ORAL HEALTH POLICIES: MINIMIZING HEALTH HAZARDS WITH NITROUS OXIDE

Policy on Minimizing Occupational Health Hazards

Associated with Nitrous Oxide
Latest Revision How to Cite: American Academy of Pediatric Dentistry. Policy on
2023 minimizing occupational health hazards associated with nitrous
oxide. The Reference Manual of Pediatric Dentistry. Chicago, Ill.:
American Academy of Pediatric Dentistry; 2023:162-5.

Purpose Exposure may increase due to patient factors, with a three-fold

The American Academy of Pediatric Dentistry (AAPD) increase in ambient N2O levels noted when patients talked,
recognizes that exposure to ambient nitrous oxide (N2O) may cried, or held their breath during administration of local
be an occupational health hazard for dental personnel and anesthesia.22 Furthermore, as the concentration of administered
encourages practitioners to take all precautions to minimize N2O increases, so does the ambient N2O level in the operator’s
associated risks. breathing zone.22
NIOSH reported in 1977 that primary concerns of chronic
Methods N 2O exposure were diminished cognition, performance,
This policy was developed by the Clinical Affairs Committee, audiovisual ability, and dexterity; conclusions on reproductive
adopted in 19871, and last revised by the Council on Clinical health were not definitive.10 That report included a recom-
Affairs in 20182. This update used electronic database and hand mended exposure limit (REL) to a time-weighted average
searches of articles in the medical and dental literature using (TWA) of 25 parts per million (ppm) yet noted 25 ppm might
the following parameters: terms: nitrous oxide, occupational not be achievable and was subject to review and revision.23
exposure, AND dentistry; fields: all; limits: within the last 10 Shortly thereafter, NIOSH published a technical report
years, English. Additionally, recommendations from the Na- intended to help limit occupational exposure in the dental
tional Institute for Occupational Safety and Health (NIOSH) setting to 50 ppm24 although the REL remained unchanged25.
were reviewed.3,4 Expert opinions and best current practices In 1986, the American Conference of Governmental Industrial
were relied upon when sufficient scientific data were not Hygienists established the threshold limit value (TLV) for N2O
available. exposure at 50 ppm.25 Unless a state or the federal government
adopts a TLV, this level is merely a recommendation.26 Only
Background the Occupational Health and Safety Administration (OSHA)
Nitrous oxide is an inhalation agent commonly used in can establish a legal limit for exposure (permissible exposure
dentistry for analgesia/anxiolysis. When used in accordance limit [PEL]).26 Notably, OSHA has not established a PEL for
with recommended techniques and patient selection criteria, N2O exposure in the healthcare setting.25 The International
N2O/oxygen inhalation exhibits a high degree of efficacy and Labor Organization and World Health Organization also have
patient safety in the clinical setting.5-9 Occupational exposure established a TLV of 50 ppm as TWA and noted that N2O is
to ambient N2O has been studied for decades, yet the effects not carcinogenic.27
of ambient N 2 O exposure on dental personnel remain The introduction of methods to scavenge N2O and other
uncertain. Early reports, many of which came from animal control measures has been effective in reducing ambient N2O
studies10 and/or preceded scavenging devices11 and ventilation in the dental environment.21,28 System maintenance, scavenging
systems, implicated chronic occupational exposure of un- of expired gases, ventilation of the operatory/room air ex-
scavenged N2O in reproductive effects10,12,13 (e.g., decreased change, use of the minimal effective dose, and patient selection9
sperm count, spontaneous abortions14, birth defects10,15), liver14 and management are important to maintaining the lowest
and kidney damage10,12,15, and neurologic considerations 10,15 practical levels in the dental environment.3,4,29 Leaks at system
(e.g., memory, hearing). In offices using scavenging systems, connectors and degradation, cracks, and tears in system
female dental staff frequently (i.e., three or more days a week) components may allow N 2O to enter room air, increasing
exposed to N 2O were found to have no elevated risk of
spontaneous abortion.16,17 A paucity of clinical research estab-
lishing a causal relationship between chronic exposure of ABBREVIATIONS
dental personnel to N2O and health problems continues. A AAPD: American Academy of Pediatric Dentistry. N2O: Nitrous oxide.
NIOSH: National Institute for Occupational Safety and Health. PEL:
recent systematic review on workplace exposure to volatile
Permissible exposure limit. ppm: Parts per million. REL: Recom-
anesthetics including N2O reported evidence is both scarce and mended exposure limit. TLV: Threshold limit value. TWA: Time-
inconsistent regarding adverse effects.18 The dentist’s exposure weighted average.
often is noted to be greater than that of the dental assistant.19-21

