Nitrous Oxide and Oxygen Sedation

By Laura Thill

More dentists are finding that nitrous oxide leads to enhanced patient satisfaction, efficiency and revenues.

When patients enter into treatment feeling comfortable, relaxed and confident, they are more likely to cooperate and follow through with their plan – and, there’s a good chance they’ll refer family and friends to the practice. From the solo office to elite DSOs, “the use of nitrous oxide in dentistry – commonly used to reduce anxiety, or to increase analgesia, relaxation, and cooperation levels of patients – can also be useful for prolonged or more complex dental procedures, as well as for patients with hyper-responsive gag reflexes or low pain tolerance,” according to Leann Keefer, RDH, MSM, director, corporate education & professional relations, Crosstex. The use of nitrous oxide/oxygen sedation is a “practice builder, enabling patients with dental fears or certain medical or mental conditions to get the treatment they need,” she says. “Patients tend to be more relaxed and comfortable, because nitrous oxide can reduce their anxiety and assist them with pain management.”

Relaxed patients are less likely to cancel their appointment and procedures often run more efficiently, she continues. That means each office can schedule an additional patient appointment each day, realize cost savings and add revenues.

The science behind the technology
Enhancements in technology have made it increasingly safer and more efficient for dentists to administer nitrous oxide. Nitrous oxide/oxygen flowmeters have traditionally relied on needle valves and glass tubes to control the flow of gas, according to Keefer. Today’s systems feature flat screen displays; digital, touch pad controls that offer greater accuracy over longer time frames; and enhancements in infection control. As such, it’s important for clinicians to stay up-to-date and educated about the process.

Nitrous oxide continues to be administered by inhalation, absorbed by diffusion through the lungs and eliminated via respiration, she notes. Proper equipment for monitoring, and storage unit integrity, are necessary in order to avoid unintended gas leakage or excessive exposure. In addition, clinicians should be educated on the various components of a nitrous oxide/oxygen sedation system:

• Nitrous oxide is stored in closed gas cylinders. Oxygen and nitrous oxide are part of the required equipment.
• Regulators ensure safe delivery of gas to the patient by reducing/controlling the pressure from the cylinders.
• Manifolds in a central delivery system connect several large cylinders of gas together, ensuring the constant availability of gas to each treatment room through copper lines within the walls of the building.
• In a portable system, a yoke stand is the metal framework on which the equipment rests and is easily moved on wheels to different areas of the dental office.
• Flowmeters are highly calibrated devices designed to indicate the amount of gas being delivered to the patient. Flowmeters further reduce the pressure level to local atmospheric pressure, and restrict the proportion as well as the flow rate of nitrous oxide with a fail-safe mechanism to keep a minimum oxygen concentration of 30 percent.
• The reservoir bag contains the gas mixture being delivered to the patient.
• Gas is delivered through conduction tubing, which runs from the delivery unit and attaches to the breathing apparatus.
• The capnography device monitors patient breathing by measuring the actual CO2 in the patient’s exhalation.
• A specially designed nasal mask/hood fits snugly around – and fully covers – the patient’s nose, allowing the mixture of nitrous oxide with oxygen to flow, while providing complete access to the patient’s mouth. Single-use, disposable masks are preferred to reduce the spread of infection. Disposable masks today are available in various designs and sizes, as well as patient-friendly scents like vanilla, strawberry, mint, grape, and bubblegum. Newer low-profile masks provide unencumbered access, with a small lightweight scavenging system, which is easier to work around than the traditional masks and co-regulated hoses, and contributes to more efficient care and reduced chair time. While traditional masks are opaque, some newer nasal hoods are translucent, allowing clinicians to visually monitor their patient’s breathing.

Resolution 37
In October 2016, the passing of Resolution 37 at the American Dental Association’s (ADA) annual meeting called for revisions to safety regulations for providing anesthesia and sedation, according to Keefer. The rules and regulations for nitrous oxide sedation largely remain the same in light of Resolution 37, she explains. “Healthcare providers are required to complete 14 hours of CE for N₂O/O₂ alone and 16 hours for N₂O/O₂ combined with a single-dose sedative up to the MRD. MRD is maximum FDA-recommended dose of a drug for unmonitored home use.

