Concerned Team Member Triggers OSHA Nitrous Oxide Inspection

And the general duty clause basically says you need to provide a safe and healthy working environment. OSHA will tell you, we can't write a specific regulation for every little thing we do, but we do expect you to follow national guidelines, including of the EPA and NIOSH. That's how they were able to cite them here, Phil. Welcome to Austin, Texas, and welcome to the Phil Klein Dental Podcast. Today, we're going to dive into a real-world story that every dental practice owner needs to hear. A pregnant team member concerned about the safety of an older nitrous oxide delivery system asked her dentist how the office was testing for leaks. When she didn't get an answer, she took her concern to OSHA, triggering an unannounced inspection. Our guest is Dr. Karson Carpenter. He's a dentist, CEO, and president of Compliance Training Partners. He's a nationally recognized expert on infection control, HIPAA, and other dental regulations. Today, he's going to walk us through exactly how this inspection unfolded. You'll hear what the inspector focused on, the records he wanted to see, and most importantly, how you can protect your practice from this kind of scenario. We'll also unpack the hidden risks of nitrous oxide in the office air. from outdated delivery units to the role your vacuum and HVAC systems may play in recirculating gas. By the end of this episode, you'll know when to test, how to test, and how to keep your patients and teams safe from nitrous oxide floating around the office, but also how to avoid the serious consequences of failing to monitor and maintain your nitrous systems. So if you're using nitrous in your practice, buckle up. We've got quite a discussion ahead. Before we bring in our guest, I do want to say that if you're enjoying these episodes and want to support the show, please follow us on Apple Podcasts or Spotify. You'll be the first to know about our new releases and our entire production team will really appreciate it. Dr. Carpenter, welcome to the show. Bill, it's great to be back. Thanks for having me. So this is going to be an interesting episode because we've never really talked about nitrous oxide as something that would be specifically targeted by an inspector to ensure that it's up to speed as far as how much... nitrous is floating around in the environment in the office. And this is something that was brought to light because an employee of a dental office, apparently a pregnant employee, was wondering how safe the operatory was since nitrous was being used on a regular basis and the employee was pregnant. So she inquired and take it from there. How did this progress? You know, Phil, what's really interesting about this is, you know, you and I are always looking for these unique situations, teaching moments, if you will, for our colleagues. And this one came along since our last podcast. Now, regarding nitrous oxide, we have taught nitrous oxide safety in our OSHA course for almost 30 years. We've always advocated that you should test. although not required. We've always talked about what the permissible exposure limits were. But we also are quite honest with people, this doesn't seem to be something that OSHA keys in on. They haven't in the past. And there's not a specific regulation that says you must test. But based on what I've seen with this inspection, these things are changing. And I'd like to give my colleagues some advice how to stay out of trouble like this office is now in. Yeah, so tell us how it played out. The employee was looking for information about how many parts per million of nitrous oxide, I guess, was floating around the operatory. And I know typically, based on discussions with you, we're talking about 50 parts per million of nitrous oxide. Anything more than that is considered violating OSHA guidelines, is it not? You're correct. And you know, it's too bad about a case like this. Again, from my viewpoint, it's a great teaching moment. why safety is important. This never should have happened. The doctor involved even admits it never should have happened. But here's how it came down. Imagine an employee, she's pregnant, young, says, you know, I've heard there's some concerns about nitrous oxide. And this is in the doctor's own words, by the way. There's some concerns about nitrous oxide. He said, you know, it's not really a concern. You know, we use a scavenger here. You don't even have to worry about it. She said, well, do you ever test? He said, no, we don't even need to. Well, She didn't like that attitude. If he had had the right answers, this never would have happened. Instead, she saw she wasn't getting anywhere. She called her states OSHA. They came out. They came out actually unannounced. And they asked for their testing records. They said, where are you testing records for nitrous oxide? They didn't have any. And from there, this whole thing went south. So OSHA comes out to do an inspection. What guidelines do they follow? And what does NIOSH have to do with all of this? OSHA goes off of NIOSH guidelines, National Institute of Occupational Safety and Health, which is a division of CDC. And here is what NIOSH has said