Nitrous Oxide/Oxygen Inhalation Sedation Consent Form

Dr. Mason and the BeanTeam take our patient’s and parent’s health very serious. For this reason we have a policy not allowing pregnant or soon-to-be mothers from being present in the treatment room during an operative procedure when Nitrous Oxide is being used. We understand this may be upsetting, but we have your’s and your beautiful little baby’s safety in mind.
  • Nitrous oxide/oxygen inhalation is a mild form of conscious sedation used to calm an anxious patient. If inhaled effectively, it can raise the pain threshold. This will make the administration of local anesthesia and dental treatment more comfortable for your child. Your child will be closely observed while nitrous oxide is administered, and that observation will continue until your child has fully recovered from the nitrous oxide’s effects.

    *Individuals who may be pregnant will not be allowed in the treatment room during any procedure that nitrous oxide is used. This is not a negotiable policy as we will not put your unborn baby at risk under any circumstance. More information can be found here.

    Nitrous oxide/oxygen inhalation, used as an analgesic and anxiolytic, has an excellent safety record.

    Potential benefits of nitrous oxide sedation:
    1. Reduce or eliminate anxiety
    2. Reduce untoward movement, especially movement in reaction to dental treatment.
    3. Enhance communication and patient cooperation.
    4. Raise the pain-reaction threshold.
    5. Increase tolerance for longer appointments.
    6. Aid in treatment of the mentally/physically disabled or medically compromised patient.
    7. Reduce the gag reflex.
    Risks include but are not limited to the following:
    1. Nausea and vomiting are the most common adverse effects, occurring in 0.5% of patients.
    2. Headache and/or slight disorientation may occur following treatment if 100% oxygen is not administered for three to five minutes.
    3. Behavior in some autistic patients may be negatively affected.
    1. Nasal congestion, difficulty breathing through the nose properly, or upper respiratory tract infection may prevent nitrous oxide from being effective. Please disclose any recent illnesses to the nearest BeanTeam member.
    2. Autism spectrum
    3. Pregnancy
    4. MTHFR diagnosis in patient or immediate family
    5. Risk factors for B12/folate deficiency
    6. Malabsorption pernicious anemia
    7. Atrophic gastritis
    8. Gastrectomy
    9. Whipple’s disease
    10. Ileal resection
    11. Crohn’s disease
    12. Prolonged antacid use
    13. Intestinal bacterial overgrowth
    14. Intestinal parasites
    I understand that nitrous oxide sedation may not be covered by my insurance company. It is my responsibility to verify coverage prior to my child’s appointment. If this procedure is not covered, I will accept responsibility for the fee.

    I further understand that using nitrous oxide sedation does not guarantee that dental treatment can be provided successfully for my child. I understand that I am responsible for the nitrous oxide fee, even if dental treatment cannot be completed due to lack of cooperation.