American Association of Oral and Maxillofacial Surgeons

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Office-based Anesthesia Provided by the Oral and Maxillofacial Surgeon
Background and Purpose
The American Association of Oral and Maxillofacial
Surgeons (AAOMS) and its Board of Trustees
embrace safety as a core value. This white paper
reflects this priority and is intended to highlight andsummarize key elements of the OMS team approachto anesthesia delivery. AAOMS believes adheringto the principles outlined in this document will
provide a solid foundation for the safe, effective andaffordable delivery of anesthesia in the office setting– understanding these principles are not set absolute
requirements nor do they guarantee specific outcomes.
A Special Committee on Office-based Anesthesia
White Paper was appointed in October 2021 by the
Board of Trustees to review and revise the 2016 paper.
The special committee was tasked with reviewing
relevant materials, including the AAOMS Parametersof Care, the American Society of Anesthesiologists’
Practice Guidelines for Sedation and Analgesia by
Non-anesthesiologists, AAOMS white papers andother publications related to anesthesia safety. The
committee supplemented this foundation with otherevidence-based resources and considered the opinions
of experts in office-based anesthesia.
Note: Each section of this Executive Summary islinked to its corresponding section of the white paper
for those who desire more information on a specifictopic. Click theicon to read more on each topic.

Oral and Maxillofacial Surgery
Residency Education and Training
From the earliest days of the specialty, there has been
an emphasis on outpatient anesthesia education, withongoing updates to formal training requirements aimed
at improving patient safety. The current standards
for OMS resident anesthesia training provide for a
progressive didactic and clinical learning experience.
Combined, anesthesia and medical service rotation

assignments are for a minimum of 32 weeks. Of
those, at least 20 weeks must be spent on anesthesia
service, and at least four weeks should be dedicatedto pediatric anesthesia. As with other off-service
rotations, the OMS resident must function as at least a
Post-Graduate Year-1 (PGY-1) anesthesia resident withcommensurate levels of responsibility. A minimum ofeight weeks must be allocated toward medical/surgicalsubspecialty services, with a focus on preoperative risk
assessment.
OMS ambulatory anesthesia delivery includes theadministration of deep sedation or general anesthesia
for procedures performed on pediatric, adult andgeriatric patients. The cumulative experience ofeach graduating resident includes the competentadministration of general anesthesia and deep sedation
for a minimum of 300 cases, at least 50 of whichmust involve individuals younger than 13 years old.
Training also includes treating children under age
8 using techniques such as behavior management,
inhalation analgesia, sedation and general anesthesia.
The clinical experience is supported by a programthat incorporates lectures and seminars emphasizing
perioperative evaluation of all patients, risk
assessment, anesthesia and sedation techniques,monitoring, and the diagnosis and management ofcomplications. These experiences are intended toprepare the graduating resident to ensure favorable
outcomes when treating the scope of patients typicallyseen in OMS offices.

History of Anesthesia in
Oral and Maxillofacial Surgery
The role of oral and maxillofacial surgeons inproviding anesthesia in an office-based setting has
a long history, emanating from the time of Horace
Wells’ practice with nitrous oxide in the 1840s tocontemporary techniques that utilize multiple agents.

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In the mid-1900s, injectable anesthetics became more
prominently used by the OMS community, allowing
better control of the depth and duration of anesthesia
without the need to intubate or otherwise use theoral or nasal pathways for delivery. Methohexital(Brevital), a barbiturate with a short duration ofaction, was reported in 1940 by Adrian O. Hubble, an
OMS who used repeated doses to sufficiently abolishpain and recall in the office setting. From 1945 to the
1960s, techniques started to combine methohexital
with meperidine (Demerol) or other opiates, alongwith an anticholinergic drug, to achieve what became
known as balanced anesthesia. The introduction of
intravenous benzodiazepines, particularly diazepam(Valium) in 1963, marked the beginning of a broader
continuum of anesthesia. As newer sedative agentswere developed, many older drugs were replaced withmore effective and shorter-acting agents with fewerside effects. For example, methohexital (Brevital)
has mostly been replaced with propofol (Diprivan)
in addition to diazepam with midazolam (Versed)
and meperidine (Demerol) with fentanyl. Low-doseketamine in combination with other agents is usedby many OMSs.
To build on the already impressive safety record of
the OMS anesthesia team model, AAOMS encourages
its members to participate in the Dental Anesthesia
Incident Reporting System (DAIRS), an anonymous,
self-reporting registry system to collect and analyze
anesthesia incidents.

OMS Team Model of Anesthesia Delivery
For any team to operate effectively, it must work as
a cohesive unit that is trained to recognize potential
problems before they arise and respond effectively
to any crisis. The OMS team employs a minimum of
three individuals: 1) a highly trained OMS, 2) a trained
staff member whose sole responsibility is to monitor
the patient and 3) a surgical assistant. The team is led
by an OMS who has completed a minimum of 12 to
14 years of post-secondary education. The OMS mustbe certified in Advanced Cardiovascular Life Support(ACLS) in addition to completing the mandatory
AAOMS Office Anesthesia Evaluation (OAE)
program. The monitor, who must be certified in BasicLife Support (BLS), is responsible for maintaining
the patient’s head position to ensure a patent airway.
They also must observe the patient’s vital signs,

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EKG, EtCO2, pulse oximeter and other importantmonitoring information. Any deviation from normal
is reported immediately. Additionally, certificationin anesthesia assistance can be obtained through the
Dental Anesthesia Assistant National Certification
Examination (DAANCE), a psychometricallyvalidated process. The third team member is thesurgical assistant who is, at a minimum, a dental
assistant with current certification in BLS.

