Anesthesia Overview

About Permits | Qualified Anesthesia Provider | Site Evaluation | Satellite Office | Capnography

The North Dakota Board of Dental Examiners and its licensees are committed to the safe and effective use of general anesthesia, deep sedation, moderate sedation, and minimal sedation. To review Administrative Rules pertaining to anesthesia and sedation see NDAC Section 20-02-01-05, as well as the definitions related to the section which may be found in NDAC Section 20-01-02-01.

Qualified Anesthesia Providers

Qualified anesthesia providers may be used by a dentist who seeks to treat sedated patients. Certified Registered Nurse Anesthetists (CRNA) registered with the North Dakota Board of Nursing, anesthesiologists licensed by the North Dakota Board of Medicine, or another dentist licensed in North Dakota holding an anesthesia permit may serve as qualified anesthesia providers. The dentist shall notify the Board prior to sedation services being provided, and arrange a site evaluation with a Board-approved site evaluator. Dental offices treating sedated patients must carefully and thoroughly review the laws related to anesthesia, including review of NDAC 20-02-01-05, and be prepared with appropriately trained staff and have requisite equipment to manage emergencies or adverse events.

Standards for 'Host" Dentist Utilizing Qualified Anesthesia Provider

A "host dentist" is a dentist that provides treatment to a patient who is under moderate sedation, deep sedation, or general anesthesia that is administered either by a qualified dentist who holds a sedation permit issued by the Board or by an independently practicing qualified anesthesia health care provider, such as an anesthesiologist or certified registered nurse anesthetist. The host dentist is subject to site evaluations for the level of sedation provided as per NDAC 20-02-01-05, including the requirement that they complete an approved initial site evaluation before treating patients under sedation.

A dentist, a dental hygienist, or registered dental assistant who performs procedures on a patient who is receiving anesthesia/sedation induced by a qualified anesthesia provider shall not schedule or treat patients for non-emergent care during the period of time of the sedation procedure.

A dentist who performs dental procedures on a patient who receives anesthesia induced by a qualified anesthesia provider shall maintain a current BLS for Healthcare Providers certificate, or its equivalent, and have the same personnel, facilities, equipment and drugs available during the procedure and during recovery as required of a dentist who has a permit for the level of anesthesia being provided. The dentist shall also maintain current pediatric advanced life support if treating patients aged 9 and younger, and maintain current advanced cardiac life support training if treating patients older than 9.

The qualified anesthesia provider who induces anesthesia shall monitor the patient's condition until the patient is discharged and record the patient's condition at discharge in the patient's dental record as required by the rules applicable to the level of anesthesia being induced. The anesthesia record shall be maintained in the patient's dental record and is the responsibility of the dentist who is performing the dental procedures.

SITE EVALUATION FORM / HOST DENTIST UTILIZING OTHER QUALIFIED PROVIDER

Permit Types

The Board authorizes sedation privileges by granting a permit to a qualified dentist. The education and training level attained by a dentist determine the type of permit that may be granted.

MINIMAL SEDATION means a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes and ventilatory and cardiovascular are unaffected. Minimal sedation may be achieved by the administration of a single drug administered in a single or divided dose not to exceed the maximum recommended dose for unmonitored home use during a single appointment. A permit is not required for minimal sedation.

MODERATE SEDATION means a drug-induced depression of consciousness during which a patient responds purposefully to verbal commands either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Administration of sedative drugs exceeding the maximum recommended dose for unmonitored home use during a single appointment or use of more than one enteral drug administered, with or without concomitant use of nitrous oxide is considered moderate sedation. A permit is required.

DEEP SEDATION and GENERAL ANESTHESIA means a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. A permit is required..

INITIAL ANESTHESIA & SEDATION PERMIT APPLICATION

Sedation/Anesthesia Permit Renewals

Both the sedation permit and the site evaluation are subject to expiration and renewal. Sedation and anesthesia permits must be renewed at the time of license renewal. Site evaluations must be within 3 years of the previous evaluation.
Six hours of anesthesia/sedation CE are required to maintain a sedation or anesthesia permit. At least six hours related to sedation or anesthesia; and at least two hours related to anesthesia emergencies that are based on actual adverse anesthesia events or actual close insurance claims. Content offered by insurance providers or licensees of the board, including content offered by dentists who hold sedation permits issued by the board, may be approved by the board.
Current BLS must be maintained at all times by all dentists. In addition, Host Dentists and Dentists who hold sedation/anesthesia permits who treat patients 9 years of age and younger must maintain current PALS certification, and those who treat patients older than 9 years of age must maintain current ACLS.
The dentist must maintain evidence of CE requirements for the purpose of a random CE audit.