for years. They have said that your permissible exposure limit that's defined as testing over an eight-hour period needs to be below 50 parts per million. And your short-term exposure limit that's defined as a 15 minute exposure can never exceed 75 parts per million so what happened was the ocean inspector came out said there's a concern about nitrous oxide can i see your testing they had no testing to provide they then went right to a particular operatory they seem to be keyed into the fact that in there was some older equipment an older manifold an old mask that really, I guess, didn't fit that well. And Phil, when they tested, they found that the short-term limits were almost a thousand, a thousand parts per million, rather than the required under 75. And the eight-hour permissible exposure limit was almost 500, 10 times the required 50 parts per million. We'll be right back to our guest in a second, but first, when it comes to chairside milling and same-day crowns and bridges, speed usually means compromise, but not anymore. Katana 1 Speed by Kirari is a major breakthrough in Zirconia CAD CAM blocks. It allows sintering in as little as nine minutes without sacrificing strength, fit, or aesthetics. That means faster turnaround, true same-day possibilities, and less downtime in your lab or practice. With the unparalleled flexural strength and aesthetics Katana is known for, you get predictable clinical outcomes and the ultimate in patient satisfaction. The bottom line is efficiency matters. And stunning beauty is non-negotiable. And Katana One Speed delivers both. Join the growing number of dental offices and labs embracing faster workflows without compromise. Learn more about Katana One Speed at curaredental.com. How do they do an eight-hour test? It's a great question because, of course, it's really easy, right, to do a 15-minute. You put the badge on your person. You're working for 15 minutes. You seal it up. You send it back to the lab. In the case of an eight hour, you can extrapolate. In other words, you expose that bag. So let's just say you and I only work six hours and 15 minutes that day. We seal it up at the end of that day. We send it in. They extrapolate to what that would be over an eight hour period. So when they did these tests during that inspection, did they go to the dental practice owner, which I assume is a dentist? and talk to that person they did they did the first thing they do is they come in they present their credentials they say why they're there they say they'd like to What the doctor didn't realize at first, he thought it was just a general OSHA inspection. And surprisingly, they were laser focused. They didn't key in on things like safety data sheets. Do you have them? Training in hazard communication, spill kits, eyewashes, the things that most people look at, they laser focused on nitrous oxide and they wanted to go into each operatory and test. Was the employee that reported it to OSHA still working in the office at the time of the inspection? Yes, yes. And of course, everyone knows who it was because there's only one employee who was pregnant. But of course, you can't treat them any different. It's their right. It's every employee's right to contact OSHA anonymously at any time. So the dental practice owner assumed that it wasn't just a spontaneous surprise inspection. He or she knew right away that it was an employee that reported it. You know, they knew very well where it came from. And to this dentist credit, when I talk with them, they don't... harbor any anger. They don't harbor any resentment. What their words were, you know, I should have taken it more seriously. I should have addressed her concerns. I should have tested. It's not that expensive to do. Even if I had said, no, we don't test, but I'd be glad to do it. You know, but he said, I didn't do any of those things. And I created this nightmare for myself. So let's keep going with this particular case. Then we'll get into why perhaps these leaks were taking place where the operatory was so much higher than the maximum allowable amount of nitrous, which we talked about was 50 parts per million. You're telling me it was a thousand parts per million over an eight hour period and 500,000 parts per million in the 15 minute period. So we've got a leak somewhere or something's not working properly. But getting back to the actual case, where does that leave the dental practice now? What's the next step? based on that OSHA investigation? Well, as a result of this, they've received a violation. And they've received orders to immediately correct this problem. There's faulty equipment that needs to be replaced. There was some leaks. There was an improperly vented scavenger system. There were some old masks. I'm surprised they didn't even key in on the fact that these masks were just being alcohol between patients. They weren't using a disposable circuit or disposable system, which is readily available. It could have been a lot worse, but they are receiving a fine. OSHA is following up. And I always say, you're on the OSHA list now. You need to do everything right because they could come in at any time to retest. They were able to get the levels