The Compliance Divas Podcast
Our podcast covers current topics such as infection prevention and control, OSHA and HIPAA compliance for dentistry. We discuss the latest regulatory information, answer frequently asked questions and give suggestions for dental practices to make compliance easy and sustainable. The Compliance Divas are a trusted source for consistent, accurate information based upon current guidelines, standards, science, and recommendations.
The Compliance Divas Podcast
#225 In The News Again: Nitrous Oxide is No "Laughing" Matter!
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In this episode, the Divas interview Dr. Anthony Carroccia who lectures nationally on nitrous oxide. He'll provide insight on FDA's new recommendation for consumers.
- FDA Information:
- Dr. Anthony Carroccia:
https://www.stbethlehemdentalcare.com/lectures-courses-dr-anthony-carroccia/
Welcome. I'm Leslie Cannum. I'm Mary Gavoni.
SPEAKER_02I'm Linda Harvey. I'm Olivia Wan, and together we are the Compliance Divas. Welcome to the Compliance Divas Podcast. My name is Olivia Juan, and I'll be your moderator today. In today's episode, our topic is in the news again, nitrous oxide, no joke. And we are interviewing the well-known Dr. Tony Karosha. Dr. Tony is known for speaking on the topic and providing training, and he's a source of much information on all things nitrous. So, Dr. Tony, before we even get started with some of our questions, why don't you introduce yourself to our listeners?
SPEAKER_00Hello, I'm Dr. Tony Karosha. And along the ways of my life, I've sort of become a subject matter expert or key opinion leader on nitrous oxide. And it all kind of started for me back when in the state of Tennessee I was applying to uh teach a certificate course for a dental assistance. And it was kind of put on me because I was the one person as a general dentist at the time who had a sedation permit. And at the time I was in charge of leading the 8th District Dental Society. And they said, Hey, uh, since this is your idea and you're the one with the sedation permit, why don't you, you know, do it? So that expanded into working with uh the hygienist for their certificate course, which then later on led to speaking at the ADA a couple of times and the Academy of General Dentistry a couple of times, and giving a few lectures at the American Dental Hygiene Association and uh a couple of state lectures here and there. So um, but really I just uh I kind of a history nerd and uh kind of plays really well into what it is that I do. And with nitrous oxide being uh infinitely tied to dentistry, they just kind of went together seamlessly.
SPEAKER_02So our listeners can recognize how knowledgeable you are. So once again, Dr. Tony, it's a real honor for you to take time out of your busy, busy dental practice and speak with us about nitrous. And to kick us off, one of the things that our diva Mary had wanted to talk with you about is you know, as a trainer, a lecturer, and a dentist actively working with patients, what suggestions do you have so that people can be confident or dental personnel be confident when talking to patients about nitrous?
SPEAKER_00Certainly. Um the beautiful thing about nitrous oxide is it plays very nicely with a lot of other drugs. Uh, so we're really not going to have to, you know, take people off of medications and things like that, like we might need for other events. Um, the other thing is it has a very, very wide safety index and that allows us to use it and not have to worry about it. But probably the most important thing is that people have been trained on monitoring the patients as well as certain uh persons in the office uh and its administration. Because we're there monitoring it, we're keeping them safe as opposed to uh some unfortunate souls that have been lost without it being monitored at home or wherever it was that they were abusing this particular drug.
SPEAKER_02So it's safe to use. And you know, you know my background. I had been a dental assistant and dental office manager, and Leslie, uh, she was uh a dental assistant as well years ago. She worked for her father for many years, so both of us have chair side experience in working with nitrous. But I know Leslie wants to pick your brain too. Go ahead, Leslie.
SPEAKER_01Well, I'd like to know a little bit about the something I've heard that there's some new guidance from FDA, the Food and Drug Administration surrounding nitrous oxide. Can you tell us what's what with that?
SPEAKER_00Yes. In the spring of this year, I think it was uh March 14th. It wasn't quite the IDs of March, but uh the FDA had put out a consumer uh advisory about people who might be abusing nitrous oxide to kind of watch out for this particular product. And they went through and they listed several different products, things like baking bad and galaxy gas, exotic whip, and things like that, and whip it's and they talked about the symptoms of the adverse health risks, B12 deficiency, uh, psychiatric disturbances, paralysis, tingling, and things like that. And then they had talked, uh they had literally named stores that could be affected, like Amazon, eBay, Walmart, and even smoke in vape shops and gas stations. And then the final part of all that is the recommendations for consumers, and the recommendations were, as one would figure, a lot of common sense, um, where they are advising people not to misuse or inhale nitrous oxide products. Um, but that's on a recreational level, and they're not talking about on a professional level under the supervision of a dentist, assistant, hygienist who have been uh trained and qualified to monitor and administer such a drug.
