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Nitrous Oxide Protocol

Subject: III. Clinical – I. Patient Care

Department: AGD, ASE, Oral Surgery, Special Patient and UMOMSA Clinics

Policy Number: CL008

Origination Date: 03/14/2008

Effective Date: April 3, 2008

Reviewed and/or Revised: 09/01/2017, 6/4/16, 5/25/17, 9/24/19, 05/16/2022, 03/13/2024, 07/31/2025

Policy Statement: The Department of Environment Health and Safety (EHS) will conduct exposure monitoring of clinical operations that utilize nitrous oxide in the Dental School. Periodic training will be conducted in each department where Nitrous oxide is administered including staff, residents and students. Equipment maintenance will be performed on a periodic basis and recorded by EHS. Reports will be provided by EHS to Dr. Windsor, Director of Clinical Operations, with a copy to the Director of Medical Credentialing and Quality Assurance.   

Purpose: The purpose of the EHS & UMSOD’s monitoring will be to:

  1. ensure that employee exposures are below National Institute for Occupational Safety and Health (NIOSH) and American Conference of Government Industrial Hygienists (ACGIH) limits;
  2. to detect leaks in the nitrous oxide delivery systems and
  3. to assess the effectiveness of work practices.

Compliance:

Nitrous Oxide Exposure Limits:

  • Permissible Exposure Limit (PEL) is not currently regulated by OSHA.
  • American Conference of Government Industrial Hygienists (ACGIH) Threshold Limit Value (TLV): 50 ppm 8-hr time weighted average (TWA).
  • National Institute for Occupational Safety and Health (NIOSH) Recommended Exposure Limit (REL): 25 ppm-8 hr TWA.

Procedure:

  1. The sampling will be conducted using a combination of a MIRAN SapphIRE Infrared Analyzer and Vapor-Trak Nitrous Oxide Badges.
  2. The infrared analyzer will be used to obtain real time data on the effectiveness of work practices and to detect leaks in the delivery systems.
  3. The nitrous oxide badges will be used to determine full day person exposure levels.
  4. Areas to be tested include:
    1. 1st Floor Oral Surgery Clinic and UMOMSA Practice
    2. 2nd Floor AGD Clinic
    3. 3rd Floor ASE Pediatric Clinic
  5. The sampling will be conducted under the direction of a Certified Industrial Hygienist (CIH) from the University of Maryland, Baltimore Environmental Health Safety Office.
  6. After initial testing, if results are within compliance standards, testing to be performed bi-annually.

Training:

  1. Training will be conducted on a periodic basis to refresh current staff, residents and students and to train newly arrived staff, residents or students.
  2. ASE Departments – coordinate new training with arrival of new class of residents.
  3. Oral Surgery – coordinate training as new residents come through the program.
  4. Training sessions will be logged by each Department.
  5. Training will include:
  • Equipment set-up
  • Selection of properly fitted mask
  • Use of monitoring badges
  • Maintenance of equipment

Maintenance:

  1. Periodic maintenance is essential.
  2. Hoses and masks will be inspected by each Department’s designated person for wear, holes and loss of elasticity.
  3. Equipment will be inspected by each Department’s designated person to be certain that connections are secure; gaskets are functional.