HAOMS (2024) 2, Editorial
Athanassios Kyrgidis
DOI: 10.54936/haoms2525962
The passing summer, the Greek Miitsterial Decision on the requirements to use nitrouse oxide seda- tion in dental practices has been published. [1] This was a long awaited decision following the Council of European Dentists resolution, which was initially presented since 2012 and last updated on 2019. [2]. The political opposition had also been pressing in this direction, notably stating that Greece was the only EU country that had not yet adopted some regula- tion on dental nitrous oxide use. [3] So the decision followed, and is now a law of the Greek State. [1] This decision gives dental practitioners the tools to overcome patient anxiety, both child and adult, in a much more “recreational” and comfortable man- ner. However, as it happens with all drugs, there are indications, contra-indications and adverse – effects. Personally, being currently appointed Secretary for Professional Development of HAOMS, but also a clinical pharmacologist, pre-hospital emergency care doctor certified by the National Centre of Direct Help (E.K.A.B.) and notably former tutor of anesthe- sia drugs in the amphitheater classes of the Medi- cal School of Aristotle University of Thessaloniki, I would like to shed light in some facts with regard to dental use of nitrous oxide.
Nitrous oxide is on the Proposition 65 list because it can cause birth defects or other reproductive harm. Proposition 65, officially known as the Safe Drinking Water and Toxic Enforcement Act of 1986, was en- acted as a ballot initiative in November 1986. [4] The guidance dictates “Women exposed to nitrous ox- ide may experience reduced fertility. Exposure dur- ing pregnancy may cause loss of pregnancy, and birth defects or other reproductive harm.” Proposition 65 requires Californian businesses to determine if they must provide a warning about exposure to listed chemicals. Sexual phenomena that occurred with use of nitrous oxide and oxygen sedation have long been described. [5]. However this association with infertility has been mainly with non-dental / medical use. [6] Still the effect is known and existent.
Another effect of nitrous oxide is that it is currently considered a global warming gas. Nitrous oxide is emitted during agricultural, land use, and industrial activities; combustion of fossil fuels and solid waste; as well as during treatment of wastewater. Dental
/ Medical use as an inhaled sedative is a subset of industrial activity. As a potent greenhouse gas (CO2 equivalent between 265 to 298 over 100 years [7, 8]), nitrous oxide is responsible for approximately 6,4% of the global greenhouse effect [7, 8]. Nitrous oxide is the second most potent Global Warm- ing Gas after Hydrofluorocarbons (which are used as refrigerants, aerosol propellants, foam blowing agents, solvents, and fire retardants in products used by homes, businesses and industry). [7]. Overall the health care systems in Western countries contrib- ute 5% of greenhouse gas emissions, thus fuelling the climate crisis [8] . Inhaled anesthetics account for about 3% of the carbon footprint of the entire health sector. [9]. Of that the majority is owing to nitrous oxide, with other volatile anesthetics contributing the 0.5%. [8] A retrospective observational study at a German university hospital with approximately 1,250 beds, between 2016 and 2020, attempted to estimate the cost of Greenhouse effect caused by medical / dental nitrous oxide[8]. The main outcome parameters were the amount of N2O used, in to- tal and converted to CO2 equivalent, and the total cost at the emission taxation scale of €0, €25, €55 and
€698 per ton CO2 equivalent in Germany. The actual cost for N2O was €14,040 in 2019, while the corre- sponding theoretic socio-economic damage due to the climate crisis was almost €1.5 million! [8]. Con- sidering the environmental effects of N2O, the con- cept of “Sustainability in dental sedation and nitrous oxide waste mitigation” has been proposed in the UK and US. [4, 7, 10] This also includes guidance on more safely abducting N2O waste from the dental practices.[10] Properly conducted, recent systematic reviews with meta-analyses confirmed that current policy recommendations to limit medical / dental ni- trous oxide use do not affect patient safety. [9]
Still, as the CED resolution mandates [2] due to fear and / or behavior management problems, some chil- dren are unable to cooperate for dental treatment using local anesthesia and psychological support alone. Sedation is required for these patients in order for dentists to be able to deliver high quality, pain- free dental care.[11] Of note the CED resolution, even in the 2019 update, cites the dated 2007 British Guideline [12] This dental need was addressed via a NICE Guideline, that aimed to evaluate the efficacy and relative efficacy of conscious sedation agents and dosages for behavior management in pediatric dentistry and to provide guidance as to which sedative agents should be used. The later guideline was developed in a multi-step approach adapted from that outlined by the National Institute for Clinical Ex- cellence (NICE 2020 Developing NICE Guidelines). Evidence for this guideline was provided from a pre- existing Cochrane review (Ashley et al. Cochrane Database Syst Rev 12:CD003877, 2018) [13] sup- plemented by an updated search and data extraction up to May 2020 [11]. The guideline concluded that oral midazolam should be recommended for con- scious dental sedation. Midazolam delivered via oth- er methods or –if those not available- nitrous oxide/ oxygen sedation could be considered. [11] It is im- portant to note that evidence levels are very low and studies are required both for midazolam and nitrous oxide. Still, one realizes that the regulation of nitrous oxide in our country, Greece, has been settled in a time that the specific treatment has been surpassed by more efficient and safe regimes.
