Nitrous Oxide and Oxygen Sedation: An Update

Ann Brunick, RDH, MS, Morris Clark, DDS, FACD

Continuing Education Units: 2 hours

Nitrous oxide and oxygen (N2O/O2) in combination have been used safely and successfully for over
160 years to assist in the management of pain and anxiety. This course will teach about the desirable
characteristics of nitrous oxide, indications and contraindications for N2O/O2 use as well as facts and myths
surrounding chronic exposure to nitrous oxide, the biologic effects associated with high levels of the gas, and
ways to assess and minimize trace gas contamination in an outpatient setting.

Conflict of Interest Disclosure Statement

• The authors report no conflicts of interest associated with this course.

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ADA CERP is a service of the American Dental Association to assist dental professionals in identifying
quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses
or instructors, nor does it imply acceptance of credit hours by boards of dentistry.

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 Overview
Nitrous oxide and oxygen (N2O/O2) in combination have been used safely and successfully for over 160
years to assist in the management of pain and anxiety. Dr. Horace Wells, a dentist in the early 1800s,
dedicated his life to promoting its use for both dental and medical procedures. Because of his persistence
in advocating the use of nitrous oxide as a method of pain control, he was posthumously recognized as the
“Discoverer of Anesthesia.” Since that time, N2O/O2 has been commonly used in many dental specialties.
Other health disciplines have also benefited.

In many instances, patients present to medical and dental offices with both pain and anxiety. It is
necessary to manage both, since they are interrelated. Nitrous oxide and oxygen sedation can assist
patients with their pain and anxiety and can be employed safely and effectively with minimal concerns.

This course will teach about the desirable characteristics of nitrous oxide, indications and contraindications
for N2O/O2 use as well as facts and myths surrounding chronic exposure to nitrous oxide, the biologic
effects associated with high levels of the gas, and ways to assess and minimize trace gas contamination in
an outpatient setting.

Learning Objectives
Upon completion of this course, the dental professional should be able to:
• Recognize characteristics of nitrous oxide that make it desirable to use for most patients.
• Evaluate indications and contraindications for the use of N2O/O2 sedation.
• Differentiate between the facts and myths surrounding chronic exposure to nitrous oxide.
• Explain what the NIOSH and ACGIH recommended exposure limits signify.
• Identify biologic effects associated with high levels and/or misuse of nitrous oxide.
• Describe methods for detecting and assessing levels of trace gas in an outpatient setting.
• List methods for minimizing trace levels of nitrous oxide in an outpatient setting.

Course Contents NIOSH – National Institute of Safety and Health

• Glossary
• Advantages N2O/O2 – Nitrous oxide and oxygen
• Contraindications
• Evidence-Based Research OSHA – Occupational Safety and Health
• Biologic Effects Administration
• Regulation
• Assessing Nitrous Oxide Levels ppm/ppb – parts per million/parts per billion
• Minimizing Trace Gas Contamination
• Recommendations for Controlling Waste TWA – time weighted average
Nitrous Oxide
• Conclusion Terms:
• Course Test Preview anesthesiologist – a physician specializing in the
• References administration of anesthetic.
• About the Authors
anxiety – a condition of heightened, often
Glossary disruptive tension accompanied by a feeling of
impending harm or injury.
Acronyms:
ACGIH – American Conference of Governmental baseline values – a reference point used to
Industrial Hygienists indicate the initial condition against which future
readings are compared.
COPD – Chronic Obstructive Pulmonary Disease

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bleomycin sulfate – an anti neoplastic antibiotic. pharmacological agents – drugs prescribed to
treat patients.
consent form – willing permission in a written
format; allowing treatment. pneumoencephalography – radiography of
fluid-containing structures of the brain after
contraindication – a symptom that indicates an cerebrospinal fluid is intermittently withdrawn by
otherwise normal form of treatment. lumbar puncture and replaced by a gas.