Therapeutic Goals and Outcomes
Therapeutic goals revolve around the successful
management of anxiety, fear and pain. Equallyimportant is an understanding of expected therapeutic
outcomes along with possible anesthesia-relatedrisks and complications. The selection of appropriatetechniques for the administration of local anesthesia,
sedation, and general anesthesia to meet the specificneeds of a given patient and procedure must be
determined by the surgeon based on training,
experience and an understanding of risks and benefits.
Providers must be trained and skilled in rescuinga patient whose level of anesthesia becomes deeper
than originally intended. Following are the recognizedlevels of anesthesia that may be employed in an effort
to manage anxiety, fear and pain:• Minimal Sedation (Anxiolysis): Patient responds
normally to verbal commands, although cognitive
function and coordination may be impaired.
Airway reflexes and ventilatory and cardiovascularfunctions are unaffected.
• Moderate Sedation/Analgesia: Patient responds
purposely to verbal commands, either alone orwith light tactile stimulation. No interventions
are required to maintain a patent airway, andspontaneous ventilation and cardiovascular function
are usually maintained.
• Deep Sedation/Analgesia: Patient not easily
aroused but responds purposely following repeatedor painful stimulation. The ability to independently

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maintain airway patency and ventilation may
be impaired. Cardiovascular function is usually
maintained.
• General Anesthesia: Patient not arousable, evenwith painful stimulation. The ability to maintainventilatory function independently is often impaired,and patients may require assistance. Cardiovascularfunction may be impaired.

Techniques
An individual patient’s medical conditions andphysiology, responses to medications, the doses
administered, and the technique used influence
the level of anesthesia. A variety of administrationroutes can be employed to achieve the desired
therapeutic goals, including local, enteral, parenteraland inhalation. The level of anesthesia achieved isindependent of the administration method.
Local anesthetics minimize the amount of otheranesthetic agents necessary to achieve therapeutic
goals. They commonly contain vasoconstrictors tomaintain higher drug concentrations at the target siteand minimize surgical bleeding. Enteral anesthetic
agents typically include benzodiazepines,
non-benzodiazepine hypnotics and alpha-2 agonists.
Many variables confound the ability to predict the
behaviors of drugs when administered via the enteralroute. Common parenteral agents include opioids,
benzodiazepines, propofol, ketamine, barbiturates
and alpha-2 agonists. Parenteral routes include
intravenous, intramuscular, and subcutaneous – with
the intravenous route providing the most rapid onset
and bioavailability. All parenterally administered
medications should follow Centers for Disease Control
and Prevention (CDC) Safe Injection Practices toPrevent Transmission of Infections to Patients as wellas American Society of Anesthesiologists labelingguidelines.

Anesthesia Risks and Complications
Known risks and complications of the planned
anesthetic must be discussed with the patient andfamily as a part of the informed consent process,with all related questions answered as accurately as
possible. For healthy patients, office-based anesthesia
has been demonstrated over time to be safe andWhite PaperE X E C U T I V E S U M M A RY

effective. There are rare instances where serious
complications occur, and the OMS team must be
prepared to appropriately recognize, diagnose andmanage them. Constant vigilance in patient selection
and appropriate anesthetic planning are essential in
minimizing and preventing anesthesia-related risks.

Patient Evaluation
The provision of local anesthesia, deep sedation or
general anesthesia involves the administration of
agents with potentially significant systemic effects. It
is important to identify patients with varying degreesof physical and medical compromise and adjust theanesthetic plan accordingly. Consultation with other
healthcare providers and additional diagnostic testing
to appropriately risk-stratify the patient may be
indicated. At times, it may be appropriate for a patient
to be treated in an ambulatory surgical center or
hospital operating room.
Patient assessment begins with a thorough medical
history that includes specific questions about previous
surgical and anesthetic experiences. The initialoffice visit should include obtaining vital signs suchas blood pressure, heart rate and oxygen saturation(SpO2), which serves as a surrogate monitor of
cardiopulmonary function. All abnormal values should
be flagged for review. Based on the above, patientsshould be classified using the American Society ofAnesthesiologists (ASA) physical status system. In an
ideal setting, patients within ASA I and II classes are
the best candidates for office-based anesthesia.
Since the ability to establish an airway remains
critical, the Mallampati classification is a good tool
for predicting difficulty related to establishing andmaintaining an airway in addition to intubating
patients. BMI also is a useful parameter to help predict
anesthesia-related complications, with patients who
fall into a normal or overweight category posing
limited risk. Challenges related to maintaining apatent airway or establishing one when it is lost arecompounded not only by the BMI but also length

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and diameter of the neck. Sternomental distanceis an important predictor for difficult intubation.
Cardiac Disease – A history of cardiac disease may
require further evaluation and consultation with thepatient’s primary care physician or cardiologist.
Important subtypes include the following:• Coronary artery disease and myocardial
infarction: Angina or shortness of breath with
exercise may suggest ischemic heart disease.
Determining functional status using metabolic
equivalents (METs) helps assess disease severity,and the use of chronic and episodic vasodilator
medications (including nitroglycerine) provides
additional insight.
• Cardiac arrhythmias: Cardiac arrhythmias canresult in significant morbidity during anesthesia.
The use of epinephrine-containing local anesthetics,
endogenous epinephrine and certain anesthetic
agents – such as ketamine and inhalational agents– can result in arrhythmias. Patients with WolffParkinson-White syndrome and those with seconddegree Type II or third-degree heart blocks are notideal candidates for office-based deep sedation or
general anesthesia. Atrial fibrillation may predispose
to a rapid ventricular rate that can lead to acutedecompensation and heart failure. Patients withimplanted pacemakers and internal defibrillators
warrant cardiac consultation.
• Congestive failure: Congestive heart failure isa progressive loss of the normal cardiac output.
Symptoms of non-compensated failure may include
shortness of breath, peripheral edema or fatigue.
The functional status provides valuable insight intodisease severity. Patients with moderate to severecongestive heart failure are not candidates for officebased deep sedation or general anesthesia.
• Valvular heart disease and prosthetic valves:
Patients may be referred for multiple extractions
prior to a planned valve replacement. Dependingon the complexity of the extractions, individuals
may not be suitable for treatment in an office-based
setting. Once valve replacement has occurred,patients are typically more stable.
Respiratory Disease – One of the major risks ofoffice-based anesthesia delivery is the development

