs ). Why or why not use N2O/O2? • Dr. Wilson et al. found that 97 % of respondents use N2O/O2 in the offices • Reason for use: • Reason for not using Calms patient (98%) o Less difficult to use general anesthesia o (58%) o Helps with gaggers (81%) Aids in distraction (73%) o Better manage patients without it (48%) o Patients do not need it (39%) o More patients require sedation (70%) o More prepared to use sedation (48%) o State legislation made sedation difficult o (21%) o “I don’t like it” (18%) o “Slows me down too much” (16%) AAPD guidelines • Last revision in 2013 • Indications o A fearful, anxious, or obstreperous patient o Certain patients with special health care needs o A patient whose gag reflex interfere with dental care o A patient for whom profound local anesthesia cannot be obtained o A cooperative child undergoing a lengthy dental procedure • Contraindications o Some chronic obstructive pulmonary diseases (COPD) o Severe emotional disturbances or drug-related dependencies o First trimester of pregnancy o Treatment with bleomycin sulfate (cancer therapy) o Methylenetetrahydrofolate reductase deficiency Patient o Cobalamin (Vitamin B12) deficiency Can you use N2O/O2 on an Asthmatic patient? • Benefit from increased concentration of oxygen administered. • Same concepts apply to Sickle-Cell trait/disease, epilepsy, liver and kidney disorders Why is there a shift in N2O/O2 usage? • Younger practitioners preferring N2O/O2 management o Older generations may prefer a more disciplinary approach o Younger generations may rely more on a deferment-style of management • Increased parental acceptance of this behavior guidance technique • Changing parental styles o Increased disruptive behavior in children? How does parents think about N2O/O2? In US, N2O/O2 sedations ranks high in parental acceptance. However, Dr. Wilson et al. in 2016 found in their survey: • Over half of the parents expressed concern over N2O/O2 • Parents are growing more concerned about their children’s safety, including vaccinations or anesthesia • Practitioners will benefit from being familiar with evidence-based studies and educate parents through conversations Parents from around the world • In UK o N2O/O2 is the most popular form of sedation o Significantly more dentists than parents believe that the child could have been managed without sedation and would not require it for further dental treatment • In Spain o Popular behavior techniques are tell-show-do, voice control and active restraint • In Arab o N2O/O2 is the “Least approved technique” A global perspective of pediatric dentistry training • Frequency of sedation type received in the advanced education training: o General anesthesia (52%) o Nitrous oxide (46%) o Oral sedation (44%) • Conclusion: Our profession moves toward a philosophy of managing children who o Cope easily with dental procedures using tell-show-do, or o Using a definitive fail-safe pharmacological method for most other who do not cope well. Nitrous Oxide - the safest drug on earth?! Side effects • Most common: o Nausea (2.2%), Vomiting (1.6%) o Diffusion hypoxia • Over-sedation • Others Nausea and Vomit • Before appointment o Light meal 2 hours prior to administration (No NPO required) o Wear loosely fitting clothes for comfort • During appointment: o Avoid drastic and constant changes in the concentration Roller coaster effect o Increase or decrease at an increment of 1L/minute every 1 minute interval • Early signs of vomiting: o Hyperventilation, sweating, nausea • Management o Remove everything on patient’s fact and in oral cavity o Turn patient’s head and body away to the side opposite to the operator o Remove vomitus pooled in the checks o Use emesis basin and high pressure suction tip to remove vomitus o Administer 100% O2 for 3-5 minutes Diffusion Hypoxia • Occur as the sedation is reversed at the termination of the procedure • N2O escapes into alveoli and dilute O2 inside O2-CO2 exchange disrupted Hypoxia created • Management o Use pulse oximeter to monitor O2 level • (>90% is danger due to rapid loss of O2 into brain) o Oxygenate for 5 miuntes after termination of N2O N2O diffuses into air-filled spaces • N2O enters into gas-filled spaces 30x faster than nitrogen exit o Increase volume and pressure in the space • The effect is in any concentration of N2O/O2 administered • The magnitude of the effect is proportional to o Blood supply of the cavity o Concentration of N2O inhaled o Length of time the patient is exposed to N2O • Dangerous in patient s with bowel obstruction, pheumothorax middle ear and sinus diseases, and retinal surgery o In eyes may lead to blindness Over-sedation • 30-50% N2O (dissociation sedation and analgesia): o Recommended concentrations for most dental procedures o Patient are relaxed, “floating, warm and tingling”, somnolent, dissociated and easily susceptible to suggestions o Some may experience amnesia but no alteration of learning or memory o Analgesic effect of 30% N2O is as effective as 10-15 mg of morphine, 50% N2O is equally effective as EMLA o Supplementatio with local anesthesia for operative dentistry and oral surgery • >60% N2O (Total analgesia): o Patient experience dis-coordination, ataxia, giddiness, increased sleepiness and loss of consciousness o Loose the ability to maintain open mouth never use mouth prop! o More likely experience nausea and vomiting • If over-sedated, decrements of N2O concentration by 5- 10% for 2 minutes or remove nasal hood and allowed breathing ambient air Latex allergy Anesthetic carpule (latex stopper and Nitrous oxide masks and hoses diaphragm) Bite block Gloves Orthodontic bands and elastics Blood pressure cuff Polishing
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