Nitrous Oxide Sedation for Dental Teams - PDF

111_GH3T_Nitrous_Oxide_Video_1A Hello, everyone. Welcome to another exciting course brought to you by NC Dental. You. One of the foremost organizations for dental education here in North Carolina. I'm Dr. Ralph Dolphy. I will be your instructor, mentor and overall guide on this journey. Now,...

111_GH3T_Nitrous_Oxide_Video_1A Hello, everyone. Welcome to another exciting course brought to you by NC Dental. You. One of the foremost organizations for dental education here in North Carolina. I'm Dr. Ralph Dolphy. I will be your instructor, mentor and overall guide on this journey. Now, the course that we're offering to you today is nitrous oxide sedation for the dental team members. Now, of course, nitrous oxide administration and monitoring is a critical component in many aspect s of dental practice. There's no question about it that we as dental professionals try very hard to. Allow our patients to be comfortable, anxiety free and hopefully pain free as well. As you well know, the dental profession in general. Tries very hard by utilizing local anesthesia, nitrous oxide, administration conscious sedation and various other methods to try to help our patients realize the most comfortable appointment they can. Now, as I'm often as I often explain in respect to how we deal with our pa tients. Compassion and help is kind of the foundation for how and why we treat our many wonderful people in our offices. I know that your settings will vary dramatically everywhere, from academic type settings to private practice to group practice to admin istrative type duties, things like that. But in taking this course today, we are going to hopefully offer you some insight and some enlightenment in respect to how you monitor these patients, how you can give them the best possible care and of course, just make sure that everything is safe, documented. Well, and you have a really good understanding of how nitrous oxide administration works. Now, the course will actually have five different classes and I'll be teaching each one of those for you. Today's sess ion is rather an introductory type session. We'll learn a little bit about the history of nitrous oxide. Talk a little bit about why we use it. We'll begin to delve a little into some of the mechanics of how it works. And then in the later lectures we'll g et into pharmacology, biochemistry, bio kinetics, documentation, safety, contraindications, all the various things that we can possibly introduce to you to help you successfully monitor these patients. I think that it will be an exciting course. I think yo u'll learn quite a bit. And I think it's really important as a team member to have a really in -depth understanding of how Nitrous Oxide Administration works, why it's a really good choice, how I can explain. I'm going to explain to you how safe it can be. And with the proper administration, you may have a happy patient as well as a comfortable patient. A lot of different things happen with nitrous oxide, and it varies quite a bit, as you'll see. Okay. Now, when we talk about the history of dentistry and the kinds of things that we do to help our patients, I think we all realize that over the centuries that we've been involved in this profession, one of the things that comes to the forefront is pain. If you go back hundreds of years into the 16 and 1700s, whe n dentistry in our country kind of got its was in his formative stages, shall I say. Many times people presented with a toothache. And the only real treatment plan for them was to have the tooth removed. What you would find is they would go to their local pharmacist in whatever village they lived, and that pharmacist would kind of have 4 or 5 different occupations druggist, dentists, medical professional and overall nice person to help the community. So when the patients would report to the so -called apothe cary, the druggist would attempt to administer some type of. Anesthetic, analgesic, whatever you want to call it, ranging from alcohol to ether. And their attempt was to sedate this patient to a point that they could successfully remove the tooth. Get the patient out of pain. Now, that's obviously hundreds of years ago, but that kind of anxiety, pain and control issue lingers through even in today's profession, despite all the amazing advances we have in dentistry today to help our patients be more comforta ble and to deliver pain free treatment as carefully as possible. There's still an overwhelming amount of anxiety in a lot of our patients. So since it's a profession of compassion and help, we have certainly endeavor over the years to try to find some thin gs that would benefit the patient. And essentially what we're trying to do is help them stay healthy. Right. Okay. Let's just talk a little bit about why nitrous oxide is used and maybe also a little bit about the history. Okay. Some background information . We do find that nitrous oxide gas was discovered by Joseph Priestley way back in 1772. Exactly how he came upon that discovery. I'm not really that sure, but he was the person responsible for putting that together. Now as it kind of found its way into th e dental profession. We found that Dr. Edmund Andrews, a Chicago surgeon, he established the ability to mix oxygen and nitrous oxide for then use in a general practice setting, particularly when he was doing any procedures that were a relatively long durat ion. Why did he do that? Mainly because we were, again, trying to elicit some comfort, some level of analgesia and also some level of anesthesia so that we could find that these patients would get to these procedures successfully and not have too much trou ble. So as things were moving on, this particular surgeon found that although this method was working well, he still needed machinery, He