down, I'm glad to say. It cost them some time, cost them some money, but more than anything, cost them a lot of embarrassment in front of their employees. And their patients, of course. I mean, they had to have some disruption of their practice. while the inspectors were coming into the operatory, I assume there were patients sitting in the dental chair. Well, you know, you're right. It is really a disruption. And I always tell people, doctors will ask me, well, how much could this OSHA fine be? I say, don't worry about an OSHA fine. I don't find life-changing OSHA fines for the most part. I find fines that, call it that, $5,000 to $50,000. Okay, that's never a good day when you have to pay a fine like that. Let's face it, but... That is not going to shut down your practice. That's not going to make you go bankrupt, but will destroy your practice. First of all, this is public domain information. Everybody can find out about it. You're perceived as a less than adequate dentist. Your staff, this has caused major disruption. I've seen a whole staff, a whole team leave over things like this. That's what really costs you money. The OSHA fine, write the check. It's the other things that cost even more. What is the fine, just out of curiosity, typically for something like this? You know, I'm going to say that this one is going to be under $10,000, but it's going to require a lot of follow-up by OSHA. They're going to continue to test. They're going to have to prove that every operatory, they're below both the short-term limit and the permissible exposure limit, the eight-hour limit. And so it's going to cost time, money. They're not out of the woods yet, even if they paid the fine. Now, the testing protocol for nitrous oxide systems, is it in the CDC guidelines, OSHA guidelines, or NIOSH, EPA? Where does a dentist look for this, and where does it say how often to test and so forth? What we teach in our course, and actually we've taught for almost 30 years, is this. We always like to take the high road. The EPA, everybody knows the Environmental Protection Agency, and NIOSH both recommend testing nitrous oxide systems quarterly. And you don't right away. You don't look good. Now, someone might say, all right, well, is there a specific OSHA reg that says I must test? There isn't. But there is what's called the general duty clause. And the general duty clause basically says you need to provide a safe and healthy working environment. That gives OSHA... a lot of, I guess, leeway, you would say, to cite the person. In this case, that's what they're going to cite them under, the general duty clause. OSHA will tell you, we can't write a specific regulation for every little thing we do, but we do expect you to follow national guidelines, including of the EPA and NIOSH. That's how they were able to cite them here, Phil. And what's the testing armamentarium, Dr. Carpenter, for an office to accurately detect? How many parts per million of nitrous is floating around? Well, you know, you can use a company like ours. We've been involved in nitrous testing for years, but because we believe in it, we think it's the right thing to do, especially when you've got childbearing age women in a facility. The process is very simple. Imagine a small round device, maybe about an inch in diameter, a half an inch thick. You take it out of the envelope. You expose it for... the appropriate time. In most cases, we recommend the PEL, permissible exposure limit, expose it for eight hours or as close as you can get to eight hours, seal it up, send it back to the lab. Now, if you're doing that, you can certainly do what we call area monitoring, where you put one every quarter, so every three months, you put one in each operatory that you use nitrous in, you expose it for the day, maybe it's eight hours, maybe it's six and a half, they'll extrapolate. send it to the lab, get the results, keep those results. Now, in the case of a violation like this office had, now they're requiring them to do not only eight-hour exposure tests, but short-term where you actually place it on your person. So we're talking about a lot more badges, a lot more money, a lot more time. They could have made this all go away if they would have tested each operatory quarterly. When you teach your course, Dr. Carpenter, where do you recommend putting this information that on this date, We tested our nitrous oxide systems. These are the numbers we got. This is the test that we used, that kind of stuff. How much information do you need to record? How often and where do you put it? We'll be right back with our guest. But first, I want to tell you about VOCO's newest composite, Grandioso 4U. Top clinicians are calling it the most tooth-like universal composite ever made. Unlike traditional composites that force you to choose between either an anterior aesthetic composite, a stronger layering posterior composite, or a fast but aesthetic compromising bulk fill, Grandioso 4U does it all. simplifying your workflow while delivering superior results in a single material. It cures four millimeters in just 10 seconds, looks stunning with five cluster shades covering all 16 Vita shades, and handles like a dream with 