ADA Guidelines for the
Administration of Nitrous Oxide and Oxygen Relative
Analgesia in Dentistry
Document version: 2021-10-15
Clinical context
Nitrous oxide mixed with oxygen is widely used for relative analgesia in dentistry. It has an impressive safety record and is
excellent for providing relative analgesia for apprehensive dental patients.
Dental use of nitrous oxide and oxygen relative analgesia are not without risk. When used alone, it is rarely capable of
producing unconsciousness, however, when combined with other inhalational, oral or intravenous agents, it can induce a
state of general anaesthesia.
Risks arise from:
• Potential unintentional loss of consciousness.
• The depression of protective reflexes.
• Individual variations in response to the drugs, particularly in children, the elderly and persons with pre-existing
medical disease.
• Differing standards of equipment and staffing.
These guidelines will:
• Ensure facilities are properly equipped and compliant.
• Ensure dentists and support staff are sufficient and suitably trained.
• Ensure protocols are safe.
General principles
The patient must be thoroughly assessed before the procedure. The dentist must:
• Take a complete medical history.
• Perform a thorough examination, with special attention given to assessing the presence of nasal obstruction.
• Assess tolerance to the nasal hood.
• Obtain valid consent for both the relative analgesia and the procedure.
The dentist administering relative analgesia requires sufficient knowledge and experience to be able to understand the
actions of the inhalation agent and detect and manage any complications arising from these actions.
Techniques intended to produce loss of consciousness must not be used unless an anaesthetist is present.
A written record of the percentage of nitrous oxide, flow rate and the duration of administration must be kept as a part of
the patient's records.
Staffing and training
Dentists using nitrous oxide and oxygen relative analgesia must be trained in its use in accordance with these guidelines.
Training for use of nitrous oxide and oxygen relative analgesia should be a dedicated course. Most undergraduate exposure
to nitrous oxide and oxygen techniques do not provide sufficient training or experience for this purpose.
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Monitoring, emergency response and discharge
A dental assistant must be present in the room throughout the procedure.
The patient’s level of consciousness should be monitored throughout the procedure, typically by assessing the patient’s
response to verbal commands or stimulation.
If at any time spontaneous respiration and/or protective reflexes are lost, or the patient does not respond to verbal
commands or stimulation, both the dentist and assistant must devote their entire attention to treating and monitoring the
patient until recovery.
The patient should not be discharged by the dentist until after an appropriate period of recovery and observation. The
ability to access and administer oxygen is essential in any area used for patient recovery.
Specialised equipment and facilities
The procedure must be performed in a location which is adequate in size and staffed and equipped to deal with an
emergency. This must include a supply of oxygen and suitable devices for the administration of oxygen to a spontaneously
breathing patient.
When nitrous oxide and oxygen is being used to provide relative analgesia, the following equipment requirements must be
satisfied.
• Installation and maintenance of any piped gas system must be according to appropriate standards (ANZCA PS54
Statement of Safety Requirements for Anaesthetic Machines and Workstations for Clinical Practice).
• Servicing of equipment and piped gases must occur on a regular basis and at least annually.
• There must be a minimum 30% oxygen flow whilst using nitrous oxide and oxygen relative analgesia on a patient.
The machine must also have the capacity to provide 100% oxygen.
• The machine must include an anti-hypoxic device which cuts off nitrous oxide flow in the event of an oxygen
supply failure and allows the patient to breathe room air.
• In dental nitrous oxide and oxygen systems, there must be a non-return valve to prevent re-breathing and a
reservoir bag. In the newer low profile hoods and tubing systems a reservoir bag is not necessary.
• There must be a fail-safe that cuts off the flow of nitrous oxide when the flow of oxygen is interrupted or cut off.
• The patient breathing circuit must provide low resistance to normal gas flows and be of lightweight construction.
• An appropriate method for the scavenging of expired gases must be used to reduce the risk of chronic exposure to
nitrous oxide.
• The risk of nitrous oxide abuse should be considered.
Use with other drugs
Nitrous oxide and oxygen relative analgesia is recognised as a very safe technique given that it has minimal effects on the
cardiovascular system. However, its use in combination with other drugs may potentiate their effects. Therefore, nitrous
oxide inhalation should not be used in combination with drugs where a patient may have other risk factors unless
administered by a dentist endorsed to perform conscious sedation, a medical practitioner or an anaesthetist.
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Related resources
ADA Policy Statement 6.33 – Relative Analgesia in Dentistry
ANZCA PS54 Statement of Safety Requirements for Anaesthetic Machines and Workstations for Clinical Practice).
ADA Guidelines for Conscious Sedation in Dentistry <<New link required when uploaded>>
ADA CPD webinars including dementia and paediatric focused content
Get information on specific questions via the ADA Digital Library
Australian Society of Dental Anaesthesiology (for training courses)
Contribute to the development of ADA guidance to the profession
This Guideline has been developed by ADA expert committees. Feedback from the profession is welcome and may
be submitted to
[email protected] for consideration in future guideline development.