COPD – Chronic Obstructive Pulmonary Disease, pulmonary fibrosis – is the formation or

such as emphysema and chronic bronchitis. development of excess fibrous connective tissue
(fibrosis) in the lungs, described as “scarring of the
cystic fibrosis – an inherited disorder causing lung”.
exocrine glands to produce abnormally thick
secretions of saliva and an elevation of sweating. psychological impairment – a mental state that
disables a patient in some manner.
evidence-based evaluation – a philosophy that
relies on up-to-date, current research to evaluate reservoir bag – a part of the NO2/O2 machinery,
the patient’s condition and course of treatment. contains the excess gas.

flowmeter – a physical device measuring the rate scavenge – to collect and remove excess.
of flow of a gas.
sedation – producing a sedative effect, the act or
graft – a slip or portion of tissue used for process of calming.
reimplantation.
sinusitis – inflammation of the sinus.
hypersensitive – abnormally sensitive reaction
when in contact with an allergen, bacteria, or spectrophotometer – an infrared instrument used
stimuli. to report nitrous oxide levels.

intracranial pressure – pressure occurring within time-weight average device (TWA) – a dosimetry
the cranium due to head trauma, inflammation or device containing a material that absorbs nitrous
infection. oxide, the badge or vial is returned for analysis.

macular hole repair – to repair the partial or full titrated – incremental increase of a drug to a level
absence of the retina in the macular area of the that provides optimum result.
eye.
trace gas – any gas that represents an extremely
methionine synthetase – one of the essential small or insignificant portion of a mixture of gases.
amino acids and essential for the production of
DNA. trimester – one-third of a full pregnancy term.

nitrous oxide – gas with a sweet odor and taste tympanic membrane – a thin, semi transparent
used with oxygen as an analgesic and sedative membrane in the middle ear that transmits sound
agent. vibrations to the internal ear.

organogenesis – the formation of organs within unscavenged trace – escaped, harmful gas left in
an embryo, within the first trimester. the air for the dental team.

paresthesia – altered sensation where the upper respiratory tract – the nose and throat and
sensory nerve in question has been afflicted by trachea, passages through which air enters and
injury or disease. leaves the body.

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Advantages treatment is generally recommended to be
Nitrous oxide/oxygen (N2O/O2) sedation offers completed during the second trimester. N2O/O2
many advantages over other sedation methods sedation can be used during the second and
or pharmacological agents. The properties of third trimesters, although medical consultation
nitrous oxide allow it to provide pain relief while with the patient’s physician is necessary.
simultaneously reducing anxiety. This action • Upper respiratory tract infections (i.e. sinusitis)
happens within a short period of time. For typically result in nasal obstruction in which
example, bronchial asthma can be triggered by the gases cannot enter the respiratory system.
various stimuli, including stress. By employing This is a situation where N2O/O2 sedation is
the N2O/O2 sedation technique, basic appointment appropriate when the condition is resolved.
stressors can be minimized for a more • There are certain chronic obstructive pulmonary
comfortable experience. diseases (COPD) that pose problems with
N2O/O2 sedation. If a patient indicates health
The drug can be titrated, which means the patient problems associated with chronic bronchitis
is given incremental amounts over time until or emphysema, N2O/O2 sedation is a
the desired level of sedation is achieved. This contraindication due to narrowed or enlarged
allows for the greatest level of patient comfort and airways that prevent proper inhalation or
safety. Elimination of nitrous oxide from the body exhalation of the gases. Depending on the
occurs as rapidly as the induction. Patients are respiratory function of the patient, some cases are
fully recovered following N2O/O2 sedation because not problematic; therefore, medical consultation is
all but an insignificant amount of drug is expelled essential for all patients with COPD.
from the lungs within minutes after the nitrous • Because of the expansive nature of nitrous
oxide is discontinued. These characteristics oxide, there are several situations/conditions
make it a desirable agent for practitioners. that warrant caution. The possibility exists
in patients with active cystic fibrosis that
In addition to these ideal characteristics, N2O/O2 complications could arise if nitrous oxide is
sedation can be used on most patients with used. Similarly, complications could occur in
minimal side effects. Patients of any age can be patients where a gas bubble was placed to
given nitrous oxide and oxygen. In addition to assist healing during a recent eye surgery.
relieving pain and anxiety, N2O/O2 sedation works This is typically surgery involving retina and
very well at calming a hypersensitive gag reflex macular hole repair.1 Also, patients who have
that can prohibit taking intraoral radiographs. recently undergone ear surgery to repair/
There are very few contraindications for its replace the tympanic membrane with a graft
use in the dental office setting because it does could have complications from the use of nitrous
not negatively impact the majority of the body oxide.2 Patients may get precautionary advice
systems to any significant extent. from their physicians about the use of nitrous
oxide following these types of surgeries. Other
Contraindications potentially problematic situations related to gas
There are some situations in which the use expansion are pneumothorax (hole in the lung)
of N2O/O2 sedation should be postponed or and significant bowel impaction. However, it
avoided. Whenever there is a question about would be unlikely that a patient would present
whether N2O/O2 sedation should be used, it is to a dental office with these conditions. Again,
always recommended to consult a physician. medical consultation is always prudent in such
The following are conditions in which medical situations.
consultation is advised prior to nitrous oxide • There is a potential to increase the incidence of
administration and/or nitrous oxide should be pulmonary fibrosis and other pulmonary diseases
postponed until the condition is resolved, or not in patients who are currently receiving bleomycin
used at all. sulfate, which is a drug used to treat certain
• The use of drugs during the first trimester types of cancers.3 This situation is not related
of pregnancy is not recommended. to the use of nitrous oxide, but rather the use of
Therefore, nitrous oxide during this period of oxygen (greater than 30%) in combination with
organogenesis should not be used. Dental the nitrous oxide. This is an unlikely situation.

