OAR 818-026-0060: Moderate Sedation Permit

Moderate sedation, minimal sedation, and nitrous oxide sedation. (1) The Board shall issue or renew a Moderate Sedation Permit to an applicant who: (a) Is a licensed dentist in Oregon; (b) In addition to a current BLS for Healthcare Providers certificate or its equivalent, either maintains a current Advanced Cardiac Life Support (ACLS) certificate and/or a Pediatric Advanced Life Support (PALS) certificate, whichever is appropriate for the patient being sedated; and (c) Satisfies one of the following criteria: (A) Completion of a comprehensive training program in enteral and/or parenteral sedation that satisfies the requirements described in Part V of the current ADA Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students at the time training was commenced. (i) Enteral Moderate Sedation requires a minimum of 24 hours of instruction plus management of at least 10 dental patient experiences by the enteral and/or enteral-nitrous oxide/oxygen route. (ii) Parenteral Moderate Sedation requires a minimum of 60 hours of instruction plus management of at least 20 dental patients by the intravenous route. (B) Completion of an ADA accredited postdoctoral training program (e.g., general practice residency) which affords comprehensive and appropriate training necessary to administer and manage parenteral sedation, commensurate with these Guidelines. (C) In lieu of these requirements, the Board may accept equivalent training or experience in moderate sedation anesthesia. (2) The following facilities, equipment and drugs shall be on site and available for immediate use during the procedures and during recovery: (a) An operating room large enough to adequately accommodate the patient on an operating table or in an operating chair and to allow an operating team of at least two individuals to freely move about the patient; (b) An operating table or chair which permits the patient to be positioned so the operating team can maintain the patient's airway, quickly alter the patient's position in an emergency, and provide a firm platform for the administration of basic life support; (c) A lighting system which permits evaluation of the patient's skin and mucosal color and a backup lighting system of sufficient intensity to permit completion of any operation underway in the event of a general power failure; (d) Suction equipment which permits aspiration of the oral and pharyngeal cavities and a backup suction device which will function in the event of a general power failure; (e) An oxygen delivery system with adequate full face mask and appropriate connectors that is capable of delivering high flow oxygen to the patient under positive pressure, together with an adequate backup system; (f) A nitrous oxide delivery system with a fail-safe mechanism that will insure appropriate continuous oxygen delivery and a scavenger system; (g) A recovery area that has available oxygen, adequate lighting, suction and electrical outlets. The recovery area can be the operating room; (h) Sphygmomanometer, precordial/pretracheal stethoscope, capnograph, pulse oximeter, oral and nasopharyngeal airways, larynageal mask airways, intravenous fluid administration equipment, automated external defibrillator (AED); and (i) Emergency drugs including, but not limited to: pharmacologic antagonists appropriate to the drugs used, vasopressors, corticosteroids, bronchodilators, antihistamines, antihypertensives and anticonvulsants. (3) No permit holder shall have more than one person under moderate sedation, minimal sedation, or nitrous oxide sedation at the same time. (4) During the administration of moderate sedation, and at all times while the patient is under moderate sedation, an anesthesia monitor, and one other person holding a current BLS for Healthcare Providers certificate or its equivalent, shall be present in the operatory, in addition to the dentist permit holder performing the dental procedures. (5) Before inducing moderate sedation, a dentist permit holder who induces moderate sedation shall: (a) Evaluate the patient and document, using the American Society of Anesthesiologists (ASA) Patient Physical Status Classifications, that the patient is an appropriate candidate for moderate sedation ; (b) Give written preoperative and postoperative instructions to the patient or, when appropriate due to age or psychological status of the patient, the patient's guardian; and (c) Obtain written informed consent from the patient or patient's guardian for the anesthesia. The obtaining of the informed consent shall be documented in the patient’s record. (6) A patient under moderate sedation shall be visually monitored at all times, including the recovery phase. The dentist permit holder or anesthesia monitor shall monitor and record the patient's condition. (7) Persons serving as anesthesia monitors for moderate sedation in a dental office shall maintain current certification in BLS for Healthcare Providers Basic Life Support (BLS), or its equivalent, shall be trained and competent in monitoring patient vital signs, in the use of monitoring and emergency equipment appropriate for the level of sedation utilized. ("competent" means displaying special skill or knowledge derived from training and experience.) (8) The patient shall be monitored as follows: (a) Patients must have continuous monitoring using pulse oximetry, and End-tidal CO2 monitors. Patients with cardiovascular disease shall have continuous electrocardiograph (ECG) monitoring. The patient's blood pressure, heart rate, and respiration shall be recorded at regular intervals but at least every 15 minutes, and these recordings shall be documented in the patient record. The record must also include documentation of preoperative and postoperative vital signs, all medications administered with dosages, time intervals and route of administration. If this information cannot be obtained, the reasons shall be documented in the patient's record. A patient under moderate sedation shall be continuously monitored and shall not be left alone while under sedation; (b) During the recovery phase, the patient must be monitored by an individual trained to monitor patients recovering from moderate sedation. (9) A dentist permit holder shall not release a patient who has undergone moderate sedation except to the care of a responsible third party. When a reversal agent is administered, the dentist permit holder shall document justification for its use and how the recovery plan was altered. (10) The dentist permit holder shall assess the patient's responsiveness using preoperative values as normal guidelines and discharge the patient only when the following criteria are met: (a) Vital signs including blood pressure, pulse rate and respiratory rate are stable; (b) The patient is alert and oriented to person, place and time as appropriate to age and preoperative psychological status; (c) The patient can talk and respond coherently to verbal questioning; (d) The patient can sit up unaided; (e) The patient can ambulate with minimal assistance; and (f) The patient does not have uncontrollable nausea or vomiting and has minimal dizziness. (11) A discharge entry shall be made by the dentist permit holder in the patient's record indicating the patient's condition upon discharge and the name of the responsible party to whom the patient was discharged. (12) After adequate training, an assistant, when directed by a dentist permit holder, may dispense oral medications that have been prepared by the dentist permit holder for oral administration to a patient under direct supervision. Pursuant to OAR 818-042-0115 a Certified Anesthesia Dental Assistant, when directed by a dentist permit holder, may introduce additional anesthetic agents into an infusion line under the direct supervision of a dentist permit holder. (13) Permit renewal. In order to renew a Moderate Sedation Permit, the permit holder must provide documentation of a current BLS for Healthcare Providers certificate or its equivalent; a current Advanced Cardiac Life Support (ACLS) certificate and/or a current Pediatric Advanced Life Support (PALS) certificate; Successful completion of a board approved course on minimal/moderate sedation at least every two years may be substituted for ACLS, but not for PALS; and must complete 14 hours of continuing education in one or more of the following areas every two years: sedation, physical evaluation, medical emergencies, monitoring and the use of monitoring equipment, or pharmacology of drugs and agents used in sedation. Training taken to maintain current ACLS or PALS certification or successful completion of the American Dental Association’s course “Recognition and Management of Complications during Minimal and Moderate Sedation” may be counted toward this requirement. Continuing education hours may be counted toward fulfilling the continuing education requirement set forth in OAR 818-021- 0060.