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of apnea or hypopnea. Improvements in surveillancewith end-tidal carbon dioxide (EtCO2) monitors anda precordial stethoscope alert the anesthetic teamto the development of apnea in real time. Obese,
pediatric or patients with comorbid medical conditions
have reduced functional residual capacity and maydesaturate relatively rapidly.
Asthma – Patients with asthma require particularattention in light of the potential for anesthesia-related
complications and should be screened with questions
such as: In the past four weeks, has the patient had:
1) Daytime symptoms more than two times per
week? 2) Night waking due to asthma? 3) Use of
short-acting beta agonists for symptoms more than
two times per week? 4) Any activity limitations due
to asthma? In general, the patient can be consideredwell-controlled if he or she answers no to all questions,partly controlled if yes to one or two questions, anduncontrolled if they report yes to three or more.
Mild intermittent asthmatics and mild persistentasthmatics are reasonable candidates for office-based
deep sedation and general anesthesia. Moderateand severe asthmatics are better managed in an
ambulatory surgery center or hospital operating room.
Avoidance of known triggers for histamine releasesuch as non-steroidal anti-inflammatory medications(NSAIDs) and morphine is important. Patients withan upper respiratory infection in the previous month
are not good candidates for deep sedation or generalanesthesia given the increased risk of bronchospasm.
Hepatic Disease – Various causes of hepatic disease
include viral hepatitis, chronic alcoholism andhepatotoxicity from drugs. Since many anesthetic
drugs are bound to plasma proteins that are producedin the liver, hepatic disease may result in increased
free-drug within the body's circulation and thepotential for enhanced and prolonged drug activity.
Since the liver is responsible for metabolism ofmany agents, there may be an increased half-lifeand prolonged anesthetic effects.

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Renal Disease – Urinary excretion is a majormechanism for drug elimination. Therefore,
renal disease can result in prolonged drug action,
particularly when metabolites also have a therapeutic
effect. Since the kidney is responsible for electrolyte
and fluid homeostasis, renal disease can result insignificant electrolyte abnormalities and fluid shifts,
which may decrease cardiovascular reserve as
predispose to arrhythmias.
Pediatric Patients – Children are not simply small
adults. They have many unique and constantly
changing anatomic, physiologic, pharmacologic
and psychologic differences with their medical andsurgical history typically derived completely fromthe caregiver. Systemic diseases and prescription
medications are uncommon, and past anesthetic
experiences may be rare. A targeted physicalexam should include an airway, heart and lungevaluation. Recent upper respiratory infection, fever,mucopurulent nasal drainage, audible wheezing or a
productive cough should prompt further evaluation.
Small nares, large tongue and enlarged tonsils or
adenoids can cause passive airway obstruction. The
pediatric airway is far more reactive to stimuli suchas secretions or foreign bodies than an adult airway.
As a result, laryngospasm must be anticipated,
quickly identified and skillfully managed. Pediatriccardiac output can be maintained over a wide rangeof preloads without failing, but young patients rely
solely on heart rate to maintain blood pressure. As
a result, bradycardia must be immediately detected
and corrected. Properly sized equipment is vital tothe delivery of anesthesia and rescue in the instanceof an emergency. Prior to anesthetic administration,
calculating emergency dosages of commonly useddrugs can facilitate a smooth, coordinated andsuccessful outcome.
Pregnant Patients – Although elective surgery canusually be delayed, there are situations in whicha pregnant female will require urgent surgery. In
addition to maternal safety, anesthetic management
must maintain fetal safety, which includes avoiding
intrauterine fetal asphyxia and preterm labor. Most
local anesthetics are considered safe during pregnancy,and single exposure to the commonly used sedatives(benzodiazepines, opioids and nitrous oxide) haveundetermined risk of teratogenicity. Consultation withthe practitioner managing the patient’s prenatal care

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may be helpful in determining appropriate timing
for surgery and the optimal perioperative care.
Obese Patients – Obese patients present withspecial anatomic and physiologic problems. Obesity,
defined by body mass index, is associated withincreased risk for Type 2 diabetes, hypertension andcardiovascular disease relative to normal weight
and waist circumference. Airway management may
be difficult due the overabundance of soft tissue or
anatomic deficiencies. Comorbid conditions, decreased
functional residual capacity, complex airways anddifficult intravenous access place obese patients at
higher risk for complications. Practitioners should
be experienced in airway management, including
endotracheal intubation and supraglottic device
placement. The use of opioids should be consideredwith caution.
Geriatric Patients – It is prudent to consider age,frailty and comorbidities as anesthetic risk factors.
Medical consultation may be necessary. Determinationof the geriatric patient’s mental status is important as
postoperative delirium is more common in patientswith dementia or preoperative mental status changes.
Assessing the level of exercise tolerance can be
integral to estimating the patient’s ability to tolerate
the combined stress of anesthesia and surgery. The
anesthetic plan should consider reduced dosing withan expectation for longer elimination half-lives ofanesthetic drugs. Medications with anticholinergic
effects should be limited and preference should begiven to reversible anesthetic agents.