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• In addition, the literature cites notable inappropriate. It is vital for all healthcare providers
intracranial pressure increases following to critically evaluate the latest research.
recent pneumoencephalography procedures.
In this case, nitrous oxide rapidly replaces the Evidence-Based Research
nitrogen resulting in an increase in pressure. Evidence-based evaluation of the scientific
N2O/O2 sedation should be postponed for one literature is the necessary basis for sound
week after this procedure.4 practice. One of the areas in which the literature
• Situations involving patients with psychologic generally has not been scientifically validated
impairment, mental illnesses or altered mental deals with nitrous oxide as an occupational
states require significant caution. N2O/O2 hazard. Unfortunately, there have been many
sedation should not be used when a patient references in scientific literature referring to
is intoxicated or “high” on drugs. In addition, nitrous oxide as a significant risk factor for
N2O/O2 sedation should not be used if a healthcare professionals exposed to the gas
patient is unable to understand the procedure during patient treatment. Historically, the literature
because of a mind-altering condition (i.e. has made reference to nitrous oxide as the
Alzheimer’s disease). And, if a person has causative agent for anything from birth defects
a condition in which psychotropic drugs to cancer. Validated research suggests that low
are prescribed, N2O/O2 sedation should be levels of trace nitrous oxide in the workplace are
avoided. It is always best to obtain medical safe, and great strides have been made regarding
consultation whenever there is a question the efficacy of the equipment used and the ability
about a specific situation. Remember, there to scavenge trace gas from the dental office. It
are other modes of sedation that are available is now possible to keep levels of trace gas to a
for use in these instances. minimum, thus reducing occupational risk.
• If a patient won’t sign a consent form for
N2O/O2 sedation, or is unwilling to receive Defining legitimate research often hinges on its
it, you should not begin the procedure. You design and methodology. From the more than
should also refrain from using N2O/O2 sedation 800 articles that have been written on the subject
with persons who can’t communicate with you of nitrous oxide up to 1995, fewer than 25 were
because of a language barrier or those who shown to merit reliability and validity.5 There have
have claustrophobic tendencies and are not been many inconsistencies and inaccuracies
able to wear the nasal mask and scavenger presented in the literature regarding the harmful
system (Figure 1). nature of nitrous oxide to those professionals who
use it for patient treatment. Many of these studies
There may in the future be other situations were done using a retrospective survey design.
in which N2O/O2 sedation will be deemed This type of research lends itself to be unreliability

Figure 1. Mask with scavenger system to redirect unused nitrous

oxide gas.

