Increasing Use of Nitrous Oxide by Dental Hygienists

Background on Administration by Dental Hygienists

Most of those states allow this expanded duty to be performed after extensive coursework by the licensee and under direct supervision of the dentist. Prior to the actual pain control courses, dental hygiene students complete anatomy, physiology, pharmacology, biochemistry, and pathology, plus cardio-pulmonary resuscitation (CPR), and emergency medical management. Pain control itself is part of regular dental hygiene curriculum at schools accredited by the American Dental Association’s Commission on Dental Accreditation (CODA).

Sedation Discussion for Dental Practice

The sedation that is recommended for most dental procedures is at a minimal level of less than 50% (based on the new American Society of Anesthesiologist’s Guidelines). This level allows for the calming of a nervous and/or apprehensive individual, without inducing loss of consciousness. This level also reduces the risk of any complications occurring for the clinician. This recommendation is highlighted in the Handbook of Nitrous Oxide and Oxygen Sedation, co-written by a dental hygienist (Clark and Brunick, ed 2, Mosby, 2003). The titration technique for administration is also regarded as the current standard of care by these authors, as well as the use of a scavenging unit.

Safety is always a concern, but nitrous oxide sedation has an important feature that other pain-control procedures do not provide: the gas flow can be adjusted or even turned off at any time during the procedure if there is a possibility of a complication. Dr. Stanley Malamed, an expert in pain control, states that, “The (clinician) will talk with the patient throughout the procedure and the individual will be able to respond without any problem. This is a major advantage, and a safety feature, of inhalation sedation. If, at any time during the procedure, the patient feels that they are getting too much nitrous oxide or if they begin to feel uncomfortable, they should tell the (clinician) immediately and within seconds they can adjust the flow of gases, and the patient will feel more comfortable again.”

“The (clinician) will talk with the patient throughout the procedure and the individual will be able to respond without any problem. This is a major advantage, and a safety feature, of inhalation sedation.”

Dr. Malamed also states that sedation is highly effective in the management of mild to moderate levels of dental anxiety. It also is an excellent technique in persons who are extreme gaggers since it usually eliminates or minimizes gagging in most patients. Finally, nitrous oxide is highly recommended for apprehensive patients who have medical problems such as angina pectoris, persons who have had a heart attack, or persons with high blood pressure, asthma, or epilepsy.

Pain and Anxiety Control for Dental Hygienists

Pain and anxiety control are becoming necessary adjuncts to dental hygiene practice. Research has shown that the exposed roots of the teeth must be thoroughly debrided in order to halt periodontal disease. For many patients, this procedure is impossible to do without some type of pain and anxiety control. The patients can have dentin hypersensitivity and soft-tissue discomfort that prevent effective treatment. Appropriate use of pain-control measures encourages patients to seek necessary preventive care.  Permitting the dental hygienist to administer nitrous oxide, along with local anesthesia administration, allows for better and more effective service.

Legal Implications for Dental Hygienists

By virtue of licensure, dental hygienists are placed into a position of legal responsibility to provide safe, competent dental hygiene care including the administration of nitrous oxide when it has been added to their scope of practice. Dental hygienists do carry professional liability insurance and the administration of nitrous oxide does not increase a dental hygienist’s malpractice premium if it is considered within their scope of practice. There has never been a malpractice claim filed against a dental hygienist in the U. S. for administering nitrous oxide.


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Pihlstrom B.L., et al: Pain After Periodontal Scaling and Root Planing, JADA, June 1999, vol. 130, no. 6, pp. 801-807.
Malamed SF: Nitrous Oxide and Oxygen During Sedation Dentistry and Dental Care Procedures, shtml; Accessed on September 8, 2006.
Malamed SF, Clark MS: Nitrous oxide-oxygen: a new look at a very old technique. J Calif Dent Assoc. 2003 May;31(5):397-403 and at; Accessed on September 8. 2006.
Sisty-LePeau N, et al: Dental hygiene licensure specifications on pain control procedures. JDH 1990 May; 64(4):179-85.
Zacny J.P., et al: Preoperative Dental Anxiety and Mood Changes During Nitrous Oxide Inhalation, JADA, January 2002, 133:1, 82-88.

The author is a dental hygienist and oral biologist. As an Educational Consultant, she presents seminars throughout the U.S. on the subjects of oral biology and pain control. M.J. Fehrenbach’s textbooks on oral biology are published by Elsevier. Her Web site is