The most dreadful but also common accident that occurs with the application of nitrous oxide anes- thesia in the dental office is that the breathing rate slows down or there is airway close off. Soon, the lack of oxygen is witnessed in the patient’s body: in younger patients, their heart rate slows down in re- sponse to N2O given through mask technique in an inappropriate manner. [14] The constant treatment monitoring of the patient alerts the dentist to the fact that such potentially fatal problems have devel- oped, so that the patient gets emergency support- ive care until the anesthesia adverse effect wears off. If the adverse effect goes unnoticed, owing to avoidance of proper protocols or methods, coma or even death can result inside the dental office [14] In this Editorial, given the circumstance, I would like to request the dental community, the anesthesiolo- gists community, the medical and dental schools, to exhaustively discuss the risks, benefits and alterna- tives for N2O sedation in children and adults inside the dental offices. The proper constant monitoring during N2O sedation -by a dedicated practitioner?- of the patient monitoring is paramount [14]
REFERENCES
DOI: 10.54936/haoms2525962
The passing summer, the Greek Miitsterial Decision on the requirements to use nitrouse oxide seda- tion in dental practices has been published. [1] This was a long awaited decision following the Council of European Dentists resolution, which was initially presented since 2012 and last updated on 2019. [2]. The political opposition had also been pressing in this direction, notably stating that Greece was the only EU country that had not yet adopted some regula- tion on dental nitrous oxide use. [3] So the decision followed, and is now a law of the Greek State. [1] This decision gives dental practitioners the tools to overcome patient anxiety, both child and adult, in a much more “recreational” and comfortable man- ner. However, as it happens with all drugs, there are indications, contra-indications and adverse – effects. Personally, being currently appointed Secretary for Professional Development of HAOMS, but also a clinical pharmacologist, pre-hospital emergency care doctor certified by the National Centre of Direct Help (E.K.A.B.) and notably former tutor of anesthe- sia drugs in the amphitheater classes of the Medi- cal School of Aristotle University of Thessaloniki, I would like to shed light in some facts with regard to dental use of nitrous oxide.
Nitrous oxide is on the Proposition 65 list because it can cause birth defects or other reproductive harm. Proposition 65, officially known as the Safe Drinking Water and Toxic Enforcement Act of 1986, was en- acted as a ballot initiative in November 1986. [4] The guidance dictates “Women exposed to nitrous ox- ide may experience reduced fertility. Exposure dur- ing pregnancy may cause loss of pregnancy, and birth defects or other reproductive harm.” Proposition 65 requires Californian businesses to determine if they must provide a warning about exposure to listed chemicals. Sexual phenomena that occurred with use of nitrous oxide and oxygen sedation have long been described. [5]. However this association with infertility has been mainly with non-dental / medical use. [6] Still the effect is known and existent.
Another effect of nitrous oxide is that it is currently considered a global warming gas. Nitrous oxide is emitted during agricultural, land use, and industrial activities; combustion of fossil fuels and solid waste; as well as during treatment of wastewater. Dental
/ Medical use as an inhaled sedative is a subset of industrial activity. As a potent greenhouse gas (CO2 equivalent between 265 to 298 over 100 years [7, 8]), nitrous oxide is responsible for approximately 6,4% of the global greenhouse effect [7, 8]. Nitrous oxide is the second most potent Global Warm- ing Gas after Hydrofluorocarbons (which are used as refrigerants, aerosol propellants, foam blowing agents, solvents, and fire retardants in products used by homes, businesses and industry). [7]. Overall the health care systems in Western countries contrib- ute 5% of greenhouse gas emissions, thus fuelling the climate crisis [8] . Inhaled anesthetics account for about 3% of the carbon footprint of the entire health sector. [9]. Of that the majority is owing to nitrous oxide, with other volatile anesthetics contributing the 0.5%. [8] A retrospective observational study at a German university hospital with approximately 1,250 beds, between 2016 and 2020, attempted to estimate the cost of Greenhouse effect caused by medical / dental nitrous oxide[8]. The main outcome parameters were the amount of N2O used, in to- tal and converted to CO2 equivalent, and the total cost at the emission taxation scale of €0, €25, €55 and
€698 per ton CO2 equivalent in Germany. The actual cost for N2O was €14,040 in 2019, while the corre- sponding theoretic socio-economic damage due to the climate crisis was almost €1.5 million! [8]. Con- sidering the environmental effects of N2O, the con- cept of “Sustainability in dental sedation and nitrous oxide waste mitigation” has been proposed in the UK and US. [4, 7, 10] This also includes guidance on more safely abducting N2O waste from the dental practices.[10] Properly conducted, recent systematic reviews with meta-analyses confirmed that current policy recommendations to limit medical / dental ni- trous oxide use do not affect patient safety. [9]
Still, as the CED resolution mandates [2] due to fear and / or behavior management problems, some chil- dren are unable to cooperate for dental treatment using local anesthesia and psychological support alone. Sedation is required for these patients in order for dentists to be able to deliver high quality, pain- free dental care.[11] Of note the CED resolution, even in the 2019 update, cites the dated 2007 British Guideline [12] This dental need was addressed via a NICE Guideline, that aimed to evaluate the efficacy and relative efficacy of conscious sedation agents and dosages for behavior management in pediatric dentistry and to provide guidance as to which sedative agents should be used. The later guideline was developed in a multi-step approach adapted from that outlined by the National Institute for Clinical Ex- cellence (NICE 2020 Developing NICE Guidelines). Evidence for this guideline was provided from a pre- existing Cochrane review (Ashley et al. Cochrane Database Syst Rev 12:CD003877, 2018) [13] sup- plemented by an updated search and data extraction up to May 2020 [11]. The guideline concluded that oral midazolam should be recommended for con- scious dental sedation. Midazolam delivered via oth- er methods or –if those not available- nitrous oxide/ oxygen sedation could be considered. [11] It is im- portant to note that evidence levels are very low and studies are required both for midazolam and nitrous oxide. Still, one realizes that the regulation of nitrous oxide in our country, Greece, has been settled in a time that the specific treatment has been surpassed by more efficient and safe regimes.
