Anesthesia Overview

Sedation Permit Types and Host Dentists | Qualified Anesthesia Providers and Site Evaluations | 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. Dental offices treating sedated patients must carefully and thoroughly review these laws and be prepared with appropriately trained staff and have requisite equipment to manage emergencies or adverse events.

Sedation 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 dental license is suffiicient for the administration of minimal sedation; no sedation permit is required.

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

Host Dentists

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 (1) a qualified dentist who holds a sedation permit issued by the Board or (2) 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.

NOTE: There is no application form to become a Host Dentist. Instead, a dentist is approved to act as a Host Dentist upon completing a Site Evaluation approved by the Board. Becoming a Host Denist in no way qualifies the individual to oversee other dentists who seek to treat sedated patients. Any non-permit-holder dentist who seeks to treat sedated patients can only do so if they themself become a Host Dentist by completing an approved Site Evaluation.

Qualified Anesthesia Providers

Qualified anesthesia providers may be used by a Host Dentist who seeks to treat sedated patients. The following individuals may serve as Qualified Anesthesia Providers: (1) a Certified Registered Nurse Anesthetists (CRNA) registered with the North Dakota Board of Nursing, (2) an anesthesiologists licensed by the North Dakota Board of Medicine, or (3) a dentist licensed in North Dakota holding an anesthesia permit. A dentist seeking to become a Host Dentist shall notify the Board prior to sedation services being provided, and must complete a Site evaluation approved by the Board.

Site Evaluations

No denitst may sedate a patient beyond minimal sedation, or treat a patient who is sedated beyond minimal sedation, until they undergo a Site Evaluation and recieve an approval letter from the Board. The Site Evaluation Form below explains all necessary information and must be carefully reviewed by a permit holder or host dentist. The denist is responsible for identifying a site evaluator, scheduling and completing the evaluation, and paying the site evaluatory fees.

A Site Evaluation is ONLY valid for dentists who are present for the site evaluation and are only valid for the evaluated office. Site Evaluations are valid for three years--and new site evalations must be approved by the Board before the prior Site Evaluation expires.

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.

SITE EVALUATION FORM

Renewal of Sedation/Anesthesia Permit

Both the sedation permit and the site evaluation are subject to expiration and must be renewed. Sedation and anesthesia permits must be renewed at the time of license renewal. Site evaluations must be completed every 3 years.
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 are renewed when the dentist license is renewed.

Satellite Office

Some dentists treat patients in more than one office--a satellite office. Such dentists must be aware that:

A Site Evaluation is only valid for the physical address where it took place.
A Site Evaluation is only valid for the dentist(s) who were present for the entire Site Evaluation and recieved an approval letter from the Board. More than one dentist may attend a Site Evaluation.
A dentist seeking to sedate patients beyond minimal sedation or treat such patients must have an approved Site Evaluation for every location or satellite office.

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.