Monitoring
Continuous real-time monitoring should reflect
the OMS team model’s shared patient safety
responsibilities. Monitoring should be started
before the administration of anesthesia and continue
throughout the procedure and the post-anesthetic
recovery period. In addition to diligent surveillancethrough direct observation, electronic monitors should
include EKG, pulse oximetry, blood pressure, and

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pulse and end-tidal CO2. Pre-cordial and pre-tracheal
stethoscopes also may be used as deemed useful.
Despite the advancements offered by today’s hightech monitors, the maxim of “treat the patient, not themonitor” should be respected.

Office Anesthesia Evaluation
The Office Anesthesia Evaluation (OAE) is a uniquepeer review process that has been in existence
since 1975. The OAE was conceived, developed,
implemented and mandated by AAOMS throughits state societies to benefit the public its members
serve. The AAOMS OAE digital app (available on
Apple Store or Google Play) can be used to assist
with this process. To maintain AAOMS membership,
all member oral and maxillofacial surgeons mustcomplete this mandatory program at least every five
years. The process involves a thorough inspection of
the member’s practice locations, team, equipment andpatient care skills particularly as they pertain to thedelivery of anesthesia and preparedness to manage
office emergencies. Inspections are typically conductedby outside surgeons or state dental board designates.
The program consists of four parts: 1) evaluationof office facilities, medications and emergency
equipment; 2) management of simulated officeemergencies; 3) debriefing; and 4) observation of
the anesthesia and surgeries performed in the office,subject to state laws and patient consent. The AAOMS
Office Anesthesia Evaluation Manual publishedperiodically (9th edition available) guides the process.
Among other things, the OAE Manual provides sample
forms, checklists and a variety of emergency scenarios
to guide crisis drills and scrimmages for the anesthetic
team.

Mobile Anesthesia
Mobile anesthesia is a model where a qualified
individual delivers services in a facility where theanesthesia provider does not practice or have input
into office design or staffing. Anyone involved in themobile anesthesia model should be aware of applicablestate laws, rules and regulations, professional
resources, and the scope of their professional training
and experience. Mobile anesthesia providers retain the
responsibility of providing coordinated and patientfocused care and must maintain the same standards as

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someone delivering anesthesia in their home office.
This includes, but is not limited to, being responsible
for patient selection, the anesthetic plan, monitoring
and recovery, emergency preparedness, record-keeping
and overall patient safety.

Emergency Preparedness
Despite the best efforts of all concerned, crisis events
can and do occur. It is important to have a process
in place to prevent as well as recognize and respondto potential crises. Preparation has two components:
systems and practice.
Systems are deliberate strategies to limit risk andenhance outcomes. Examples include writtenpatient assessment protocols, standardized clinicaldocumentation forms or electronic medical record
templates, pre-procedure timeout checklists, and crashcart checks to ensure all supplies are available andfunctioning.
Practice is an effective approach to improving
outcomes. It has two components: drills andscrimmages. Drills are used to develop the skills
necessary to perform effectively, while scrimmages
require the application of knowledge and skills during
simulated challenges. Together, they help the team toprogress through stages of learning from unconscious
incompetence (unable to do something with little idea
what needs to do done), to conscious incompetence(understand what needs to be done but unable to doit), conscious competence (aware of what needs tobe done and able to do it with conscious effort), andunconscious competence (know what to do and able toact without conscious effort).
Practices should be conducted on a regular basis,be challenging, mimic real-life situations, include
constructive feedback, emphasize a growth mindset
and incorporate an element of engaging team building.
Scenarios should emphasize the types of patients theoffice typically treats, including age, medical and

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physical status, and procedure types. While focusing
on events where anesthetics are most likely to beadministered, they also should include other spaces
such as the recovery room, waiting room, hallway andbathroom. Algorithms should be creative rather thanformulaic and allow for progression through a variety
of workable solutions. To make sessions realistic, theteam should use a manikin and carry out tasks in amanner that approximates reality, such as performing
CPR, managing the airway, connecting IV tubing anddrawing up mock drugs. AAOMS members and theiroffices must conduct quarterly mock crisis drills.

Provider Training/Continuing Education
Active engagement in lifelong learning from multiple
sources supports the efficiency and effectiveness ofboth the OMS and his or her staff. AAOMS supports
the OMS team in keeping abreast of the latest
knowledge and techniques through the efforts of the
AAOMS Committee on Continuing Education andProfessional Development and the Committee on
Anesthesia. Together, they are responsible for creating
high-level contemporary lectures, webinars andsymposia on anesthesia topics offered as in-person
and online programs. Examples for members include
but are not limited to the Anesthesia Update lecture
series delivered before the AAOMS Annual Meetingand the AAOMS Anesthesia Patient Safety
Conference. Courses intended for members and theirstaff include Advanced Protocols for Medical
Emergencies in the OMS Office, Anesthesia Assistants
Skills Lab and the Anesthesia Assistants Review
Course.

Simulation Training
AAOMS has created a simulation-based learning
experience intended to provide every OMS and theirstaff training in Office-Based Emergency Airway
Management (OBEAM) and Office-Based Crisis
Management (OBCM). Modules in the program
include didactic and hands-on mastery-based skills
training and adult cooperative learning modules thatallow participants to learn and update their airway
skills as well as improve team dynamics.