The most dreadful but also common accident that occurs with the application of nitrous oxide anes- thesia in the dental office is that the breathing rate slows down or there is airway close off. Soon, the lack of oxygen is witnessed in the patient’s body: in younger patients, their heart rate slows down in re- sponse to N2O given through mask technique in an inappropriate manner. [14] The constant treatment monitoring of the patient alerts the dentist to the fact that such potentially fatal problems have devel- oped, so that the patient gets emergency support- ive care until the anesthesia adverse effect wears off. If the adverse effect goes unnoticed, owing to avoidance of proper protocols or methods, coma or even death can result inside the dental office [14] In this Editorial, given the circumstance, I would like to request the dental community, the anesthesiolo- gists community, the medical and dental schools, to exhaustively discuss the risks, benefits and alterna- tives for N2O sedation in children and adults inside the dental offices. The proper constant monitoring during N2O sedation -by a dedicated practitioner?- of the patient monitoring is paramount [14]
REFERENCES
- Health GMo: Αριθμ. Γ1δ/Γ.Π. οικ. 29172 . “Όροι, προϋποθέσεις και προδιαγραφές για τη χορήγηση πρωτοξειδίου του αζώτου σε οδοντιατρεία και πολυοδοντιατρεία.”. Greek Goverment Gazzete 2024;B’ 2024:32369
- Various: CED Resolution on the use of Nitrous Oxide Inhalation Sedation – Update. In (ed. Council of European Dentists, 2019.
- Σκουφά Ε: Χορήγηση ειδικής αδείας για τη χρήση του πρωτοξειδίου του αζώτου στα οδοντιατρεία Ερώτηση της βουλεύτριας ΣΥΡΙΖΑ Ε. Σκούφα στον υπουργό Υγείας. In (ed., 2018.
- Assessment COoEHH: California Environmental Protection Agency (CalEPA) Office of Environmental Health Hazard Assess- ment (OEHHA)Nitrous Oxide Use in Dental Care on Nitrous Oxide Use in Dental Care. In Proposition 65 Warnings Office of Environmental Health Hazard Assessment, (ed., 2024.
- Jastak JT, Malamed SF: Nitrous oxide sedation and sexual phe- nomena. J Am Dent Assoc 1980;101:38
- van Amsterdam J, van den Brink W: Nitrous oxide-induced re- productive risks: Should recreational nitrous oxide users worry? J Psychopharmacol 2022;36:951
- Agency USEP: Overview of Greenhouse Gases. In Agency USEP (ed) (ed. Washington, D.C., 2024.
- Lehmann F, Schulz CM, Leicht D et al.: Persistent use of nitrous oxide for anaesthesia in European hospitals despite its harmful- ness to the climate - how emission taxation can achieve the cou- pling of cost-effectiveness and climate protection: observational study. BMC Health Serv Res 2023;23:1392
- Kampman JM, Plasmans KYQ, Hermanides J et al.: Influence of nitrous oxide added to general anaesthesia on postoperative mortality and morbidity: a systematic review and meta-analysis. Br J Anaesth 2024
- Various: Sustainability in dental sedation – nitrous oxide waste mitigation. Scottish Dental Clinical Effectiveness Programme (SD- CEP). SDCEP operates within NHS Education for Scotland 2024
- Ashley P, Anand P, Andersson K: Best clinical practice guidance for conscious sedation of children undergoing dental treatment: an EAPD policy document. Eur Arch Paediatr Dent 2021;22:989
- Craig DC, Wildsmith JA: Conscious sedation for dentistry: an update. Br Dent J 2007;203:629
- Ashley PF, Chaudhary M, Lourenço-Matharu L: Sedation of chil- dren undergoing dental treatment. Cochrane Database Syst Rev 2018;12:CD003877
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