International Journal of Dental and Health Sciences Volume 01,Issue 02 Review Article NITROUS OXIDE INHALATION SEDATION IN PEDIATRIC DENTISTRY: A REVIEW Garima Malhotra1, Sambhav Jain2 1. Post Graduate, Department of Pedodontics and Preventive Dentistry, Teerthanker Mahaveer Dental College & Research Centre, Moradabad, India 2. Post Graduate, Department of Periodontology, Teerthanker Mahaveer Dental College & Research Centre, Moradabad, India ABSTRACT: Modern general anesthesia and conscious sedation procedures are predictable, effective, and safe with appropriate patient selection, drugs and techniques. The use of conscious sedation in pediatric dentistry in office-based settings continues to increase. Nitrous oxide is the most commonly used inhalation anesthetic (sedative) used in dentistry, and has withstood the test of time with an excellent safety record. It reduces anxiety, pain, and memory of the treatment experienced, and is a valuable component of the armamentarium available to clinicians. Key words: Conscious Sedation, Inhalation Sedation, Nitrous Oxide, Oxygen, Pediatric Dentistry, Uncooperative child. INTRODUCTION: alternative for the dentist to adopt and manage dental anxiety, stress and fear Providing comprehensive oral care to related to dental procedure and avoid young patients is a unique challenge. Child unpleasant and unproductive behavior can never become an alibi for a confrontation with the child [1]. sub-standard work in the mouth. However, in spite of all its technical and Pharmacological management may materialistic advances, behaviour science divided into three categories, conscious still seems to provide limited options for sedation, deep sedation, and general its uncooperative young children. anaesthesia, but due to increased risks Guidance of children’s behaviour in and costs associated with deep sedation dentistry has been limited to an art rather and general anaesthesia, conscious than a science. It is no wonder that today sedation has emerged as a preferable there are more and more dentists are technique, it is a minimally to moderately afraid of children than children afraid of depressed level of consciousness that dentists, Henceforth pharmacological retains the patient’s ability to intervention becomes an important independently and continuously maintain *Corresponding Author Address: Dr. Garima Mahrotra, Department of Pedodontics and Preventive Dentistry, Teerthanker Mahaveer Dental College & Research Centre, Moradabad, India E-mail: [email protected] Mahrotra G. et al., Int J Dent Health Sci 2014; 1(2): 161-169 an airway and respond appropriately to “A technique in which the use of a physical stimulation and verbal command. drug or drugs produces a state of This level of sedation may be depression of the central nervous accomplished by inhalation, oral and system enabling treatment to be parenteral administration of a single carried out, but during which sedative drug or by combining sedative verbal contact with the patient is agents. Sedative agents often include maintained throughout the period nitrous oxide‐oxygen, narcotics, of sedation. The drugs and benzodiazepines, chloral hydrate, techniques used to provide barbiturates as well as antihistamines. [2] conscious sedation for dental treatment should carry a margin of According to Shapiraet al [3], the ideal safety wide enough to render loss paediatric dental sedative should possess of consciousness unlikely”. [4] a number of qualities, including safety, minimum respiratory depression, adequate sedation, minimal patient movement, early onset of drug action, “A medically controlled state of and adequate working time. Inhalation depressed consciousness that sedation should be the first choice for allows the protective reflexes to dental patient who are unable to tolerate be maintained; retains the fear and stress of dental treatment. patient’s ability to maintain a Nitrous oxide is delivered with oxygen as a patent airway independently and titrated dose via a nasal mask. It is cost continuously; and permits an effective alternative to general appropriate response by the anesthesia. [4] Inhaled nitrous oxide also patient to physical stimulation or produces anxiolytic and mild analgesic verbal command, e.g., ‘Open your [6] effects. [5] The present review article eyes’.” discusses the nitrous oxide inhalation Inhalation Sedation with Nitrous Oxide: conscious sedation in paediatric dentistry. Drugs used for pediatric inhalation Definition Of Conscious Sedation: sedation includes Nitrous oxide and Oxygen gas. “Conscious sedation is a minimally to moderately depressed level of NITROUS OXIDE consciousness that retains the patient’s ability to independently Nitrous oxide is the only inhalation agent and continuously