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Ongoing Quality Assessment
and Lifelong Learning
Ongoing quality assessment and lifelong learning are
signature elements in practice efficiency, procedural
effectiveness, the delivery of high-quality state-ofthe-art patient care, and optimized patient safety andemergency response. Given that oral and maxillofacial
surgery spans both medicine and dentistry, ongoing
quality assessment has been an integral part of thespecialty from both process and quality improvement
perspectives.
Lifelong learning continues beyond the completionof formal education and results in the growth ofimportant knowledge and skills. The results should bemonitored using objective measures. AAOMS and theAmerican Board of Oral and Maxillofacial Surgery
fully support this process in tangible ways.

Conclusion
AAOMS expects this white paper will be revisedover time as warranted, as is the case where there
is ongoing evolution of knowledge, technology andpractice preferences. Reality informs AAOMS that
there is a necessary balance between what is ideal andwhat is practical, particularly in communities where
resources are limited and access to care is challenged.
While it is understood the choice of agents andtechniques is dependent upon the experience, training
and preferences of individual practitioners, safety cannever be sacrificed.

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American Association of Oral and Maxillofacial Surgeons

White Paper

Office-based Anesthesia Provided by the Oral and Maxillofacial Surgeon
Background and Purpose
The American Association of Oral and Maxillofacial Surgeons (AAOMS) and its Board of Trustees embracesafety as one of its core values. Accordingly, anesthesia will always be an important research and educational
priority. AAOMS has long recognized the pursuit of safety in anesthesia requires a multi-faceted approach,understanding that more than one approach matters. This white paper was developed with the intent of identifying
and summarizing key elements of the team approach to anesthesia delivery.
Topics that were reviewed include the importance of formal (residency) education and lifelong learning, the roleof quality assessment programs such as the AAOMS Office Anesthesia Evaluation (OAE) program and the valueof implementing systems that promote safety and mock/practice drills to prepare for possible crisis events. Other
topics addressed are therapeutic goals and outcomes, the evaluation of factors that affect risks and complications,and principles of patient assessment. Consideration is given to special patient groups, including pediatric,
geriatric, pregnant, obese, developmentally disabled, and medically and physically compromised. The essentials
of monitoring – both during the procedure and as a part of the recovery process – are reviewed. The importanceof emergency preparedness efforts such as procedural routines to limit adverse events, simulation training andmock/crisis management drills is addressed as are challenges inherent with delivering anesthesia using an outside
provider.
This document was developed by a Special Committee of oral and maxillofacial surgeons and was approved
with input by the AAOMS Board of Trustees. The first stage in the development was to identify a committee of
topic experts and task them with reviewing relevant documents, including the AAOMS Parameters of Care, The
American Society of Anesthesiologists’ Practice Guidelines for Sedation and Analgesia by Non-anesthesiologists,
previous AAOMS white papers on anesthesia, and documents developed by other organizations that have aninterest in outpatient anesthesia. Committee members were expected to supplement this literature base withother evidence-based resources and to consider the opinions of those experienced and experts in office-based
anesthesia. Throughout the process, the goal was to offer concise evidence-based information that promotes safety
and procedural consistency among clinicians and grows understanding about the elements key to practicing in amanner that limits the risk of adverse outcomes. It is not intended to set absolute requirements and appreciatesthat following the recommendations set forth does not guarantee a specific outcome. However, it is the beliefof AAOMS that adhering to the principles outlined herein provides a solid foundation for the delivery of safe,
effective and cost-effective anesthesia in the office setting.
AAOMS expects this document will be revised over time as warranted, as is always the case where there isongoing evolution of knowledge, technology and practice preferences. While reality informs all that there is anecessary balance between what is ideal and what is practical – particularly in communities where resources arelimited and access to care is challenged – and while it is understood that the choice agents and techniques are
dependent upon the experience, training and preferences of individual practitioners, safety can never be sacrificed
in the interest of excellent care.
Note: Click theicon to return to each corresponding Executive Summary section of this white paper.

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Oral and Maxillofacial Surgery Residency
Education and Training

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Patient safety in the delivery of anesthesia and surgical care isof critical importance. From the earliest days of the specialty, there has been an emphasis on
education and experience in outpatient anesthesia. Over time, there has been some variability inthe educational requirements during residency. Changes were always made after much deliberatethought and with the goal of strengthening training and improving patient safety. The AAOMS Committeeon Education and Training (CET) remains central to this process.
The CET committee is composed of representatives of differing constituencies of oral and maxillofacial surgery
related educational groups. This includes direct appointments of residency-related educational thought leaders
and representation from the OMS National Insurance Company (OMSNIC), the OMS Surgery Foundation,
the AAOMS OMS Faculty Section, the Oral and Maxillofacial Surgery Commissioner to the American Dental
Association, the Commission on Dental Accreditation (CODA) Residency Review Committee, the American
Board of Oral and Maxillofacial Surgery (ABOMS), the predoctoral faculty and AAOMS Board liaisons. The
committee provides an invaluable service to the development and implementation of the standards by which
OMS residency education is defined.
An example of the forward-looking philosophy of the CET is the development of standards directly related topatient safety in OMS residency education. Miller’s Pyramid of Assessment provides a framework to assess
clinical competencies, defining progressive stages of “Knows (Knowledge),” “Knows how (Competence),”“Shows how (Performance)” and “Does (Action).” Central to this assessment concept, residents receive an
ongoing and comprehensive focus on promoting safety and quality improvement through the implementationof training standards.
Residents are exposed throughout training to theoretical and practical means to ensure that consideration ofpatient safety is routine and consistent. This includes participation in patient safety-focused initiatives such as
Crew Resource Management or Root Cause Analysis programs. Safety training is further enhanced by immersing
residents at all stages of training in policies, procedures and practices that minimize the risk of harm to patients.
Active participation by residents, faculty and appropriate clinical staff in regular safety-focused routines suchas mock emergency drills reinforces the theoretical concepts as well as models the attention to patient safety
expected of the contemporary surgical team. There must be the regular participation of the faculty, residents andstaff in clinic-based mock emergency drills. It also can include the use of high-fidelity simulation in the OMS
clinic-based environment. The faculty, residents and staff are expected to always adhere to established emergency
preparation protocols, such as those found in the AAOMS Office Anesthesia Evaluation Manual.
Additionally, OMS residents must demonstrate the use of other patient safety aids in the outpatient clinicalenvironment. This includes adaptation of pre-procedural timeouts and checklists for preanesthetic preparation as
well as procedure readiness verification. Lastly, the use of cognitive aids such as charts or guides for anesthetic
or medical emergencies has been adopted. Taken together, the implementation of all the patient safety-focused
initiatives has been to improve the routine care of the patients the OMS specialty serves. Ultimately, theeducational goal remains to transition the learner (resident) into safe and competent practitioners in all facets ofthe specialty to serve the public’s interest. By fostering patient safety during training, the development of lifelong
knowledge and skills in this critical area begins and lays the foundation for the surgeon’s career.