Permits- Non-renewal or late renewal

A dentist may not act as a host dentist and treat patients sedated by a qualified anesthesia provider unless the dentist has an approved, current site evaluation for that location. Site evaluations must be renewed very three years.
A dentist may not provide moderate sedation, or deep sedation or general anesthesia services, unless they have a current permit and a current site evaluation. Permits are renewed when the dentist license is renewed, and site evaluations are renewed every three years.

Violation of these requirements is grounds for disciplinary action. If a permit renewal application is late, the dentist’s sedation privileges are suspended until a late renewal application is completed and formally approved by the Board. A late fee is incurred when the permit renewal is postmarked after the December 31^st deadline of odd numbered years. Site Evaluations

All providers of anesthesia/sedation, and dentists who seek to treat sedated patients are required to have a site evaluation at the location(s) where sedation or anesthesia services are rendered. A site evaluation only applies to the dentists who were physically present for the site evaluation, and only applies to the physical site that is evaluated. Separate site evaluations are required for each location at which a dentist seeks to treat sedated patients.
The Board accepts the AAOMS inspection and evaluation for deep sedation and general anesthesia site evaluations. OMFS’s site evaluations shall be conducted by an OMFS.
Site evaluators must be approved by the Board. Any dentist who holds a deep sedation permit issued by the Board is approved as a site evaluator. CRNAs and anesthesiologists may serve as site evaluators, but must be individually reviewed and approved by the Board prior to acting as a site evaluator..
Initial Site Evaluations: Permit holders must complete their initial site evaluation and receive Board approval within 60 days of the approval of the dentist’s initial anesthesia/sedation permit application. Host dentists must complete a site evaluation and receive Board approval prior to treating a sedated patient.
Renewing a Dentist’s Site Evaluation. Site evaltuions are only valid for three years. They must then be conducted within every three years following a successful initial application or renewal.
It is the applicants responsibility to schedule the site evaluation.
In order to ensure the protection and safety of patients, every dental facility must be properly equipped, supplied and permitted for the administration of specific types of anesthesia and levels of sedation, and every dental hygienist or registered dental assistant must be properly educated, trained, and authorized to assist with the specific type of anesthesia or sedation being administered.
SITE EVALUATION FORM

Satellite Office

All offices and locations where sedation services are provided must comply with the standards established by the Board for a sedation practice.
Anesthesia or sedation permit holders providing services at satellite clinics are responsible for ensuring that each office location has undergone a site evaluation.
A site evaluation only applies to the dentists who were physically present for the site evaluation, and only applies to the physical site that is evaluated.
A dentist must complete and be present for a separate site evaluation for each location at which a dentist seeks to treat sedated patients

Capnography

Following the lead of the American Society of Anesthesiologists (ASA), the American Heart Association and other organizations that develop parameters of care and practice guidelines for their dental and medical surgical specialists, the AAOMS Board of Trustees approved the following revised guidelines requiring capnography equipment in the OMS office beginning January 2014:

During moderate or deep sedation and general anesthesia the adequacy of ventilation shall be evaluated by continual observation of qualitative clinical signs and monitoring for the presence of exhaled carbon dioxide unless precluded or invalidated by the nature of the patient, procedure or equipment; and

Improvements in monitoring exhaled CO₂ during anesthesia continue to evolve. Anesthesia Evaluations require capnography for moderate sedation, deep sedation and general anesthesia unless precluded or invalidated by the nature of the patient, procedure or equipment.

The statements appear in the 2012 Parameters of Care: Clinical Practice Guidelines for Oral and Maxillofacial Surgery (AAOMS ParCare 12), version 5.0, which is also a component of the revised Office Anesthesia Evaluation Manual, 8th edition.

Note: The North Dakota Board of Dental Examiners requires any facility where dentistry is performed that provides moderate sedation, deep sedation or general anesthesia, or permit holders of moderate sedation, deep sedation and general anesthesia to include capnography for monitoring ventilation during moderate sedation and anesthesia.