Choosing the Right Pediatric Patient for Nitrous Oxide/Oxygen Administration

Nitrous oxide is not indicated for every patient. Indications for use with the pediatric patient are:

• The fearful or anxious, yet cooperative patient. Cooperative pediatric dental patients will exhibit a range of behaviors and emotions. Some patients will run into the treatment room, jump into the chair, open their mouth and practically beg for treatment. Others will step warily into the treatment room, holding back tears while clinging to their parent’s leg. They are full of anxiety but will remain cooperative until they experience even the smallest amount of discomfort and then the floodgates will open. This is an optimal situation for nitrous oxide/oxygen analgesia/anxiolysis. If administered before a potentially uncomfortable procedure is attempted, nitrous oxide/oxygen analgesia/anxiolysis can prevent a behavior malfunction. However, the dentist should not assume that plopping a nitrous oxide face mask on an anxious child will magically eliminate potential problems. As will be discussed in a later section, basic behavior management techniques must be used to introduce the pediatric patient to the nitrous oxide experience.

• The patient with a strong gag reflex. A strong gag reflex can interfere with the most basic treatments; clinical examination (the child gags while the mouth mirror is still outside the mouth), radiographic examination, prophylaxis and fluoride treatment, sealants and restorative dentistry. The etiology of a strong gag reflex is attributed to physiologic, psychologic and genetic factors. If distraction techniques (watching the procedure in a mirror, humming, or asking the patient to wiggle their toes) doesn’t work, the dentist can turn to the gag reflex reduction properties of nitrous oxide. Although nitrous oxide reduces or eliminates the gag reflex it has no effect on the cough reflex so the risk of aspiration of foreign objects during treatment is not compromised.

• The patient that is fearful of specific procedures. The dentist will encounter patients (children and adults) that are cooperative and accepting of the dental experience, except for specific procedures, such as the “needle or shot” or the drill. The analgesic and anxiolytic properties of nitrous oxide can reduce or eliminate the difficulty in accomplishing these procedures. For those patients that are afraid of local anesthesia, nitrous oxide can raise the patient’s pain threshold to the point that mildly uncomfortable procedures (periodontal scaling, curettage and minor restorative treatment) can be accomplished without the use of local anesthesia. For those procedures where the use of local anesthesia cannot be avoided, the analgesic and anxiolytic properties of nitrous oxide can help the patient accept the discomfort and psychologic trauma of the “shot” or “drill.”

• Aid in the treatment of the mentally/physically disabled or medically compromised patient. Patients suffering from a mentally/physically, disabling or medically compromising condition may benefit from the use of nitrous oxide/oxygen analgesia/anxiolysis. Its effectiveness will vary from patient to patient. It may reduce the level of activity in a hyperactive child or extend the treatment time available for a patient with cerebral palsy. It is worth attempting before progressing to deep sedation or general anesthesia for treatment.

• A patient for whom profound local anesthesia cannot be obtained. There are times when local anesthesia is ineffective. There may be an acute infection present or the patient may have a low pain threshold. Nitrous oxide’s analgesic properties raise the patient’s pain threshold. Not only will it add in pain management during an uncomfortable procedure, administering nitrous oxide prior to injection may allow the dentist to administer a more comfortable injection.

• A cooperative child undergoing a lengthy dental procedure. Younger children may not have the ability to sit for extended periods of time. Nitrous oxide not only distorts one’s perception of time, but it also improves the success of hypnotic suggestion, especially the use of imagery and storytelling.