History of Anesthesia in Oral and Maxillofacial Surgery
The administration of anesthetic agents to prevent pain, suppress awareness and recall, and eliminate anxiety andfear during surgery was first introduced by Hartford, Conn., dentist Horace Wells at Harvard Medical School in
1845. Wells discovered that nitrous oxide – a gas still used in dental and medical practice today – could induce a
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state of unconsciousness and suppress pain and recall during surgery.
The next year, another dentist, William Morton, introduced the useof a more potent anesthetic agent, diethyl ether.

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The use of potent nonflammable inhalation anesthetic agents such as halothane, introduced in
1951, replaced inhalation agents that were flammable. Similar halogenated hydrocarbons included
enflurane (1972) and isoflurane (1979), which had significant hepatic and cardiotoxic effects. In
1990, sevoflurane and, in 1993, desflurane – with fewer cardiac and hepatic complications – replaced halothaneand enflurane. The use of potent inhalation agents for anesthesia was complicated by the need to intubate thepatient in order to accurately regulate anesthetic doses and to keep operating room personnel from being affectedby the gases and vapors. Sevoflurane is still in common use as an inhalational agent for selected cases in OMS
offices and ambulatory surgical centers.
The development of injectable intravenous anesthetics allowed more control in the depth and duration ofanesthesia without the need to intubate or otherwise use the mouth and nose as pathways to deliver inhalation
agents. An example was methohexital (Brevital), a barbiturate with a short duration of action, first reported
in 1940 by Adrian Hubble, an oral and maxillofacial surgeon. Hubble used repeated doses of methohexital tomaintain anesthesia sufficient to abolish pain and recall of tooth extractions in the office setting. From 1945
to the 1960s, other OMSs developed and published techniques using methohexital combined with meperidine(Demerol), or another opiate, and an anticholinergic drug to achieve what became known as balanced anesthesia.
The introduction of intravenous benzodiazepines, particularly diazepam (Valium) in 1963, marked the beginningof a broader continuum of anesthesia than previously possible. The term “sedation” was coined to describe a stateof depressed consciousness well-suited for many patients undergoing oral and maxillofacial surgery procedures in
the outpatient office setting. OMSs were the first to employ the use of what is now called ambulatory surgery andgeneral anesthesia for their short duration procedures in the office setting.
As newer sedative agents were developed, many of the older drugs were replaced in the practices of oral
and maxillofacial surgeons with more effective and generally shorter-acting agents with fewer side effects.
Methohexital has mostly been replaced with propofol (Diprivan), and diazepam with midazolam (Versed).
Meperidine has mostly been replaced with fentanyl and other short-acting opioids. Low-dose ketamine in
combination with midazolam is used by many OMSs, often to eliminate the opioid component of balanced
anesthesia.
Contemporary anesthesia practices in oral and maxillofacial surgery are based primarily on intravenous deliveryof one or more agents to produce balanced moderate sedation or deep sedation/general anesthesia. The additionaluse of local anesthetic blocks and infiltrations is nearly universal practice, reducing the need for higher doses ofthe sedative agents, promoting rapid return of consciousness and controlling postoperative pain. The first local
anesthetic was the naturally occurring alkaloid cocaine, used in the United States as early as 1884 for minor
procedures. Cocaine, which was highly addictive, was replaced in 1905 with procaine (Novocaine). Procaine
was widely used in dentistry until around 1944 when lidocaine (Xylocaine) was introduced. Lidocaine, whencombined with epinephrine, provided better local anesthesia without the potential allergic reactions experienced
with procaine. Lidocaine remains in widespread use today. Local anesthetics rely on tissue pH for effective
passage across nerve membranes to cause blockage of pain and other sensations. Infection at or near a surgical site
will create low tissue pH and prevent effective action of local anesthetics. Historically, many teeth were extracted
because of underlying infection, making local anesthesia ineffective.
The development of safe and affordable procedural sedation by OMSs has provided countless patients theability to experience anxiety-free and pain-free treatment for a variety of pathologic conditions of the mouth,
face and jaws.