still needed a way, an apparatus that would conveniently administer both oxygen and nitrous oxide. So what we then fou nd was Dr. Charles Taylor, a Cleveland dentist. He came up with the idea of let's find a way to to have a flowing machine of oxygen and nitrous at the same time and give us the ability to monitor and make this a. Fail safe type system. Now, that's really g oing to be something that here we are in 1903. So now we're talking 119 years later. We're still using that concept of of a failsafe system. However, it's been upgraded dramatically. And if you've had any exposure so far to utilizing any nitrous oxide mach ines, you'll find that they're actually quite simple to use, extremely safe and will help you in your monitoring procedures. However, we know that Dr. Teeter was one of the first people that kind of got this going. And again, you go back to that issue of h ow can we comfortably treat our patients in a dental practice setting without having tremendous levels of anxiety? Nitrous oxide can be the answer to that. To that problem. If you've already been in a practice setting where nitrous oxide has been used, may be you've had the occasion to find that the reactions by the patients are really highly variable all the way from, Gee, I'm not really feeling anything to who I am really out in the zone somewhere. So we want to be careful, right, that we keep them at a le vel that would be compliant with the law, safe for the patient and at the same time lower their level of anxiety and allow the dental procedures to be completed without too much trouble. Okay. So it's basically been employed in dentistry and the primary pu rpose for reducing anxiety, 20 to 40 million people. Are presenting to a dental procedure with some level of anxiety. I'm sure that you have already encountered many people in your practice in whatever setting you are working in, where people are borderlin e terrified. All the way down to those that present with a they'll sort of say to us, you know, I'm not real happy about being here. I know this needs to be taken care of, but I guess I have to do what I have to do. So this is where Nitrous Oxide Administr ation can come into play to help these patients. Now, think it's important as we start to discuss some of the workings of nitrous oxide, let's try to get a little bit better understanding of the properties because it's a key component of understanding and how you monitor while the patient is undergoing nitrous oxide inhalation therapy, while you're monitoring, you must have a good feel for how is this stuff work? This is a lot different from taking a tablet for like conscious sedation of some type where you 're then kind of dealing with the biomechanics of how that tablet sedation is being metabolized and what effect it has on the patient, especially short term mid -term, long term. All right. Nitrous oxide, for starters, is a colorless gas. It it has a relati vely sweet taste and odor to it. It's not overwhelming. I mean, there are some companies who have experimented with the nose cap that we place in position and having it have a certain scent to it that might some people may find more pleasing. But in and of itself, it does have a bit of a sweet odor. Now in its true setting it is a general anesthetic. However, in our purposes in the dental office, we're kind of using it as an anti -anxiety type regimen, not necessarily looking for general anesthesia. However, if utilize at its highest range, it will actually produce general anesthetic effects. Now, of all the many gases that are used for general anesthesia and of course, today in the surgical procedures in the operating room, mainly sedation is done with IV. W e don't usually use that many inhalation type therapies for for surgery. However, nitrous oxide is still one of the most the best and most effective methods for utilizing in dental treatment. This particular gas moves through the bloodstream in a free gas state. Okay. And that's critically important because if you take a tablet and you're metabolizing a medication, that medication is moving through the bloodstream and its pharmacological properties are working. And you have to really understand how long is this going to hold up? What kind of effect am I going to get? Can I reverse it? And it can be a little tenuous when you're trying to walk through this. The beautiful thing of nitrous oxide, it's in a free gas state. And I'll explain in a minute how that's going to kind of work for you. Blood saturation can occur really within about three minutes or so. So that's really effective, too. Okay. What might be the effects of nitrous oxide and how does it work on your system? Basically, you're looking at two diffe rent areas of the body that are affected. The nervous system is affected and the respiratory system is affected. Okay. When we talk about the nervous system, of course, we're talking about the central nervous system and the spinal cord. Both of them do com e into play. There are various parts of the brain that will kind of interact and show you symptoms that you will be able to identify that will help you in the monitoring process, the cerebrum, which is responsible for conscious function. So those things th at you are aware of, for instance, I'm putting my finger on my face, I'm smiling, okay? There's all sorts of things there. The cerebrum interacts with the nervous system, complex environment, and sort of tells you what's going on consciously. The outer sur face of that area is called the cerebral cortex. It gets sensory information from the skin and other organs in your body, ear, nose, mouth, all things like that, so that you bite down on something. Oh, yeah, that's kind of a hard peanut or whatever. The ce rebellum on the cortex, rather, on the outside of the cerebrum gives