Section 17 clarifies that nitrous oxide when used in combination with a sedative agent may produce minimal, moderate or deep sedation. If a patient enters a deeper level of sedation than the dentist is authorized to provide, the dentist must stop the sedation and procedures until the patient returns to the intended level of sedation.
Section 18 provides the education requirements approved by the Board for Class 2 permit. The program shall be at least 60 hours in administration and management of moderate sedation and include:
- Aspects of anxiety and pain control.
- Patient evaluation and selection based upon review of medical history, physical diagnosis and psychological profiling.
- Use of patient history and examination for ASA classification, risk assessment and fasting instructions.
- Definitions and descriptions of physiological psychological aspects of anxiety and pain.
- Description of the sedation anesthesia continuum.
- Review of adult respiratory and circulatory physiology and related anatomy.
- Pharmacology of local anesthetics and agents used in moderate sedation.
- Indications and contraindications for use of moderate sedation.
-Review of dental procedures possible under moderate sedation.
-Patient monitoring using observation and monitoring equipment.
-Maintaining proper records with accurate chart entries.
-Prevention, recognition and management of complications and emergencies.
-Description, maintenance and use of moderate sedation monitors and equipment.
-Discussion of abuse potential.
-Intravenous access anatomy, equipment and technique.
-Prevention, recognition and management of complications of venipuncture and other parenteral techniques.
-Description and rationale for the technique to be employed.
-Prevention, recognition and management of systemic complications of moderate sedation.
20 individually managed cases.
Section 19 repeals the sections on requirements for anxiolysis, conscious sedation-enteral, conscious sedation-parenteral, and deep sedation and general anesthesia sue to being obsolete.
Section 20 creates a requirement for a dentist holding a sedation permit must complete 2 hours of continuing education on the topic of sedation and anesthesia each biennium. The continuing education can count toward the general continuing education requirements for dentists.
Section 21 repeals the office facilities and equipment section as it is addressed under the standards of care section.
Section 22 requires auxiliary personnel to be certified in basic life support for the health care provider. A dentist administering moderate sedation must have one additional person present during the procedure and another person on the premises and available to respond to a patient emergency. A dentist administering general anesthesia or deep sedation must have two additional persons present during the procedure. If the dentist is both performing the dental procedures administering moderate or deep sedation, or general anesthesia, then an auxiliary person must be designated to only monitor the patient.
Section 23 delineates the standards of care. A dentist administering anesthesia or sedation must be in the room to continuously monitor the patient until the patient meets the criteria for transfer to recovery. The dentist may not leave the dental office or facility until the patient meets the criteria for discharge and is discharged from the dental office or facility.
Preoperative preparation includes:
-Determine the adequacy of the oxygen supply and equipment necessary.
-Take and record the patient’s baseline vital signs.
-Complete medical history and a focused physical evaluation.
-Instruct the patient on specific dietary limitations based upon the sedative and anesthetic technique to be used and patient’s physical status.
-Provide pre-operative instructions to the patient.
-Notify and require a patient to arrive and leave with a vested escort.
-Establish and secure, an intravenous line throughout the procedure.
-Advise the patient of fasting requirements.
Utilizing moderate or deep sedation or general anesthesia, a dentist must continuously monitor and evaluate:
-Level of consciousness.
-Oxygenation saturation by pulse oximetry.
-Chest excursions.
-Ventilation monitored by end-tidal carbon dioxide.
-Auscultation of breath sounds by precordial or pretrachial stethoscope.
-Respiration rate.
-Heart rate and rhythm via electrocardiogram.
-Blood pressure.
-Color of mucosa, skin or blood.
-Body temperature whenever triggering agents associated with malignant hyperthermia are administered.
Utilizing minimal sedation, a dentist must continuously monitor and evaluate:
-Level of consciousness.
-Chest excursions.
-Ventilation by either auscultation of breath sounds or by verbal communication with the patient.
-Color of mucosa, skin or blood.
-Blood pressure, heart rate, and oxygenation saturations by pulse oximetry pre-operatively and post0perative and intraoperatively.
A dentist shall maintain and implement recovery and discharge procedures which must include:
-Immediate availability of oxygen and suction equipment.
-Monitor and document the patient’s blood pressure, heart rate, oxygenation and level of consciousness during recovery.
-Determine and document that blood pressure, heart rate, level of consciousness, oxygenation, ventilation, and circulation are satisfactory for discharge.
-Post-operative verbal and written instructions are provided.
-If a reversal agent is administered before discharge criteria have been met, the patient must be monitored until recover is assured.
A dentist administering anesthesia or sedation shall have immediately available and maintain in good working order the following equipment:
-Alternative light source for use during power failure.
-Automated external defibrillator.
-Disposable syringes in assorted sizes.
-Oxygen in a portable cylinder E tank capable of administering positive pressure ventilation via a bag-valve-mask system.
-Sphygmomanometer and stethoscope for pediatric and adult patients.
-Suction and backup system.
-An operating chair capable of withstanding cardiopulmonary resuscitation or a back board.
-Emergency airway equipment.
A dentist administering sedation or anesthesia shall maintain and properly store drugs in current and unexpired condition (and properly dispose of expired drugs). The emergency drug kit shall include:
-Non-enteric coated aspirin.
-Ammonia inhalants.
-Antihistamine
-Antihypoglycemic agent.
-Bronchodilator.
-Epinephrine.
-Oxygen.
-Nitroglycerin.
-Reversal agents.
-Muscle relaxant.
A dentist administering anesthesia or sedation must be responsible for the management, diagnosis and treatment of emergencies and for ensuring the equipment, drugs and protocols for patient rescue are immediately available.
A dentist must maintain an anesthesia record that documents all events related to the administration of the sedative or anesthetic agent.
Sections 24, 25, 26, and 27 require a dentist to report to the board any anesthesia or sedation related mortality within two business days and any morbidity which may result in permanent physical or mental injury within 30 days.