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 ORAL HEALTH POLICIES: MINIMIZING HEALTH HAZARDS WITH NITROUS OXIDE

occupational exposure. Frequent and continual inspection will Policy statement

allow timely maintenance and replacement of components The AAPD encourages dentists and dental auxiliaries to main-
thereby minimizing environmental exposure. 30 A double- tain the lowest practical levels of N2O in the dental environ-
chamber mask delivery system has been shown to be more ment. The AAPD also encourages practitioners to weigh
effective in the removal of waste N2O than a single-chamber the risks and benefits of using N2O when treating pediatric
mask with a scavenging cap.31,32 Use of a well-fitted double- patients. Adherence to the following safety practices can help
chamber mask with recommended scavenging system flow minimize occupational exposure to N2O.
rate can decrease occupational exposure to N2O.31,33 Recently, • Educate dental personnel on minimizing occupational
disposable masks and mask/circuits have been developed and exposure to and potential abuse of nitrous oxide.
marketed for improved infection control, but studies • Use scavenging systems that remove N2O during pa-
comparing their efficacy in scavenging waste gases are lacking. tient’s exhalation.
Establishing a balance of gas flows entering and exiting the • Ensure that exhaust systems adequately vent scavenged
delivery system is important for effectiveness and decreasing air and gases to the outside of the building and away
ambient levels. If the flow of inhalation gases overinflates the from fresh air intake vents.
breathing bag, excessive leakage from the mask can occur.4 Al- • Use, where possible, clean outdoor air for dental
lowing the bag to expand and collapse with each breath ensures operatory ventilation.
proper delivery of gases. Likewise, the rate of suction of the • Monitor ambient N2O levels in dental operatories in
exhaled gases needs to be sufficient to allow removal of gas- accordance with local and state regulations.
es from the system but maintain the desired clinical effects. • Implement a plan for careful, regular inspection and
NIOSH has recommended that the exhaust ventilation of N2O maintenance of the nitrous oxide/oxygen delivery
from the patient’s mask be maintained at an air flow rate of equipment according to manufacturer’s recommen-
45 liters per minute and vented outside the building away dations.
from fresh air intakes.4 However, scavenging at this rate has • Carefully consider patient selection criteria (e.g.,
been shown to reduce the level of psychosedation achieved tolerance of nasal hood, ability to breathe from the
with N2O inhalation.34 nose, cooperative potential, recent illnesses, indica-
Additional steps can be taken to lower the ambient N2O tions, contraindications) prior to administering N2O.
levels. Ambient concentration will change with increased room • Select a properly-fitted double-chambered mask size
air turnover and percentage of fresh air intake. One hundred for each patient.
percent clean outdoor air has been recommended for dental • During administration, visually monitor the patient
operatory ventilation. 3 Well-separated supply and exhaust and titrate the flow/percentage to the minimal effective
vents allow good mixing and prevent short-circuiting.3 Use of dose of N2O.
supplemental measures, such as high-volume dental suction • Encourage patients to minimize talking, moving, and
placed in proximity to the mouth 22,35 and administration of mouth breathing during N2O administration.
100 percent oxygen following termination of N2O flow 36, • Use high volume dental suction when possible during
has been shown to reduce ambient N2O levels significantly. N2O administration.
Measuring levels of N2O in the dental operatory can be helpful • Use a rubber dam or isolation devices with suction
in determining the type and extent of remediation necessary evacuator when possible during operative treatment.
to decrease occupational exposure. • Administer 100 percent oxygen to the patient for at
Patient selection is an important consideration in reducing least five minutes after terminating N2O flow to replace
ambient N2O levels.9,29 Patients who are unwilling or unable the N2O in the gas delivery system.
to tolerate the nasal hood and those with medical conditions
(e.g., obstructive respiratory diseases, emotional disturbances, The AAPD encourages an interprofessional approach be-
drug dependencies) that contraindicate the use of N2O are tween dental team members who are pregnant or trying to
candidates for other behavior guidance techniques.9,29 In the conceive and their physicians regarding the effects of N2O
dental environment, patient behaviors such as talking, crying, on reproductive health to assure comfort and safety with the
and moving have been shown to result in significant increases administration of nitrous oxide/oxygen analgesia/anxiolysis.
in baseline ambient N2O levels despite the use of the mask- The AAPD encourages research on the efficacy of newer-
type scavenging systems.22,37 Titration of N2O concentration style (e.g., disposable mask, disposable mask/circuit) nasal
levels in relation to procedure difficulty can help lower levels hoods in scavenging waste gases. Furthermore, because of the
of ambient N 2O. N 2O can be discontinued once adequate paucity of literature on health effects of occupational N2O
anesthesia is achieved38, or decreased levels can be maintained exposure in the dental setting with modern delivery, scavenging,
during easier procedures and increased for stimulating ventilation, and monitoring systems, the AAPD encourages
procedures39. additional studies and periodic review of the occupational
exposure recommendations by NIOSH.

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ORAL HEALTH POLICIES: MINIMIZING HEALTH HAZARDS WITH NITROUS OXIDE

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