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because it is unable to control for extraneous reported in individuals chronically exposed to
factors. high levels of unscavenged nitrous oxide.9 The
issue of DNA interruption is important to those
The earliest study referring to nitrous oxide as professionals early in pregnancy or trying to
a hazardous agent dates back to 1967. Nitrous become pregnant. Knowing trace gas levels in
oxide was cited by a Russian anesthesiologist as the office would be beneficial in these cases. It
the cause of both male and female reproductive is the individual’s decision whether to continue
problems among anesthesiologists.6 Since or postpone employment during this time. The
nitrous oxide was a common gas used for toxicity of nitrous oxide and its effects on the
operating procedures, it was singled out as human body remains a topic of discussion in the
the etiologic factor. Articles of a similar nature current literature.10-12 It is certainly recommended
surfaced in the United States in the 1970s and to keep updated on this topic; however, it
early 80s, each claiming similar results. These continues to seem that nitrous oxide is safe when
studies quoted significant biologic effects when administered in low therapeutic doses for short
high levels of unscavenged, trace nitrous oxide periods of time.
were measured. Since those early studies,
methods of delivering and scavenging nitrous Neurologic signs and symptoms are associated
oxide have improved tremendously. It is now with nitrous oxide abuse. Individuals professing
considered the standard of care to use equipment misuse of nitrous oxide experience numbness,
with scavenging capabilities. The equipment tingling, and possibly paresthesia in their limbs.
manufacturing industry has been instrumental Impaired dexterity, clumsiness, and slowed
in providing professionals with quality products gait are also signs. Reflexes may be impaired;
and machines capable of scavenging much of muscles can weaken. The length of time and
the trace gas. Also, it is important to note that amount of exposure can influence these signs and
these manufacturers are continually improving symptoms. The cases of overexposure stated in
the capabilities of their equipment. Research is the literature ranged from one to several hours
ongoing at each manufacturing site; new products per day and up to several times per week. Some
and methods are constantly being evaluated. individuals report gradual improvement of these
symptoms upon termination of the abuse activity
There is one reputable study that has determined while others note permanent neural injury.13
the level at which true biologic effect occurred
on humans following nitrous oxide exposure. In Regulation
1985, Sweeney et al. used a sensitive measure, The National Institute for Occupational Safety and
the deoxyuridine suppression test, to identify Health (NIOSH) and the American Conference of
this critical level. His results showed the first Governmental Industrial Hygienists (ACGIH) were
signs of detectable biologic effect were found at instrumental in establishing recommendations for
1800 parts per million (ppm).7 Noteworthy is the threshold limits during administration and for an
fact that, to date, no biologic effects have been 8-hour time-weighted average. In 1977, these
evidenced when low levels of trace nitrous oxide organizations established threshold limits for
gas have been measured. health professionals. It was established that a
level of 25 ppm and 50 ppm must be achieved in
Biologic Effects operating rooms and dental offices respectively.
The most significant biologic effect that has been These levels were based on unfounded research
linked to nitrous oxide exposure is its ability results later recanted by Bruce, Bach, and
to inactivate Vitamin B12. This inactivation Arbit as well as the scavenging ability of the
further affects an enzyme called methionine equipment at that time. Health professionals
synthetase. Methionine synthetase is essential are required to uphold these arbitrary values
for the production of DNA. Abnormalities in even at the present time. The Occupational
fetal development were seen in animal fetuses Health and Safety Administration (OSHA) is the
that were exposed to 24 hours of 60% nitrous organization that has the authority to enforce
oxide for 12 days.8 Despite flawed research, these recommended levels; however, because
reproductive problems with humans have been of the controversy regarding the appropriateness

