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 Table of Contents  
Year : 2020  |  Volume : 10  |  Issue : 1  |  Page : 3-5

Professional negligence during nitrous oxide sedation and child fatality in dental office and suggested precautions: A short communication on childcare and nitrous oxide sedation

1 Department of Forensic Dentistry, School of Dentistry, Federal University of Pelotas, Pelotas-RS, Brazil
2 Department of Restorative Dentistry, School of Dentistry, Federal University of Pelotas, Pelotas-RS, Brazil
3 Department of Forensic Dentistry, Karnavati School of Dentistry, Karnavati University, Gandhinagar, Gujarat, India

Date of Submission19-Nov-2019
Date of Acceptance09-Dec-2019
Date of Web Publication03-Jan-2020

Correspondence Address:
Mohammed Irfan
School of Dentistry, Federal University of Pelotas, Pelotas-RS 96020-010
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/AIHB.AIHB_118_19

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Paediatric death inside dental office by the effect of anaesthesia in dentistry is a very difficult case but not rare. In this article, we reviewed more than thirty studies with data focussing on death associated with dental anaesthesia using nitrous oxide (N2O). In children, most cases died at the age of 2–5 years. Hypoxia was the most common cause of death and cardiovascular, respiratory. Although rare death following general anaesthesia in dentistry, it is a critical side effect mostly seen in adult patients with compromised health conditions. Therefore, appropriate case selection in regard to patient's general health status as well as standard technical and equipment conditions is mandatory to reduce the risk of death during N2O dental anaesthesia in children. We have also given the list of guidelines and dietary care for children during N2O anaesthetic procedures inside the dental office.

Keywords: Accidents, dentistry, morbidity, mortality, nitrous oxide, sedation

How to cite this article:
Irfan M, Lund RG, Kumar S. Professional negligence during nitrous oxide sedation and child fatality in dental office and suggested precautions: A short communication on childcare and nitrous oxide sedation. Adv Hum Biol 2020;10:3-5

How to cite this URL:
Irfan M, Lund RG, Kumar S. Professional negligence during nitrous oxide sedation and child fatality in dental office and suggested precautions: A short communication on childcare and nitrous oxide sedation. Adv Hum Biol [serial online] 2020 [cited 2023 Feb 9];10:3-5. Available from: https://www.aihbonline.com/text.asp?2020/10/1/3/275084

  Introduction Top

For many anxious patients in the dental chair, the little mask-delivering nitrous oxide (N2O) and other anaesthetic gases have been salvation, which also saved dentist's operating time and reduced unwanted stressful situations in the dental clinical. However, for some patients, that life saviour mask has brought coma or death as especially the younger patients.[1],[2],[3] Some years back, these kind of tragic occurrences were rare, but as the number of dentists using mask anaesthesia increased the fatality rate followed along with, most of the time the dentist prefer mask anaesthesia to use in younger patients during paediatric dental procedures to save operating time and patient comfort during the procedure.

The most common accident that occurs with the application of mask anaesthesia in the dental offices is that the breathing rate slows down or there are air passages close off.[1],[2] Within no time, the lack of oxygen is witnessed in the patient's body. In younger patients, their heart rate slows down in response to N2O or any other anaesthetic drug given through mask technique in an inappropriate manner. However, the reactions that can be readily reversed with other medications and avoidance of adverse effects through appropriate pre-sedation evaluation, early identification of changes in respiratory and cardiovascular function.[1] The treatment monitoring of the patient alerts the dentist to the fact that such potentially fatal problems have developed, he/she can give the patient help until the anaesthesia wears off. If he/she is unaware of the adverse effect avoidance protocols or methods, coma or death can result inside the dental office.[4],[5],[6]

Here, in this article, we are going to talk about the types of professional negligence inside private dental office while administering mask anaesthesia in younger patients and their management and also to see the patient party/family management (mother, father and other family members who are accompanying patient at the time of accident).

  Discussion Top

Children are not simply 'small adults' but have many unique and constantly changing anatomic, physiologic, pharmacologic and psychological differences. These differences make the child more susceptible to airway obstruction and bradycardia.[4],[5] The delivery of any kind, method or technique of anaesthesia in children inside the private dental office is not without risk. It is a complex and uncertain environment, which is ever-changing. The unpredictable and imperfect human performance, especially in times of urgency, intensity and time pressure while treating younger patients, contributes most of the time to cause such accidents.[6],[7] Risk and human error cannot be eliminated but can be reduced and managed by eliminating the culture of blame and punishment and replacing it with a culture of technical understanding, vigilance and co-operation to reduce such situations occurring in the future.

Till date, there is no clinical evidence of permanent developmental effects on paediatric patients due to the administration of any kind of anaesthesia. Some clinical trials assessing the effects of anaesthesia on the paediatric development are ongoing and definitive data will likely require numerous studies over many years. At this time, there is not enough information to draw any firm conclusions between anaesthetic administration and subsequent disabilities.

Common negligence in private dental offices, which are prime factors in anaesthetic administration accidents

It is very common and tempting to blame a complication on a single professional error and say the practitioner gave the wrong anaesthesia and the child died. Most complications are unfortunate alignment of series of errors, which results in accidents. These errors can arise from multiple anaesthesia complications in the dental office sources, which include are the following:

Latent errors

  • Heavy patient booking
  • Failure to update medical histories
  • Failure to check equipment
  • Lack of training
  • Poor communication.

Psychological precursors

  • Fear of lawsuit
  • Embarrassment.

System defects

  • Untrained staff in emergency protocols
  • Failure to use checklists
  • Failure to update medical emergency drugs.