you that feedback information. So those things are going to come into play as nitrous oxide is inhaled and those areas of the brain are affected by it. Now, I'll give you an idea of of ho w the central nervous system may work. Our example here is a foreign object lodged in the eye. All of a sudden the eye starts to water. And that's sort of a a reflex that you can't really control, uh, based on previous experiences trying to get relief from a foreign object. Now, when you try to kind of compare this to dental pain and anxiety, the patient might react to an oral injection by turning around or moving their head or putting their hand up or something like that. And oftentimes that may be a sensa tion in the oral cavity, but it's also a reaction based on prior experience. So if you think about, Hm, what, what might we want the nitrous oxide therapy to do? Well, you'd like to kind of erase some of the past experiences and you might also like to affe ct those areas of the brain that will deliver those symptoms all related to anxiety, so that if you can reduce some of the input in that in those areas, you will then have a patient who won't necessarily be as anxious and might not perceive or react to pai n in the same way that they normally do. Okay. Now the brain stem is another part of the whole complex central nervous system that has an impact that you might not really kind of realize until you kind of look at it more closely. This is located at the bas e of the brain and many of the functions that it is responsible for are in fact related to the physiological effects of nitrous oxide. Some of these things may include moving in a sensation of your throat or swallowing in your neck and face. You may also h ave the reflex activity of just breathing. All right. So that if you're taking a nice, deep breath. The brainstem is sending information to the interior of the brain to tell you that that is functioning normally. Eye movement and reflex activity. And did y ou watch me move my eyes? Anyway, those kinds of actions also feed through the brainstem. What we might say that a waking state like that, everything is up and running. Okay. The brainstem has that, too. It's really a major relay system for so many differe nt factors in the central nervous system. So once again, if you can administer some type of therapy. Um, vis a vis the nitrous oxide inhalation system and affect these three areas cerebral cortex, cerebrum and brainstem that will interact, causing a decrea se in sensory feedback to the brain, altering the patient's perception of how this should work. Okay, so the cerebellum, another part of the brain that also comes into play, gives you a little bit of a feel for where you are in space. For instance, I'm sit ting here talking to you right now in my office. My hands are on the table. I'm looking at your at the camera that's giving me that orientation. I'm not turned sideways. I'm not upside down or anything like that. This cerebellum gives you that kind of info rmation. So when the effects of nitrous oxide come into play, some people may feel a bit lightheaded because the nitrous oxide has an effect on the cerebellum part of the brain too. And therefore that lightheaded feeling may be a good reaction. Then again, I've had patients who said, I don't like that feeling. So, again, nitrous oxide isn't for everybody. And we'll talk a little bit more as the classes as these different make these different presentations to you. And as we proceed through it, we'll talk mor e about the reactions that may occur and how you can administer and or monitor the nitrous oxide levels so that they are maximum you get the maximum result and most comfort. Now, once again, I use the word administer and monitor. The dentist in your office is responsible for administering nitrous oxide and titrating the levels. As a dental team member, your responsibility is to monitor the patient and you can in fact have the ability to lower the concentration. However, you do not have legally the ability t o increase the the concentration, I must say, conversation, which may come into play with nitrous oxide, too. We'll get into that a little bit later so everybody can respond in different ways. And you'll see that as you walk through this and have different cases. There are really what I call some major points to think about. Remember that the pain that the patient may be perceiving and or reacting to. Okay. Kind of two different things come from a part of the brain stem and the the thalamus area. And then t hat reaches into the cortex and starts to give you all the different feedbacks. Pain in the oral cavity is perceived by the brain and is relayed to the cortex and tells the person how they're doing. Like, man, that's killing me or well, you know, I've got a little bit of pain, but not too bad. So then the patient's reaction to that is what concerns you as they move through the procedure. Once again, if we can somehow reduce their perception and their reaction to the discomfort that's going to make for a mor e comfortable appointment. A bit of a rough diagram here. You have the cerebellum, you know, the cerebrum, rather, the main functioning area, giving the sensory information from the brain to the rest of the body, the thalamus, which gives relays the activi ty that's going on, the brainstem and cerebellum, interested in giving you that orientation to space. Okay. Now, since nitrous oxide acts in sort of a depressing kind of fashion on the brain, the signs and symptoms that are relayed can be sort of subdued. And that's good. That's what we want because we don't want the patient to perceive the pain or react to the pain like they did before. Okay. In fact, nitrous oxide, because of its ability to depress some of these functions and also to depress respiration a little