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of the recommendations, OSHA recognizes that through a number of reputable companies. The
these limits must be validated. hand-held unit aforementioned also has TWA
measurement capabilities with immediate readout
In order to bring several issues up-to-date on the machine.
regarding nitrous oxide, a meeting was convened
in October 1995 by the American Dental Minimizing Trace Gas Contamination
Association Council on Scientific Affairs. Several It is prudent to employ as many measures to
interested parties were represented including reduce the amount of trace gas contamination
respected experts in the field, educators, in the office as possible.14 Scavenging nitrous
manufacturers, and government officials. It was oxide can occur before, during, and after patient
concluded that a true recommended exposure use. Nitrous oxide can leak from several sources.
limit to nitrous oxide has not been established.14 Certainly, the equipment and its connections are a
Sweeney and colleagues have proposed a level potential source of trace gas. Gas can leak at any
of 400 ppm for regulatory consideration. They place of connection on the equipment, whether the
believe this level is attainable and well below system is portable or centrally installed. The tanks
the level (1800 ppm) at which they first detected themselves may leak at the valve stems. Gas
biologic effect. Other countries have adopted can leak through any portion of a central piping
exposure limits ranging from 25 ppm (France and system or through connections near the flowmeter.
Denmark) to 100 ppm (Sweden and Germany). Manufacturers of nitrous oxide equipment suggest
periodic evaluation and routine maintenance
Assessing Nitrous Oxide Levels checks. Check with your manufacturer for the
In order to determine whether trace nitrous oxide recommended time period; one company has
levels are significant in your facility, it is necessary suggested a maximum of two years. Conduction
to measure the levels in parts per million. An tubing and reservoir bags provide a potential
instrument called an infrared spectrophotometer is source of trace gas. These items should be
designed to instantaneously report nitrous oxide inspected frequently for cracks and tears. The
levels. Many other gases can be measured with soap/water test (instructions for this test are in
this instrument as well. This technology can the next section) is appropriate for testing these
detect levels as low as parts per billion (ppb). It is items. The evacuation system used to pull trace
not necessary to purchase this piece of equipment gas from the mask into the suction must be in good
since periodic evaluation is all that is needed. It working order and have properly vented pumps. If
may be rented directly through a manufacturer or equipment is used that is not able to pull trace gas
it is possible to consult a biomedical engineering into the evacuation system from the nasal hood,
agency through a local hospital or surgical the professional is practicing below the standard of
center for available services. Also available is a care set by the dental profession. This could lead
small, lightweight, hand-held device that gives a to serious legal repercussions.
continuous measure of nitrous oxide in room air.
This machine can also detect gas leaks around Another significant potential source of trace gas is
equipment. from the patient. One of the most critical means
for waste nitrous oxide invading the operator’s
It is also possible to determine the amount of breathing space is through patient talking. It is
nitrous oxide exposure to an individual over a imperative to keep patient talking to an absolute
specified period of time. A personal monitoring minimum during administration. It is also possible
device is worn similar to a radiation-dosimetry for gas to escape into the room from the patient’s
badge for the recommended period. The time- mask. Considerable effort should be made
weighted average (TWA) dosimetry device to ensure a properly fitting mask. There are
contains a material that absorbs nitrous oxide. many varieties of masks and a range of sizes.
The badge or vial is returned to the supplier Appropriate flow will not force gas out the sides
for analyzing. A written report is provided by of the mask. Sometimes, all that is needed to
the company indicating exposure levels for the create a snug fit around the patient’s nose is a
specified period of time. These devices are slight twist of the conduction tubing on the mask.
inexpensive, easy to use, and readily available A physical property of nitrous oxide is that it is

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heavier than nitrogen (air). While it may seem • Assess room ventilation and air exchange in
logical to think that because of this property, the the office. It may be necessary to supplement
gas would immediately fall to the floor and pose no local ventilation to assist the removal of waste
risk to the operator(s), one must not forget that the nitrous oxide. Be wary of air conditioners that
gas is extremely expansive in nature. The partial may recirculate waste gas within the office
pressure of nitrous oxide is 31 times greater than rather than remove it. It is possible in the
that of nitrogen (air), so it will exit the patient’s future that fresh air exchanges will become
mouth and enter the operators’ breathing space mandatory in offices that use nitrous oxide/
before it falls to the floor. oxygen sedation.
• Make sure all office personnel are educated
Recommendations for Controlling Waste on the facts regarding chronic exposure to
Nitrous Oxide nitrous oxide. Develop a hazard control team
The following is a list of recommendations and to continually assess the effectiveness of the
preventive measures to minimize trace gas office scavenging system.
contamination in your dental office.14
• Establish baseline values of nitrous oxide Conclusion
concentrations in the office. Evaluate Nitrous oxide/oxygen sedation remains a viable
the ambient air using an infrared option for managing a patient’s pain and anxiety
spectrophotometer. in the dental office. There are several advantages
• If desired, use time-weighted dosimetry devices to its use and relatively few contraindications.
to monitor exposure of office personnel to Knowing how to minimize the operator’s exposure
nitrous oxide over a specified period of time. to the gas is also an important consideration.
• Every 2 years send the equipment to the N2O/O2 sedation has a long-standing history of
manufacturer for routine maintenance and safety and success and it is likely that this type of
evaluation. sedation will be used far into the future.
• Visually inspect the conduction tubing and
reservoir bag for cracks and tears. It is necessary to educate the entire office team
• Use the soap/water test on fittings and on the biohazard issues of nitrous oxide safety
connections to assess for gas leaks. To do this, in the dental office and keep abreast of sound
place a few drops of dishwashing detergent in scientific literature in this area. Many states are
a small amount of water. Wipe some of this starting to include nitrous oxide administration and
solution around the fittings where the gas lines monitoring in their state practice acts for dental
attach to the flowmeter. If these areas are assistants. Refer to your state practice act for
leaking, bubbles will form around the fittings. current requirements in your location.
Wipe off the solution and tighten the lines.
• Ensure the adequacy of the evacuation system
in place.