SPEAKER_01Well, that might get folks thinking that it's possibly not helpful or helpful to have nitrous oxide during dental treatment. So, um, how can we minimize that message of the negative message and the impact of nitrous oxide?
SPEAKER_00Well, there's lots of different ways. One way is that I believe uh FDA had actually come back in the summer back in June and was talking and kind of updated a little bit about that. But at the same time, they need to recognize that in dentistry we have all these different fail safes that prevent us from giving them 100% nitrous oxide, like they would be getting if they were abusing these drugs recreationally. In our offices, we have um fail safes that have been put in since the 60s. And these fail safes talk about minimum oxygen flow and a minimum percentage of oxygen. For the minimum percentage of oxygen, we have to be giving at least 30% oxygen. Now, it's important to note that our room air, our ambient air, has about 21% oxygen. So we're getting more oxygen than we would just from breathing whatever air we're breathing in our homes, our offices, our cars, outside, wherever it is that we're respiring.
SPEAKER_01And in your certificate training, you clearly teach that. Can you tell me about any of the other safety uh protocols surrounding nitrous oxide?
SPEAKER_00Oh, certainly. There's lots of different uh safety mechanisms. Uh, some of the safety mechanisms are uh more mechanical where they prevent the crossing of the lines either by a pin index system on a portable unit or a diameter index safety system. The cylinders themselves have to be labeled. In central systems, there is a use of a manifold. Uh, some offices might use capnography to make sure that the patient is exhaling carbon dioxide appropriately in their sedations. So there's lots of different things that are often available to us.
SPEAKER_02Good information. You know, I I've wondered, and maybe this is a dumb question, Dr. Tony, but I've wondered why in the medical world they don't use it. Like you go in for a procedure and they say, Oh, it's going to be uncomfortable. When they say that, I know it's going to hurt. I've often wondered why is nitrous not available in other settings.
SPEAKER_00Well, actually, Olivia, it is. Uh, believe it or not, while nitrous oxide might be forever linked to dentistry, uh, dentistry only uses about 10% of the nitrous oxide that's out there. The majority of users are these uh same-day surgery centers and things like that, and ambulatory post-care units, stuff like that, where they might introduce nitrous oxide and then a more halogenated gas later on before starting uh a parental approach towards a sedation.
SPEAKER_02Hmm. Interesting. I was not aware of that. So, what about Dr. Tony in in looking at the evolution and history of using nitrous in dentistry and any new laws or especially any relevant court cases that our readers might be our listeners might be interested in?
SPEAKER_00Oh my gosh, I am so shocked that you as a lawyer would ask me. I'm I'm honored and just kind of dumbfounded, but that's okay. But yes, there's all sorts of things that are always happening there. Um, one of the things that's happened probably that's been of interest is the state of Louisiana. In Louisiana, because there was a point in time where all these whippets or cartridges of nitrous oxide were just kind of lining the streets there in New Orleans and at Tulane, that people thought it was just part of the culture. And then later on realizing that, hey, this is happening in lots of other places. But after some bad experiences and even some deaths, some morbidity and mortality, if you will, uh things would lead and change to other things. Um, in that city, in New Orleans, in the state of uh Louisiana, they were the first state to have a law where uh it is illegal to you know vend or possess nitrous oxide recreationally. So this isn't something that applies to a lot of other places, but they have general retail as a felony. And uh the governor Jeff Landry had signed that in May of 2024 and it became a law officially it started being punishable in August of 2024. A couple of incidents has happened there. One was a 19-year-old young lady, Jenna Campbell, who became paralyzed from abusing this drug. And then also um uh hygienist Ashley Broha had lost her fiance uh to abuse of this drug in January of 2024. So those two events kind of back to back kind of had led uh Representative Joe Stagney to introduce this uh bit of legislation and it went through the appropriate channels and became a law.
SPEAKER_02Uh sorry to hear how they make these laws because of injuries and death, but so so needed. Uh you mentioned earlier when we were talking about your background of doing training and speaking. If any of our listeners want to reach out to you to see if you are available for a speaking engagement, what would be the best way for them to reach you?
SPEAKER_00Uh they can send me an email at drtonikarosha at yahoo.com, dr t-o-n-y, c A-r-o-c-ci-a at yahoo.com. Uh they could always call or text myself, although I never keep my cell on me during clinical hours. But that's 931-980-2072. And in addition to those lectures, I've written uh some articles, coined the term nitronomics, and uh written a couple of textbook chapters along with my uh good friend and colleague Ann Brunick, who is more famous than I because she has co-authored the handbook of nitrous oxide and oxygen sedation.
SPEAKER_02Wow, that's interesting. Now, your classes and trainings that you provide, are those only exclusively available for Tennessee people, or how far is your reach?