bit, you may actually induce a sleep like state. Okay. What's sometimes called somnolence and somnolence is the production of sleep. And as I'm talking to you, I'm closing my eyes. I'm thinking, no, I'm wide awake. Don't don't worry. But nitrous ox ide is related to that waking state of the brain so that as we depress those, some of those sensory reactions, some people will actually fall asleep. Patients will many times ask you, do I expect to fall asleep during the procedure? And you can certainly o ffer to them. There is a likelihood that you may doze off or that you may drift away and feel a little lightheaded. Oh, good. Everything's safe. No worries. It's going to be a matter of how you react to this particular treatment. Now, I think it's also imp ortant to kind of understand that if they start to drift away too much and they get disoriented, then you have to be responsible to watch and monitor those patients so that you can kind of reduce or titrate the level downward. And we'll talk more about tha t titration when we look at the different pieces of equipment and things like that. But as you begin to look at the patient and you see them and maybe they're you're sensing they're uncomfortable, it will be good to monitor that and titrate that downward s o that they don't have a problem. Okay. I will do my best throughout these these productions and these that I'm giving you in the information we're giving you to relate to you things that have happened to me in private practice. I've practiced in central a nd eastern North Carolina for 43 years. I've certainly had my experience, my share of experiences with nitrous oxide as well as other forms of sedation, as well as trying really hard to deliver a compassionate and thoughtful treatment to these patients. Ok ay. Now, if you if if by using the nitrous oxide inhalation therapy, you begin to get a depressed sensory perception. That person's ability to sort of perceive the procedure is lessened. That's good. All right. So almost all forms of this sensation are dep ressed, not only pain, but things like touch, vision, hearing. They essentially things just get a little dreamy. That's a pretty good way to put it, I think. Once again, though, everybody does react differently. You may even get a little bit of a dulled me mory reaction so that sometimes people, when you have completed the therapy and kind of with the input of full oxygen, brought them back to normal. Quote, They sometimes don't always remember exactly the procedure we have done. Another thing that comes int o play is the autonomic nervous system. Another component of the overall central nervous system is involved in this issue with nitric oxide therapy because the autonomic nervous system being amongst the other brain components and how it's controlled. You m ay get some responses there that you're going to want to look at. For instance, dilation or constriction of the pupil. That's an autonomic nervous system that's in an unconscious in your respect, response to something when the light shines in your eyes. If I get up close to the camera, my pupils will constrict As I back further away, it's a little bit darker. Pupils get a little bit wider. You can't control that. That's part of the autonomic nervous system and acceleration or deceleration of the heart rate. If in fact you're in trouble, your heart just starts moving. It starts bumping because that's part of the fight or flight mechanism. Okay. Also respiration. Now you can control respiration. If you're working out, you need a good breath. You breathe in. Go od. That's not really autonomic nervous system. That's the general central nervous system at work. However, nitrous oxide will affect some of these other areas. In respect to the respiratory system. This is going to be the body function that is really inte gral to the patient having a good inhalation therapy appointment. Now, what do you mean by that? Since nitrous oxide exists as a free gas in the bloodstream. If you're thinking and I hope you are. Wouldn't it make sense that in order to get it to where it needs to be to work, you've got to breathe in. If you have a patient that reports for an appointment for nitrous oxide and they are suffering from allergic reactions to pollen and things like that, where they have just your basic, really bad cold and serio us congestion. Mm Might not be the best day for nitrous oxide. Why? Because you have to breathe through your nose in order for it to work. Now. So in order to get that nitrous oxide to the areas in the lungs that will do the job and release it into or diff use, allow it to diffuse from the alveoli into the bloodstream. And I'll show you a little diagram in a moment. You must be able to breathe through your nose. So if you're congested or having severe allergy problems, it may not be the best day for that. No rmal respiration allows for the transport of oxygen from the different aspects of the lungs into the bloodstream. I mentioned that nitrous oxide is a free gas in the blood, meaning that it's it's going to what we call bump out the nitrogen. Nitrous oxide w ill bump the oxygen out of the way and replace it with the nitrogen. That's going to start to give you those different effects. Again, if you really thinking about that. Doesn't that at least give you the thought that, wow, this is a really, really safe in halation therapy because it's absorbed from the lungs right into the bloodstream existing as a free gas. How would you then reduce or eliminate the effects of nitrous oxide if the patient was getting into a spot where you weren't happy about it? Simple. Tu rn up the oxygen all the way. Turn off the nitrous or have them breathe through their mouth. Now, that can be a plus or minus for the nitrous oxide treatment, meaning that if they start talking a lot or