50% less resin. It's a 91% filled nano hybrid, giving you tooth-like strength, ultra-low shrinkage, exceptional wear resistance, and an amalgam-like high radio opacity. So as they say, seeing is believing. So grab your free sample of Grandioso for you today at voco.dental. Well, this would come under the moniker of occupational safety. So I'll give you an example. Our company, if you happen to have our OSHA compliance manual. there is a section in there where you actually record this. If you have our automated system comply, it's a compliance dashboard. We actually have a spot where you record it right on that website. I suggest that you keep these results for at least five years. How do you do it? You basically take the results that come from an approved laboratory. a government approved laboratory you get a printout it tells you what the parts per million are you scan and upload that into your system you you keep copies long term that's how you stay out of trouble and i always tell people too even if you're never inspected by osha this may keep you from being inspected by osha because when you have a staff that feels you care about them you test for things like nitrous that might affect their health they appreciate it it's actually a great practice builder it's actually a great hr tool in my opinion It's also a lot healthier to work in an office where this stuff's not floating around. It's interesting to me how OSHA doesn't contact the office when there's a report from an employee or a patient that there's a possible violation. And I guess they do that purposely, right? Because they want to surprise the office so that the office doesn't mitigate the damages perhaps before they come. Like why wouldn't they reach out to the office and maybe the office has lots of testing data? Did they ask the dentist when they came into the office, do you have test data? Well, actually, that is the first thing they asked when they came in. Do you have the results of testing? We'd like to see them. And of course, they had nothing. That's right away. You don't look good, right? You don't have any documentation at all. Even if they've been well below 50 parts per million, they can't prove it, right? So it was a huge mistake, in my opinion, to not have quarterly testing. You asked a very good question, Phil. Don't they sometimes contact you, first call you, send a letter? What we find in most cases when it comes to things like nitrous, they send a letter. And the letter would say, the following has been alleged. And it would say, bullet point number one, high levels of nitrous oxide. Two, no testing of nitrous oxide. Three. old masks that are cracked, ill-fitting. And now you have a chance, as you say, to refute that. Often they won't even come in. They want to see your nitrous oxide testing. If you show them five years of data or even two years of data where everything is well under 50 parts per million, guess what? They're probably not even going to come in. This was unusual. This was an outlier in that they immediately came in. Right. That's what I was asking. So typically they would contact the office. allow the office to respond. And the best way to respond, obviously, is to show them that you've been testing accordingly. In your experience, how many dental practices are actually doing this, are testing nitrous oxide equipment? You know, I'm going to say when we first started offering testing, and by the way, I do want to mention the reason we got into nitrous oxide testing many years ago is we saw what the law said. We saw our colleagues out there didn't know how to... get the test. They're not really readily available. So we made them available for our dental colleagues. And it's been a good thing. I think we've protected a lot of people along the way. And again, it's not an expensive thing to do. It's not a time consuming thing to do. And I didn't quite honestly feel I didn't push it as hard as I'm going to from now on, including in 2026, because I see that OSHA is starting to really look at this. So when you have an office that's testing their nitrous and their numbers are way higher than the recommended 50 parts per million or less on the eight-hour test, on the short-term one, the 15-minute one, they're way over the 75 parts per million. You're talking 1,000 parts per million. These numbers are so excessive. What is the main culprit to this? Do you think it's an old mask, outdated scavenger equipment or no scavenger equipment? Is it medical gas piping problems where things are leaking? What do you see as the number one culprit for the problem? And I assume at some point, the doctor just should invest in a completely new and updated nitrous oxide system. Well, you know, in one sense, it can be all of the above. But the main problems I see are this. First of all, we have a lot of older offices out there. Now, a scavenger system, you might say your scavenger system is not perfect, right? Your scavenger system, how is it ventilated? I've been involved with a number of cases where somebody had high nitrous levels. They couldn't figure out why. Turns out they had an old wet vacuum system. All the modern ones today are dry vac systems where they have