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Course Test Preview
To receive Continuing Education credit for this course, you must complete the online test. Please go to
www.dentalcare.com and find this course in the Continuing Education section.

1. The dentist who has posthumously been recognized as the “Discoverer of Anesthesia” due
to his clinical use of nitrous oxide is ____________.
a. Humphrey Davy
b. Joseph Priestly
c. Gardner Quincy Colton
d. Horace Wells

2. All of the following are relative contraindications for N2O/O2 sedation except _____________.
a. hypersensitive gag reflex
b. severely claustrophobic patients
c. current upper respiratory infection
d. first trimester of pregnancy
e. alcohol intoxication or drug use

3. Nitrous oxide is primarily eliminated from the body via the ____________.
a. kidneys
b. lungs
c. skin
d. urine
e. liver

4. The concept of titration is defined as _______________.

a. large doses of a drug administered at one time
b. incremental doses of a drug administered over time

5. _______________ is/are advantages of using N2O/O2 sedation in a dental office setting.

a. Rapid onset of action
b. Administered to patients of any age
c. No negative impact toward any of the body systems to any significant extent
d. Patients are fully recovered at the conclusion of the procedure
e. All of the above.

6. Symptoms of N2O-induced neuropathy include all the following except _______________.

a. unsteady gait, clumsiness
b. tingling or paresthesia in extremities
c. increased mental acuity, hyperactive senses
d. impaired psychomotor function and dexterity

7. Chronic exposure to high levels of nitrous oxide can inhibit _______________, a Vitamin
B12-dependent enzyme.
a. methionine synthetase
b. monoamine oxidase
c. catechol-o-methyl transferase
d. reverse transcriptase

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8. The level at which biologic effects of exposure to nitrous oxide were first evident according
to sound research (by Sweeney) is ____________.
a. 100 ppm
b. 400 ppm
c. 800 ppm
d. 1200 ppm
e. 1800 ppm

9. The organization that enforces the exposure limits for nitrous oxide in a dental setting is the
_______________.
a. National Institute of Safety and Health
b. Occupational Safety and Health Administration
c. International Federation of Industrial Hygienists
d. American Conference of Governmental Industrial Hygienists

10. Nitrous oxide has shown significant biologic effects on the ____________ body system.
a. respiratory
b. circulatory
c. hepatic
d. cardiovascular
e. None of the above.

11. In order to establish a baseline trace gas level in the office or to periodically monitor the
efficacy of the scavenging system in place, it is necessary to use a(n) _______________.
a. personal dosimetry badge
b. infrared spectrophotometer
c. passive diffusion monitor
d. air-diffusion monitor

12. Flowmeters should be periodically sent to the manufacturer for routine maintenance. A
time guideline for this evaluation has been suggested at ____________.
a. 6 months
b. 1 year
c. 2 years
d. 5 years

13. A major source of trace nitrous oxide that contaminates the ambient air in a dental office is
from _______________.
a. the patient talking
b. cracked reservoir bags
c. leaking valve stems on the cylinder
d. improperly soldered central piping

14. Administering nitrous oxide/oxygen sedation using equipment without the ability to pull
trace gas into the evacuation system is considered an acceptable standard of care set for
health professionals. The partial pressure of nitrous oxide is 31 times greater than that of
air, so as it is exhaled from the patient’s mouth, it enters the operators’ breathing space
before it falls to the floor.
a. Both statements are true.
b. The first statement is true. The second statement is false.
c. The first statement is false. The second statement is true.
d. Both statements are false.