SPEAKER_00Um, my reach will I can kind of go to anywhere that would like to have me because I have my own AGD PACE provider number. Uh, but at the same time, I've also partnered in the past with Docs Education. Uh, I think it was last year or this month, uh, they sent me to Florida to uh lecture to a study club there and kind of begin to get people ready to uh have their changes there in Florida where the hygienists can uh monitor but how the laws are written, it almost looks like that they can actually administer as well.
SPEAKER_02Interesting.
SPEAKER_00And another interesting nitrous oxide law that's out there on the books is in the state of California. They have that proposition 65 warning where they have to post a sign somewhere stating that, quote, this area contains nitrous oxide, a chemical known to the state of California to cause cancer, birth defects, or other reproductive harm. So we got some states doing some things like that. And there's even some states where uh people are required to have permits to uh use nitrous oxide as well, just kind of on the uh level of, you know, you know, either in the dental office or the medical office.
SPEAKER_02Interesting. Well, I know that I've worked with you for many, many years, Dr. Tony, and uh admired your dedication to the profession and not only your dedication, but your leadership that you've always been willing to spend your time, your valuable, limited free time in working with your dental colleagues. And and we appreciate that. Leslie, you have something else you'd like to ask?
SPEAKER_01Uh yes, I wanted to ask uh specifically about uh monitors for nitrous oxide and your recommendation that dental team members wear the monitors when they're administering nitrous.
SPEAKER_00That's an interesting point. Uh here's the thing about the monitors they're nice, they work, and they do lots of interesting things. However, the specific gravity of nitrous oxide is heavier than that of room air, and it's going to drag it down more towards the floor. If you've ever looked at infrared spectrophotometry of people respiring nitrous oxide, you'll actually see it kind of fall to the floor. So the monitor would be best, I guess, worn more towards the pant lake, but at the same time, we're not down in that zone. Um, the other issue with those monitors is they can be expensive. So there's probably a vast majority, I would say an overwhelmingly vast majority of dental offices who don't use them. And another good feature to that is that uh all of the offices in dentistry have to have a um the vacuum system so that it kind of uh will scavenge the waste anesthetic gas and kind of go into those lines. So it's kind of protecting us more from being exposed to what we might be occupationally breathing from the patient just kind of breathing in our face and in general. Other things that can be done for monitoring is uh some of the newer uh products and flow meters that are out there will do a little bit of that, uh like the one from Air Techniques will kind of guide and give you some of the printouts and readouts as to how much you're using. But probably the newest and most innovative one is uh actually from Porter. It's their uh Midas flow meter, and you can get readouts as to how much you've used and how much more is left in the tanks. And this way you can kind of keep an eye on how much is being uh used, how much is available, and you can get readouts that you can add into the chart as to exactly how much you know medical gases were used. So that's kind of a new thing, and I think that's probably going to be a game changer where the other companies are gonna kind of step up their levels to have products to match it.
SPEAKER_01And another part of my question has to do with how you might detect leaks, is whether that's something do you smell the nitrous oxide or do you have to see? What do you teach your students on this?
SPEAKER_00Okay. Uh leaks, you can always do the basic things, just look. And you know, you might see dry rot around your reservoir bag, and then that's leaking. That's happened in my office where one of my hygienists said, Hey, the bag's not filling. And I look at the bag and there's a little, you know, dry rod, and it's got a little hole to it. But some of the other places that we might see leaks is in the tubes, especially if we've stepped on or dropped instruments on them that could have punctured the lines. But also on uh the equipment itself, like the failsafe, there's a little uh flow meter there where you, if it's made out of plastic, it can break, and then you can have a little leak there as well. Uh, things that people can do is they can use um a little soapy water and see if any bubbles develop, but they could also get a hold of um a little micro mammometer there. And a lot of times hospitals will have these things for their JCO inspections and they will rent those things out very cheaply. And you could monitor for those sorts of things, as well as carbon monoxide, radon. I mean, it's kind of like a little Geiger counter where you just watch the needle jump and it tells you whether or not there's any issues there. If you're concerned more about maybe uh an office member abusing it, you could always have some uh blood testing as well. Look at their uh B12 counts and myelinic acids and things like that.
SPEAKER_01Wow, that's really great information. Thank you.
SPEAKER_00Yes, ma'am.
SPEAKER_02Well, I believe that our listeners are going to truly enjoy all the information that you've provided. And hopefully those that are in need of education will reach out to you. And I could just tell by listening to you, Dr. Tony, that you are a well-seasoned trainer and speaker, in addition to all your hats that you wear uh in dentistry and and your own busy, busy private practice. So thank you for being a guest.
SPEAKER_00My pleasure.
SPEAKER_02So, as the compliance divas, we bring clarity and simplicity to compliance by navigating regulatory compliance to keep you on course. Please submit your questions to support at the compliance divas.com. So thanks again for tuning in, and we'll see you next time.