an outside air source. It's vented to the outside. Imagine that many of these old systems, if you can believe it, Phil, they actually suck up that waste anesthetic gas in the operatory, use the vacuum system to take it back to the mechanical room where it dumps into the mechanical room. And in a small office, guess so many times what happens to be in the mechanical room? The heating and cooling system. So now it picks up that heavier than air gas in the cold air return and circulates it back through the office. So you may have an old wet vac system, not properly ventilated. You may have old medical gas piping. It was good 30 years ago, but now it's leaking. Another thing I see quite often, the masks today are dramatically improved. There's disposable circuits where the whole mask and tubing are disposable. They're not expensive. That way you kill two birds with one stone. First of all, you alleviate your infection control concerns. Second of all, these new masks, they're very tightly fitting. As a matter of fact, when we switched to them years ago, we found out that we could use less nitrous and less oxygen because the seal was so tight, we were being more efficient. So I find mask is also a big problem. So if I had a problem, I'd say focus on your scavenger system, focus on using a quality disposable mask, and also focus on training because the best scavenger system in the world is going to do you no good if you have people who turn on the nitrous, then put the mask on the patient, or they take it off when the nitrous is still running. A scavenger system only is able to evacuate waste anesthetic gas, not what's blowing through the nosepiece. Yeah, and it's something to consider, I would assume, that if you have an old nitrous oxide system that you've been using for over 15 years maybe or longer, maybe you bought the practice from an associate who had a system in there that existed when they bought the practice. I guess even though it's functioning as far as getting the patient comfortable with delivering nitrous to the patient, It's not functioning regarding the free nitrous. that's floating around the operatory. So if you continue to get test results that are not passing that maximum allowable level of 50 parts per million, maybe it's time to consider getting a whole new unit because you certainly don't want to have anything like what just happened to this doctor that you're handling, the case that you're handling right now. No, you really don't. It could have been so easily avoided. And again, I truly believe the small amount you'll spend on nitrous testing. will be more than made up for by happy employees, employees who appreciate the fact that you're concerned about their health and be proactive about it. Let them know, hey, I'm concerned about all of you. I want to make sure these levels are low. This is why we're doing this. And you know what? They won't find many other offices that do that. That's the sort of thing that employees and we're all in a very tight market for employees. They really appreciate this. They really do. Yeah. So I want to wrap up with this. Now we've talked about. uh surprise inspections in the past and you know you've mentioned that it's not that often that it's a surprise inspection usually they do communicate with the office they're good about that but when they do come physically to your practice i don't remember us i know that they ask for certain things they ask what are the typical things you tell us what are the typical things that you have to have the written documentation the training and in that do they Talk about nitrous oxide testing, because I don't remember that being a question that was typically asked in a visit by OSHA or the Department of Public Health or whoever comes to look at the office during an inspection. Well, I think you're right, Phil. And I think the public has become more aware. Certainly, employees have become more aware of safety issues in the office as opposed to 10, 20 years ago. And I also think OSHA inspectors are probably better trained. Imagine if you only had an industrial background and you came to a dental office, the last thing you're going to look for is a nitrous oxide problem. They've done enough OSHA inspections in dental offices. I think they know it's important to look for this. It's very meaningful to employees. I think we need to be prepared. Certainly in our training at Compliance Training Partners, we're going to emphasize it more than we have. We've always talked about it. We've always encouraged testing. But I think going forward, we need to be even more diligent. Again, we're talking to the founder, president, and CEO of Compliance Training Partners, who has offered so much incredible insight and training to the dental profession, especially Viva Learning. And we thank you for that, Dr. Carpenter. So look for Dr. Carpenter's webinars that are coming up and also the on-demand webinars that we already have on our site. type in Carpenter in the search field. The first name is Karson, K-A-R-S-O-N, Compliance Training Partners. Dr. Carpenter, pleasure to have you here and have a great evening. Thank you so much. Thank you again, Phil. See you next time.