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15. Scavenging devices recommended to minimize nitrous oxide concentrations in the dental
operatory include all of the following except _______________.
a. adequate suction systems that vent outside
b. use of scavenging mask/nasal hood
c. regular inspection of equipment for leakage
d. local recirculating exhaust ventilation system

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References
1. Hart RH, Vote BJ, Borthwick JH, McGeorge AJ, Worsley DR. Loss of vision caused by expansion of
intraocular perfluoropropane (C(3)F(8)) gas during nitrous oxide anesthesia. Am J Ophthalmol. 2002
Nov;134(5):761-3.
2. Munson ES. Complications of nitrous oxide anesthesia for ear surgery. Anesth Clin North Am.
1993;11:559–72.
3. Fleming P, Walker PO, Priest JR. Bleomycin therapy: a contraindication to the use of nitrous oxide-
oxygen psychosedation in the dental office. Pediatr Dent. 1988 Dec;10(4):345-6.
4. Frost EA. Central Nervous System Effects of Nitrous Oxide. In Eger EI, Editor: Nitrous Oxide N2O,
New York, 1985, Elsevier Science Publishing.
5. Clark MS, Renehan BW, Jeffers BW. Clinical use and potential biohazards of nitrous/oxide oxygen.
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Eksp Khir Anesteziol. 1967 May-Jun;12(3):44-9.
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8. Fujinaga M, Baden JM, Mazze RI. Susceptible period of nitrous oxide teratogenicity in Sprague-
Dawley rats. Teratology. 1989 Nov;40(5):439-44.
9. Rowland AS, Baird DD, Weinberg CR, Shore DL, et al. Reduced fertility among women employed as
dental assistants exposed to high levels of nitrous oxide. N Engl J Med. 1992 Oct 1;327(14):993-7.
10. Weimann J. Toxicity of nitrous oxide. Best Pract Res Clin Anaesthesiol. 2003 Mar;17(1):47-61.
11. Myles PS, Leslie K, Silbert B, Paech MJ, Peyton P. A review of the risks and benefits of nitrous oxide
in current anesthetic practice. Anaesth Intensive Care. 2004 Apr;32(2):165-72.
12. Wiesner G, Hoerauf K, Schroegendorfer K, Sobczynski P, et al. High-level, but not low-level,
occupational exposure to inhaled anesthetics is associated with genotoxicity in the micronucleus
assay. Anesth Analg. 2001 Jan;92(1):118-22.
13. Layzer RB. Myeloneuropathy after prolonged exposure to nitrous oxide. Lancet. 1978 Dec
9;2(8102):1227-30.
14. Nitrous oxide in the dental office. ADA Council on Scientific Affairs; ADA Council on Dental Practice.
J Am Dent Assoc. 1997 Mar;128(3):364-5.

About the Authors

Ann Brunick, RDH, MS

Ms. Brunick is Chairperson and Professor of the Department of Dental Hygiene at
the University of South Dakota. She received an A.A. degree from the University
of South Dakota, a B.S. degree from the University of Minnesota, and a master’s
degree from the University of Missouri-Kansas City, School of Dentistry. She has
served on numerous committees at the local, regional and national levels, including
the ADHA Institute for Oral Health Scholarship and Research Review Committees, the
National Dental Hygiene Board Examination Construction Committee, the International
Federation of Dental Hygienists’ editorial board and the ADA Commission on Dental Accreditation as a
site visitor. Ms. Brunick has published numerous articles and abstracts. Her most recent work is the
third edition of a textbook entitled Handbook of Nitrous Oxide and Oxygen Sedation that she co-authored
with Dr. Morris Clark.

Email: [email protected]

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Morris Clark, DDS, FACD
Dr. Clark is a nationally and internationally recognized expert on the subject of
nitrous oxide/oxygen therapy. His is a graduate of the University of California School
of Dentistry and completed his training in Oral Maxillofacial Surgery at Columbia
University. He is a Professor at the University of Colorado School of Dental Medicine
and on the faculty of the medical school there as well. He has been President of the
American Society for the Advancement of Anesthesia in Dentistry and the American
Dental Society of Anesthesia for the states of Colorado, Arizona, Kansas, Utah,
Wyoming and New Mexico. Dr. Clark did the original clinical research on Versed (Midazolam) and
Romazicon (Flumazenil), the antagonist for all the benzodiazepine class of drugs. He is on the Board
of Directors for the American Dental Society of Anesthesia and a member of the American Dental
Association Council on Scientific Affairs. He is co-author of the best-selling text Handbook of Nitrous
Oxide and Oxygen Sedation, published by Elsevier.

Email: [email protected]

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Crest® Oral-B at dentalcare.com Continuing Education Course, March 12, 2012