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OMS Team Model of Delivery

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In 1970, the OMS team concept of anesthesia delivery was
introduced in California, with formal requirements for thecomposition of the anesthesia team, training standards, and requirements for the infrastructure
and monitors needed for safe administration of deep sedation and general anesthesia. Membershipin the Southern California Society of OMS required compliance, and mandatory on-site officeinspections were conducted by teams of OMSs. OMS anesthesia teams for deep sedation/general anesthesia arecomposed of a minimum of three personnel: 1) a trained surgeon/anesthesiologist, 2) a monitor whose duties
include maintenance of the patient’s airway by appropriate head positioning and observation of the monitoring
equipment for any deviation from normal values, and 3) a surgical assistant who suctions the surgical field andassists with the surgery. Didactic training programs are offered by AAOMS and other groups for OMS anesthesia
assistants with a certification of successful completion available through the Dental Anesthesia Assistant National
Certification Examination (DAANCE).
In 1975, AAOMS adopted similar requirements for OMS anesthesia teams and mandatory office inspectionsof its members throughout the United States. As technology advanced, the AAOMS infrastructure requirementsfor office-based moderate sedation and deep sedation/general anesthesia evolved to require state-of-the-art
monitoring, including electrocardiograph, noninvasive blood pressure, pulse oximetry and capnography inaddition to the use of traditional approaches such as pre-tracheal and pre-cordial auscultation that supplement
careful observation of the patient.
The OMS team is led by the surgeon-anesthesiologist who has completed a minimum of 12 to 14 years of postsecondary education. During the four to six years of OMS residency, he or she has trained full-time in a hospitalbased medical anesthesiology residency program for a minimum of five to six months, followed by an additional
30 months of training in applying these skills to patients using the OMS Team Model of Anesthesia Delivery
in outpatient settings. OMS residents must complete and maintain active certification in the American Heart
Association’s Advanced Cardiac Life Support and Pediatric Advanced Life Support programs before graduation.
The second team member is the monitor. The monitor maintains the patient’s head position to ensure the patientis breathing normally and observes the displays showing the patient’s vital signs and other important safety
information. Any deviation from normal is reported to the surgeon immediately.

AAOMS standards recommend that monitors complete a minimum of six months of on-the-job training in an
OMS office where moderate sedation and deep sedation/general anesthesia are routinely performed before being
enrolled in a focused didactic educational program in Oral and Maxillofacial Surgery Team Model anesthesia
assisting. Monitors must be certified in basic cardiac life support. Note: the AAOMS Dental Anesthesia AssistantNational Certification Examination (DAANCE) is a psychometrically validated examination. The third teammember is the surgical assistant who is, at a minimum, a dental assistant with current certification in basic cardiac
life support.
The OMS Anesthesia Team Model has been in widespread use for more than 50 years. During calendar years
2018 to 2021,* office-based dental anesthesia services were delivered to 24,194,239 individuals insured by private
dental insurance in the United States. Of all the moderate and deep sedation/general anesthesia cases performed
in 2018-2021 (a total of 8,894,182), oral and maxillofacial surgeons performed 6,929,439 – or 78 percent – of thetotal case load. In children ages 8 to 12 requiring deep sedation/general anesthesia, OMSs provided 80 percentof the procedures. For children ages 1 to 7 requiring procedural sedation, OMSs provided 41 percent of these
services. The availability for patients to receive OMS-provided anesthesia care is clearly critical to providing
access to compassionate dental care.
*Statistics calculated by AAOMS using data from the U.S. Census Bureau and information provided by FAIR
Health based on its privately insured dental claims data for calendar years 2018-2021.
PAGE 11 Office-based Anesthesia Provided by the Oral and Maxillofacial Surgeon

Definitions 		
For consistency and clarity, definitions of the anesthesia-related
terms are listed below. Additional anesthesia-related terminology
will be defined in specific sections of this white paper.

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Airway Techniques – There are numerous techniques for managing the airway during an anesthetic.
• Open Airway Technique: Common in the OMS Anesthesia Team Model, this technique involves constant andvigilant attention to the airway by the oral and maxillofacial surgeon and the trained surgical assistant, both ofwhom are in direct and continual control of the patient’s airway. A throat screen or throat pack is used alongwith constant suctioning to keep the posterior oral cavity dry and free of debris. The team maintains the open
airway by positioning of the patient’s head, neck, tongue and mandible. Nasopharyngeal or oropharyngeal
airways are sometimes useful adjuncts. Supplemental oxygen is used, and end-tidal CO2 is constantly
monitored with capnography to ensure ventilation and oxygenation. A third trained anesthesia assistantcontinually monitors the patient.
• Supraglottic Airway Technique: This technique can be used for routine anesthetics with an inhalation agent
and an anesthesia machine. It also can be very useful in establishing an emergency airway. Laryngeal Mask
Airways (LMAs) and other similar devices are readily available and easy to use.
• Endotracheal Intubation Airway: This method is most useful for longer, more extensive surgical procedures
and in patients where the potential loss of the airway is a greater concern. It is used with an anesthesia machine.
It also can be used as an emergency airway.
Anesthesia Provider – An oral and maxillofacial surgeon, dentist anesthesiologist, physician anesthesiologist,
anesthesia assistant (a new category of trained anesthesia provider), or certified registered nurse anesthetist(CRNA) who is trained, licensed and permitted by a state to perform specific types of anesthesia services.
Anesthesia Routes of Administration – Various methods used to administer anesthetic medications. Parenteral
techniques include intravenous, subcutaneous, intramuscular, transdermal and transmucosal administrations.
Enteral techniques include oral and rectal. Inhalation techniques and intranasal administrations are additionalroutes.
ASA Physical Status Classification System – Commonly used system for assessing and communicating apatient’s pre-anesthesia medical co-morbidities. When used along with other clinical perioperative and patient
factors, it can help to predict perioperative risks. A summary of the ASA PS Classification System includes thefollowing (with a more detailed document on the ASA website):• ASA PS I – A normal healthy patient who is a non-smoker with no or minimal alcohol use.
• ASA PS II – A patient with mild diseases only, with no substantive functional limitations.
• ASA PS III – A patient with severe systemic disease and substantive functional limitations.
• ASA PS IV – A patient with severe systemic disease that is a constant threat to life.
• ASA PS V – A moribund patient who is not expected to survive without the operation.
DAANCE – Dental Anesthesia Assistant National Certification Examination, a two-part continuing education
program comprised of approximately 36 hours of self-study material and quizzes and a standardized, computerbased exam. The course is designed for oral and maxillofacial surgery assistants or assistants employed by otherdental professionals with valid anesthesia permits. The course and examination cover five major areas: Basic
Sciences, Evaluation and Preparation of Patients with Systemic Diseases, Anesthetic Drugs and Techniques,
Anesthesia Equipment and Monitoring, and Office Anesthesia Emergencies. This comprehensive training helps
oral and maxillofacial surgeons maintain high levels of safety in their offices for patients.
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Dental Anesthesia Assistant – Trained dental assistant who
has additional training and experience in helping an oral andmaxillofacial surgeon or other anesthesia provider with monitoringa patient under sedation or general anesthesia and with airway or
emergency management.