Triggering factors

  • Loss of airway
  • Unintended drug overdose
  • Hypotension.

Outright unsafe acts

  • Lack of knowledge
  • Errors of the moment
  • Ignoring a monitor
  • Failure to address a problem
  • Wrong drug given.

Techniques of safer mask anaesthetic administration in younger patients

Pre-operative evaluation

Cardiovascular, pulmonary and upper airway complications are three major causes of morbidity and mortality in the dental office.[8],[9],[10] The American Society of Anaesthesiologists (ASA) recommends the following sequence for pre-operative evaluation:

  • Patient interview and review of the medical/surgical/anaesthetic history
  • Physical examination
  • Assigning of an ASA physical status score
  • Formulation and discussion of the anaesthetic plan.

The first two steps will guide decisions regarding refusal of anaesthesia, limit setting on the depth of anaesthesia and location of care, this process is called risk assessment. The ASA physical status is assigned to a patient to stratify the risk of the anaesthesia and planned surgery.

Pre-operative fasting and food control

The concept of pre-operative fasting before a child patient receiving sedation or anaesthesia for elective procedures, including dentistry, has been around since the 1850s.

Breast milk and infant formula

Guidelines state that breast milk is allowed up to 4 h pre-operatively, whereas infant formula must be held at least 6 h pre-operatively.

Solid foods and nonhuman milk

While solid foods are permitted up to 6 h before surgery, the ASA guidelines discuss limiting the solids to a light meal, consisting of dry toast and clear liquids. Non-human milk, when consumed and mixed with gastric fluid, congeals into a semisolid mass and should be considered a solid rather than a liquid.

Contraindications for nitrous oxide mask anaesthesia in children

  • Vitamin B12 deficiency
  • COPD or pulmonary bullae
  • Upper respiratory infections with nasal congestion
  • Recent middle ear infections
  • Eye surgery within the past 3 months
  • Bleomycin chemotherapy within the past 1 year
  • Children with Type III homocystinuria.

By now, it should be obvious that cockpit resource management training is not just for the doctor and should even include more than just the health-care practitioners. All people in the environment can benefit from such training, as they all have a role to play.

Other situations in which N2O administration could be problematic include middle ear infections with blocked Eustachian tubes, which can lead to tympanic membrane injury or pain in obstructed sinuses.[11],[12],[13] N2O administration may cause post-operative nausea and vomiting in some young patients. In such patients, including propofol and dexamethasone in the sedation protocol can help prevent this complication.[13]

  Conclusion Top

Data from this systematic review can help in shared decision-making to discuss the risks, benefits and alternatives for N2O sedation in children inside the dental office. The routine monitoring during N2O sedation equipment and patient monitoring is recommended which allows the detection of hypoventilation and apnoea earlier than pulse oximetry and/or clinical assessment alone The authors of the article have also created follow-up steps for N2O sedation in children, which can be followed in paediatric or general dental offices where N2O sedation technique is used in children.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Tobias JD, Leder M. Procedural sedation: A review of sedative agents, monitoring, and management of complications. Saudi J Anaesth 2011;5:395-410.  Back to cited text no. 1
  [Full text]  
Wilson S, Gosnell ES. Survey of American academy of pediatric dentistry on nitrous oxide and sedation: 20 years later. Pediatr Dent 2016;38:385-92.  Back to cited text no. 2
Huang C, Johnson N. Nitrous oxide, from the operating room to the emergency department. Curr Emerg Hosp Med Rep 2016;4:11-8.  Back to cited text no. 3
Smith MM, Barbara DW, Mauermann WJ, Viozzi CF, Dearani JA, Grim KJ. Morbidity and mortality associated with dental extraction before cardiac operation. Ann Thorac Surg 2014;97:838-44.  Back to cited text no. 4
D'Eramo EM, Bontempi WJ, Howard JB. Anesthesia morbidity and mortality experience among Massachusetts oral and maxillofacial surgeons. J Oral Maxillofac Surg 2008;66:2421-33.  Back to cited text no. 5
Qiam F, Khan M, Mehbood B, Un Din Q. Assessing the mortality rate of patients in a maxillofacial surgical unit. JKCD 2012;3:2-6.  Back to cited text no. 6
Flick WG, Katsnelson A, Alstrom H. Illinois dental anesthesia and sedation survey for 2006. Anesth Prog 2007;54:52-8.  Back to cited text no. 7
Gonzalez LP, Pignaton W, Kusano PS, Módolo NS, Braz JR, Braz LG. Anesthesia-related mortality in pediatric patients: A systematic review. Clinics (Sao Paulo) 2012;67:381-7.  Back to cited text no. 8
Li G, Warner M, Lang BH, Huang L, Sun LS. Epidemiology of anesthesia-related mortality in the United States, 1999-2005. Anesthesiology 2009;110:759-65.  Back to cited text no. 9
Patel R, Lenczyk M, Hannallah RS, McGill WA. Age and the onset of desaturation in apnoeic children. Can J Anaesth 1994;41:771-4.  Back to cited text no. 10
Clark MS, Brunkick AL. Nitrous Oxide and Oxygen Sedation. 3rd ed. St Louis, Mo: Mosby; 2008. p. 94.  Back to cited text no. 11
Fish BM, Banerjee AR, Jennings CR, Frain I, Narula AA. Effect of anaesthetic agents on tympanometry and middle-ear effusions. J Laryngol Otol 2000;114:336-8.  Back to cited text no. 12
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;10:345-6.  Back to cited text no. 13


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