“Sedation levels deeper than what are typically found with nitrous oxide (minimal sedation) now require considerably more training than in the past,” she continues. “Performing oral, intravenous or any other method of moderate sedation now requires a 60-hour course and at least 20 patients. Previously, only a 24-hour, 10-patient course was needed. Dentists who were already practicing sedation dentistry before the guidelines [were issued] are now required to be re-trained and will not be grandfathered in as in the past. Critics of the resolution cite the financial impact of the new regulation, as the increased training will drive costs up, preventing dentists from pursuing advanced sedation training.

“Resolution 37 is only a guideline and the ADA has no enforcement authority,” Keffer explains.  However, most state dental boards will adapt the ADA guidelines in drafting their own regulations. “Dentists offering sedation can vastly expand the scope of their practice,” she says. “Yet, probably fewer general dentists will elect to go through the trouble and expense to get their moderate sedation certification. Following the dramatic increase in training required for deeper states of sedation, many will limit their practice to nitrous oxide, with or without a single-dose oral sedative up to the MRD.”

Regular service, enhanced safety and longer life expectancy
It is important for dental offices to have their nitrous oxide and sedation equipment serviced and calibrated at a minimum every two years, notes Keefer. Doing so can help avoid the potential for leakage and ensure the equipment is safe to use, as well as ensure it runs efficiently for 15-20 years. “Manufacturers recommend various levels of maintenance and service for their units, including routine, preventive, scheduled and recalibration,” she says. In addition to recalibration, service protocols should include pressure testing and internal component integrity/replacement, as well as any other necessary factory testing procedures. Clinicians should refer to the specific manufacturer’s IFU  (Instructions For Use) and follow the recommendations to ensure safe use and delivery of NO2/O2 for patients and staff. The service and inspection of anesthetic gas equipment should be performed by qualified service personnel.”

An investment for the practice
Implementing nitrous oxide/oxygen sedation in a dental practice – no matter how small or large – can quickly become a source of revenue, as well as help the practice address the needs of patients anxious about their pain management. (The current ADA/CDT-4 code for billing dental procedures using nitrous oxide/oxygen sedation is 09230.)

There are two options for delivering nitrous oxide, notes Keefer: portable units and central systems. “Portable – or self-contained units – can cost between $3,500 for a two-cylinder system to $8,000 for a four-cylinder, enclosed system,” she says, noting that portable systems are recommended for offices that only occasionally use nitrous oxide/oxygen sedation.

The cost of centrally installed systems – which are recommended for practices that routinely implement nitrous oxide/oxygen sedation – ranges from $2,500 to $4,000 per operatory, with a total average cost of $28,000 for a mid-sized office, notes Keefer. “Although the initial set-up costs are high, the central system is more cost-effective in the long run,” she points out. “The smaller E cylinders of a portable system are approximately five times more expensive than the larger G or H cylinders, due to the high cost of packaging the gases. In addition, the centralized system is more convenient, as it minimizes the need to change cylinders frequently. Not only are the cylinders larger than those of a portable system, several cylinders can be connected via a manifold system. When one cylinder is depleted, the system automatically switches to the next available cylinder.”

Indeed, when a dental practice considers that the use of nitrous oxide/oxygen sedation systems helps patients relax in the chair – thereby reducing patient chair time and increasing office efficiency – and leads to greater revenue, most clinicians will agree it’s a worthwhile investment. At the end of the day, satisfied patients mean more return visits, more patient referrals and a greater bond with the community.

A conversation starter

Sales reps can initiate a discussion about nitrous oxide with their dental customers by asking a few probing questions:

• “Doctor, do you currently offer N2O/O2 sedation?”
  • “If not, can you tell me why?”
  • “If so, how often is it used per week?”
  • “Do you charge a fee?”
• “Do you consider your patients’ comfort levels valuable?”
• “Are you less stressed when your patients are relaxed and cooperative?”
• “Are you aware that by implementing nitrous oxide at your practice, you can potentially generate about a $30,000 profit annually, simply by using it just 3-4 times each day?”
• “Have you considered the number of potential new patients who might call your practice to inquire whether you offer nitrous oxide/oxygen sedation, and how many might not schedule an appointment if you do not offer it?”
• “Have you seen the Digital Ultra Flushmount Flowmeter by Crosstex/Accutron?”
• “Have you seen the new Crosstex/Accutron Axess LOW PROFILE Nasal Mask?”