The North Dakota Board of Dental Examiners are committed to the safe and effective use of general anesthesia, deep sedation, moderate sedation and minimal sedation. The Board's Anesthesia Committee bases their standards on the ADA Guidelines for The Use of Sedation and General Anesthesia by Dentists, ADA Guidelines for Teaching Pain Control and Sedation and the American Association of Oral and Maxillofacial Surgeons Office Anesthesia Evaluation Manual 8th Edition. Requirements for permits are not identical to ADA Guidelines for moderate parenteral sedation therefore please carefully review the permit application and the site evaluation form for your appropriate level of education and training requirements.
NDBDE SEDATION SUMMARY SPREADSHEET
Qualified Anesthesia Providers - CRNAs
A dentist who is not authorized by permit to provide anesthesia or sedation services AND who intends to use the services of a qualified anesthesia provider such as a Certified Registered Nurse Anesthetist (CRNA), anesthesiologist or another dentist holding an anesthesia permit, shall notify the Board prior to sedation services being provided and arrange a site evalutation with the Board's appointed anesthesia professional. CRNAs are safe and effective anesthesia professionals who can also improve patient safety in office based dental practices. Dental offices who wish to provide conscious sedation services via contractual agreement with a CRNA or other qualified sedation provider are subject to site evaluations. Dental offices providing sedation should be prepared with appropriately trained staff and have requisite equipment to manage emergencies or adverse events.
Standards for Dentists Utilizing Qualified Anesthesia Provider
- A dentist who does not hold an anesthesia permit may perform dental procedures on a patient who receives anesthesia induced by a qualified anesthesia provider licensed by the ND Board of Medical Examiners, a licensed dentist holding an appropriate anesthesia permit, or a CRNA licensed by the ND Board of Nursing.
- 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 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.
The Board authorizes sedation privileges by granting a permit to a qualified dentist. The education and training level attained by the general dentist determine the type of permit that may be granted. A moderate sedation permit may be granted for enteral sedation only or parenteral sedation. The ADA
- MINIMAL SEDATION - a minimally depressed level of consciousness, produced by a pharmacological method, that retains the patient’s ability to independently and continuously maintain an airway and respond normally to tactile stimulation and verbal command. Although cognitive function and coordination may be modestly impaired, ventilatory and cardiovascular functions are unaffected. NOTE: When Nitrous oxide/oxygen is used in combination with any dose of a single enteral drug(s), a permit for minimal sedation is required.
- MODERATE SEDATION: Parenteral and Enteral - means depressed level of consciousness that retains the patient’s ability to independently and continuously maintain an airway and respond appropriately to physical stimulation or verbal command and that is produced by a pharmacological or nonpharmacological method or a combination thereof. The drugs or technique, or both, should carry a margin of safety wide enough to render unintended loss of consciousness unlikely. Patients whose only response is reflex withdrawal from repeated painful stimuli would not be considered to be in a state of conscious sedation.
- DEEP SEDATION and GENERAL ANESTHESIA – Deep Sedation 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. General Anesthesia means a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug induced depression of neuromuscular function. Cardiovascular function may be impaired.
- Both the sedation permit and the inspection are subject to expiration and renewal. Sedation and anesthesia permits must be renewed at the time of license renewal. Site evaluations must be within 5 years of the previous evaluation.
- Four hours of anesthesia/sedation CE are required to maintain a sedation or anesthesia permit.
- Current BLS and ACLS must be maintained at all times for any level of sedation or anesthesia. Practitioners utilizing sedation on children 12 and under must have PALS.
- The Board no longer requires practitioners to submit evidence of CE; the licensee must maintain evidence of CE requirements for the purpose of a CE audit.
Permit - Non-renewal
- A dentist may not provide minimal sedation services without a permit or with an expired permit. Providing minimal, moderate, deep sedation and general anesthesia is prohibited and unlawful without a permit and is grounds for disciplinary action. If the renewal application is late, sedation privileges are suspended until a reinstatement is completed and formally approved by the Board’s Anesthesia Committee. A late fee is incurred when the permit renewal is postmarked after the December 31st deadline of odd numbered years.
- All providers of anesthesia/sedation are required to have an evaluation at the location(s) where sedation or anesthesia services are rendered.
- 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. A Certified Registered Nurse Anesthetist (CRNA) shall provide site evaluations for general dentists seeking initial sedation privileges or a re-evaluation.
- An initial evaluation must be completed within 60 days of the approval of the initial anesthesia/sedation permit application. A licensed anesthesia or sedation provider authorized by the board shall reevaluate the credentials, facilities, equipment, personnel, and procedures of a permitholder within every five 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.
- All offices where sedation services are provided must comply with the minimum 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 been evaluated.
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 observes anesthesia and sedation guidelines provided by AAOMS and the ADA. The Board 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.