Piped vs. Portables

By Laura Thill

Piped nitrous oxide systems often offer the best solution – provided they are properly installed.

More and more dental offices rely on nitrous oxide/oxygen sedation to reduce patients’ anxiety and help them relax during complex dental procedures. For offices that use nitrous oxide/oxygen sedation even a few times each week, piped – or plumbed – systems could offer the most efficient and economical solution.

Although there is an upfront cost for piping a nitrous oxide/oxygen sedation system (i.e., the cost of a medical gas plumber, copper piping, a manifold system, zone valve emergency shut off systems, if required, and a verification/inspection fee), there are long-term cost savings and benefits of which some clinicians might not be aware, notes Michael Civitello, sales manager, Porter Instrument. “It makes sense for dentists to sit down and evaluate the long-term benefits before making a decision that they may later regret,” he points out.

In some cases, portable e-cylinder carts continue to offer a viable solution, he continues. He recommends portable systems when:

• The dental office is already built, and there are no options for running piping through a drop ceiling or basement.
• The current dental owner will only be at that location for a couple of more years, after which he/she plans to build a new office or stay on as an associate.
• The office has no plans to incorporate nitrous oxide/oxygen sedation into its regular routine, and only expects to use it a few times each year.

For dental offices looking to offer nitrous oxide/oxygen sedation more routinely, however, there are a number of benefits to adding piped or plumbed nitrous oxide systems, says Civitello, including:

• The cost of gas from larger H/G type cylinders compared with E size can easily equate to a $10 savings per patient on the gas itself. “Multiply that times the number of uses per week, and calculate that out over five, 10 or 20 years. It’s a large expense.”
• Portable e-cylinder systems may seem like a good idea, but compared to a centrally plumbed system, many dentists (as well as assistants) often find reasons to not use them. Portable systems are never ready for use; often are located in another room; require a constant change of cylinders; and take up valuable floor space. In addition, the cylinders generally arrive from the gas suppliers dirty and rusty, and they will be in plain sight of their patients.
• With a central system, every operatory is ready for nitrous use. Having operatories set up for all types of uses helps avoid situations where one case may run long and the office must move a scheduled patient to another operatory, where nitrous may not be available. “Dentists don’t want to be in a position where they are unable to provide nitrous to patients who want or need it.”
• If nitrous oxide/oxygen sedation is easier to use, it will be used more often. “The whole reason to have a nitrous system is to provide comfort and relaxation for patients, while at the same time make it easier for the dentist to provide the treatment. Dentists who have easy access to nitrous oxide/oxygen sedation are likely to offer it to their patients more often, in situations where it could be beneficial.”
• Offices that can offer nitrous oxide – and, in turn, offer their patients a more comfortable, relaxed experience – can make a positive impression and facilitate more return visits. “Patients draw conclusions quickly based on what an office looks like and how it is set up. For instance, is it clean? Does it have modern equipment? That said, does the dentist really want to wheel in a portable cart that has rusty and dirty cylinders and various hoses hanging from it? Or would he/she rather have a built-in professional looking system that is designed for the space?”
• Nitrous oxide can be very profitable for a practice. When centrally plumbed, the per-patient cost is very low, particularly when one considers the concurrent fees the office may charge (on average, $75). And, when patients are satisfied with their care, they are more likely to complete – or follow up with – their treatment, return for future care and refer their family and friends to the practice.
• Many states are adopting expanded duties certifications for hygienists, permitting those who are qualified to administer nitrous oxide, provided the dentist is on site. “Think of the additional profit the hygienist can produce by offering nitrous oxide to every patient. This isn’t easy to do with a portable E-cylinder cart.”
• As more general dentists bring in specialists to their offices, who rely on nitrous oxide/oxygen sedation, an accessible piped-in system is more important than ever.

It’s never too early for dentists to start planning their exit strategy, and piped nitrous oxide should be part of it, Civitello adds. “If dentists plan to sell their practice at some point, they should keep in mind that it may not attract specialists, such as pediatric dentists or oral surgeons, who are used to relying on easy access to piped nitrous oxide.”

Rely on the experts
Manufacturer equipment specialists can ensure that piped nitrous oxide systems are installed correctly and safely, and dentists and their sales reps should involve their nitrous equipment manufacturer representative early in the process, notes Civitello.  “There are many flowmeter options from which dentists can choose, as well as several installation options,” he points out. Once the needs of the practice and the design of its operatories are clear, the manufacturer rep/equipment specialist can recommend the best possible solutions, as well as advise on what is required from a code perspective. “Many Porter representatives have an ASSE 6005 Medical Gas System Generalist certification, which is essentially the same course that a Certified Medical Gas Plumber takes (without the hands-on/brazing portion).”

Equipment specialists can work with a dental office to address a number of important points, including:

• Flush mount flowmeters. It’s important to consider the style and type of cabinetry in which the flowmeter will be installed, as not all flowmeters fit in all cabinets. The manufacturers rep can advise which flowmeter will work best in each cabinet style, and how best to position the flowmeter.
• Outlet stations. If using outlet stations, it is critical to plan where the outlets will be located. Installing outlets on the wrong side of the room can be a disaster.
• It is essential to pipe all operatories, even if they are not being set up with a flowmeter. Non-functional operatories can be piped, with a termination-point shut-off valve installed. If at some point the practice wishes to expand, the piping is in the wall; it will be easy to access the piping and connect a flowmeter. (If an operatory is not piped, and the office decides to expand, it must bring in a medical gas plumber to cut pipes, rip open walls, etc.)
• Detached tank room. When the tank room is detached from the main office, both an automatic changeover manifold and zone valve will be required. An example of this would be a tank room in the basement or in a storage room located outside the main building (with no internal door from the main office to access).

Dentists should consider installing an automatic changeover manifold, rather than a manual changeover manifold, notes Civitello. “The manual changeover manifold may appear to save them some money,” he says. But, with this option, when the cylinder is empty, someone must go to the tank room to close one cylinder and open another, wasting time. It can be disruptive to a patient’s procedure and inevitably lose the practice money. “With an auto-changeover manifold, when one cylinder runs low, it automatically switches to a full cylinder,” he says. “There is no disruption in the patient procedure, nor does anyone have to go to the tank room.”

An experienced manufacturer rep can also ensure that the piped nitrous oxide system is installed by a properly certified plumber, and inspected by an independent third party, Civitello continues. “It’s important that only a certified medical gas plumber works on the piping system,” he says. “These plumbers have an ASSE 6010 certification. They are required to carry an identification card at all times and are the only ones allowed to handle the piping and installation.” In fact, they can’t have an apprentice assist them unless that individual is ASSE 6010 certified, he points out. “Dentists and/or general contractors absolutely should not hire Joe the plumber who is trained to fix toilets. This is where major mistakes can happen, and it can cost patients their life.”

The piping system must be inspected by an independent verifier, notes Civitello. “This cannot be the person who did the installation, and he or she must have an ASSE 6030 medical gas system verifier certification. Dentists and/or general contractors cannot skip the verification to save $1,000. This is required.” Installation is not complete until both the medical gas plumber and medical gas verifier have conducted all required safety and functional tests, including the crossed lines test, he adds. “In the end, these documents must be turned over to the dentist.”