breathing a lot through their mouth. The results of t he therapy will be reduced. Okay, So remember that the respiratory system is divided into basically two segments. You have the inhalation part. That's where transporting air from the outside into the lungs. And then you have the exchange part where it goes from the alveoli in the lungs into the bloodstream and transmit it into the body cells. External respiration, internal respiration. Both of these are functioning and doing what they're supposed to do. And if you can breathe properly through your nose, nit rous oxide works beautifully. External respiration is going to involve all those systems until the oxygen actually gets down into the bronchial tubes in the lungs. So you have, what, the nose, trachea or air tube? Phenix in the back, larynx below trachea, the things that extend out toward the lungs, the bronchi and bronchioles, those are all involved in external respiration. The final exchange of the of the gas from the inhalation portion into the bloodstream occurs at the alveolus. A group of alveolus is c alled the alveoli. Essentially it's a pocket, a microscopic pocket of tiny, tiny little membranes with capillaries running through them that allow for the diffusion of either oxygen or nitrous oxide to go into the blood vessels. It's really a miraculous system when you think about it, right? You're breathing in this air and microscopically goes into the bronchioles, into the alveoli and amazingly exchanges into the bloodstream, providing the hemoglobin with the life saving and and enhancing qualities of oxy gen. However, with nitrous oxide therapy, if you're breathing in the correct amount of nitrous through the nose, it causes its shift in the gradient so that more nitrogen is diffusing and absorbed by the bloodstream than oxygen. Thus, the effects that it b egins to have go back to the ones I talked about earlier in guarding the brain and the brain stem and the cerebellum and the cerebral cortex and all the different things like that. So this is an inhalation therapy. You're gonna get that stuff right through your nose, through the little nose cap. And it travels there and absorbed, as I said, via the alveoli and the diffusion process process. Okay. As we come to an end on this first class, a few terms about breathing and these may be applicable to your docume ntation. Now, I'm not one to generally read off the slide, but these terms are a little different, so I'm just going to kind of buzz through each one of them. Yeah, which is just normal breathing. You could document patient experiencing Junia know no areas of concern with breathing. Tachypnea would be rapid breathing. Okay. And you may need may have the need to document how fast the patient is breathing. It may or may not come into play. Britney would be depressed or slower breathing. Okay, now think about it. Some of these things are brought on by the local environment. Meaning if you're breathing normally and you start running, your respiration will go up or you'll have tachypnea. If, in fact you're ready to doze off and you're just falling asleep and your breathing starts to decrease, that could be called brain apnea. All right. I know they are peculiar words and they're not ones that you generally hear in the English language, but I want to go over them with you. Now, some other terms that you probably ha ve heard, hypertension, which is over respiration. Like like almost like, wow, I'm taking in too much stuff here, like breathing through a bag and you're increasing your. That's too much. Too much respiration. The frequency of breathing in and out is going just too quickly. That's different from rapid breathing. Hypertension is over breathing. You're breathing not only quickly, but sucking too much air in hypoxia in turn would be under respiration, meaning that an individual might have a respiratory rate of , say, eight liters per minute. If you have hypertension, maybe they're bumped up to 10 or 12. If you have hypoxia, maybe they were only breathing 4l or 3l a minute. Then these things, these term this terminology will then affect how that patient physicall y presents. All right. So that if you have a long range part of hypoxia, then you may induce a state of anoxia, which means a lack of oxygen. Other areas of dentistry and medicine that you may have that those terms may have come across your path. For insta nce, in sleep apnea. They talk about how you experience various hypotheses throughout sleep hypotheses being depressed, breathing under sparring, just not breathing enough. That can then turn into an anoxia state where you're not getting oxygen at all. Oka y. Hypoxia in and of itself is a decreased oxygen in the tissue. So when someone is turning blue in, someone is becoming unresponsive. It's probable that they're in a hypoxic state. Okay. So those are some of the terms we may have kind of weave those throu gh the next classes just to see how things are going. Important for you to understand that you may have to use these in your documentation. Then again, if you're not sure of the of those terms, you can just write out patient who's experienced an increase i n rate of breathing. Okay. Which may be hypomania or it may be tachypnea, just depends on whether they're breathing rapidly or over breathing. So I hope that makes sense. So that was our first class in this particular course. I hope it gave you a good intr oduction to how nitrous oxide got started and some of its various capabilities, as well as starting to learn a little about how it affects the brain and how that's going to directly relate to the monitoring systems that you will use in practice. Okay. So i n that regard, thank you very much for your time. I will look forward to seeing you at the second class. Have a wonderful rest of the day. Bye now.