maintain an currently in routine use of conscious airway and respond appropriately sedation in dental practice. It was to physical stimulation and verbal discovered by Joseph Priestly in 1772 and command”[2] first used as an anesthetic agent for dental exodontia by Horace Wells in 1844. Nitrous oxide has been used as the basic 162 Mahrotra G. et al., Int J Dent Health Sci 2014; 1(2): 161-169 constituent of gaseous anesthesia for the be separate from, and additional to, the subsequent 160 years, demonstrating its supply kept for use in the management of acceptability and usefulness. Nitrous emergencies. Oxygen will sustain and oxide is a colorless, faintly sweet smelling enhance combustion and therefore no gas with a specific gravity of 1.53. It is naked flames should be allowed in an area stored in light blue cylinders in liquid form where oxygen is being used. [7] at a pressure of 750 pounds per square inch (43.5 bar). [7] Nitrous oxide is a gas with anxiolytic and sedative effects combined with varying degree of analgesia and muscle relaxation. Recent research suggests that both GABA a and NMDA-receptors are affected by nitrous oxide [8,9]. Nitrous oxide when administrated to patients for inhalation must be given in a mixture with oxygen (30% or more) to safeguard the patient’s oxygen supply. Nitrous oxide is non-irritant to the respiratory tract, has a low tissue solubility, and a minimum alveolar concentration (MAC) value of more than one atmosphere. Therefore nitrous oxide has a rapid onset, a fast recovery (both within minutes) and is a poor anesthetic. [6] Inhalation Sedation Apparatus OXYGEN Indication of Nitrous Oxide Sedation: Oxygen is not a sedating agent, however, Most patients requiring sedation are inhalation sedation agents is always those with a simple, genuine fear or delivered in an oxygen-rich mixture phobia of dental treatment. containing a minimum of 30% oxygen by volume. Oxygen is stored as a gas in black Children can present particular cylinders with white shoulders, at an problem & often require very careful initial pressure of 2000 pounds per square handling inch (137 bar). Because it is a gas under pressure, the gauge on the inhalational Patients with mild systemic disorders sedation machine will give an accurate such as controlled hypertension, representation of the amount of oxygen angina which may be exacerbated by contained in the cylinder. The oxygen the stress of dental treatment supply used for inhalation sedation should represent a medical indication. 163 Mahrotra G. et al., Int J Dent Health Sci 2014; 1(2): 161-169 Patient with neuromuscular disorders First trimester of pregnancy: such as spasticity, Parkinsonism & Teratogenicity [10] involuntary movement conditions Patient Assessment: often wishes to cooperate but physically cannot. A useful means of estimating fitness for sedation is to use the classification system Dentally related problems such as introduced by the American society of gagging & trismus, persistent fainting anesthesiologists (ASA). In this system, & moderately difficult or prolonged patients are allocated to specific grades surgery. [7] according to their medical status and Contraindication Of Nitrous Oxide operation (or sedation) risk. The Sedation: classification uses six grades as follows: Moderate/severe learning ASA 1: fit and healthy disability: Inability to tolerate the ASA 2: mild systemic disease (for example, nasal mask and cooperate with well controlled hypertension, diabetes, nasal breathing epilepsy, asthma) Severe anxiety: Inability to tolerate ASA 3: severe systemic disease which the nasal mask and cooperate with limits lifestyle, but not incapacitating (for nasal breathing example, poorly controlled epilepsy Chronic obstructive pulmonary diabetes or asthma) disease: Theoretical risk of ASA 4: incapacitating systemic disease respiratory failure when exposed which is a constant threat to life to high concentrations of oxygen ASA 5: life-threatening systemic disease, Nasal obstruction: For example, death likely within 48 hours nasal polyps, deviated nasal septum ASA 6: A declared brain dead patient whose organs is being removed for donor Patients treated with bleomycin [6,11,] purposes. (chemotherapy agent): Patients predisposed to respiratory failure Preoperative Fasting: when exposed to high The ASA guidelines for minimum fasting concentrations of oxygen periods for infants and children Patients who have had recent *Clear fluids: = 2 hours retinal surgery: Risk of raised pressure within the eye and Clear liquids include, but are not limited damage to sight to; water, fruit juices without pulp, carbonated beverages, clear tea and black 164 Mahrotra G. et al., Int J Dent Health Sci 2014; 1(2): 161-169 coffee. The volume of liquid ingested