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Dental Anesthesia Incident Reporting System (DAIRS) – An anonymous, self-reporting systemused to collect and analyze anesthesia incidents in order to improve the quality of dental anesthesia care. All
dental anesthesia providers are encouraged to report events related to the delivery of anesthesia. Incidents reported
to DAIRS are maintained as privileged and confidential data. For more information, visit AAOMS.org/DAIRS.
Levels of Anesthesia – Sedation and general anesthesia levels are a broad continuum with significant variability.
An individual patient’s medical conditions and physiology, their responses to medications and the doses
administered, and the anesthesia techniques used are all factors that can determine the level of anesthesia that
occurs. Level of sedation is entirely independent of the route of administration. Moderate and deep sedationor general anesthesia may be achieved via any route of administration. Every anesthesia provider intending to
produce a specific level of anesthesia should be trained and skilled in rescuing a patient whose level of anesthesia
becomes deeper than originally intended. It is inappropriate to continue a procedure at an unintended level ofsedation. More detailed information on Levels of Anesthesia can be found on the ASA website. The following
are the recognized levels of anesthesia:• Minimal Sedation (Anxiolysis): A drug-induced state during which patients respond normally to verbal
commands. Cognitive function and coordination may be impaired. Airway reflexes, ventilatory functions
and cardiovascular functions are unaffected.
• Moderate Sedation/Analgesia: A drug-induced depression of consciousness during which patients
respond purposely to verbal commands, either alone or accompanied by light tactile stimulation (but not areflex withdrawal from a painful stimulus). No interventions are required to maintain a patent airway, andspontaneous ventilation is adequate. Cardiovascular function is usually maintained.
• Deep Sedation/Analgesia: A drug-induced depression of consciousness during which patients cannot beeasily aroused but respond purposely following repeated or painful stimulation (but not a reflex withdrawal
from a painful stimulus). 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: A drug-induced loss of consciousness during which patients are not arousable, even by
painful stimulation. The ability to maintain ventilatory function independently is often impaired. Patients often
require assistance in maintaining a patent airway, and positive pressure ventilation may be required becauseof depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascularfunction may be impaired.

Therapeutic Goals and Outcomes
Knowledge of the therapeutic goals of sedation and general anesthesia is an essential part of providing officebased anesthesia services to patients. Equally important is a clear understanding of expected therapeutic outcomesalong with possible anesthesia-related risks and complications. The AAOMS Parameters of Care and the AAOMS
Office Anesthesia Manual are resources to help oral and maxillofacial surgeons and their staff in these areas.
The therapeutic goals for office-based anesthesia revolve around the management of anxiety, fear and pain. Most
patients have such concerns about their proposed surgical treatment. All three must be addressed during theperioperative period to allow safe and successful completion of the needed surgical procedure. The selection of
the best technique for controlling anxiety, fear and pain for a specific patient and procedure must be determined
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by the surgeon based on training, experience and an understandingof risks and benefits.
The AAOMS Parameters of Care outlines the following:

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General Therapeutic Goals for Anesthesia in Outpatient Facilities• Full recovery within a reasonable period of time.
• Appropriate understanding by patient and family of treatment and anesthesia options and acceptanceof treatment plan.
• Appropriate understanding and acceptance by patient and family of favorable outcomes and known risks
and complications.
General Factors Affecting Risk During Anesthesia in Outpatient Facilities• Degree of patient’s and/or family’s understanding of the origin and natural course of the condition and/or
disorder and the knowledge of the patient’s and/or family’s medical history• Presence of coexisting systemic disease (e.g., diseases that increase a patient’s ASA PS Classification
to II, III or IV)• Age of the patient• Use of prescribed or over-the-counter medications and/or herbal medications or vitamins• Current or past use of illicit drugs or alcohol• History of or current use of tobacco• Degree of patient’s and/or family’s understanding of the therapeutic goals and acceptance of the proposed
treatment, resulting in the patient’s and family’s cooperation and compliance with perioperative anesthetic
instructions• Conditions that promote airway obstruction• Conditions that impede ventilation and/or intubation of the hypopneic/apneic patient• Family history of problems related to anesthesia• Diagnosed obstructive sleep apnea (OSA) or elevated Body Mass Index (BMI)• Presence of infection• Pregnancy
General Favorable Therapeutic Outcomes for Anesthesia in Outpatient Facilities• Recovery of the patient from the anesthetic effects, returning to his/her preanesthetic physiologic andpsychologic state within an appropriate time after the cessation of the administration of the anesthetic drugs.
• Agreement that the anesthetic experience was satisfactory by the surgeon, patient and family.
• Recovery from the administration of sedatives, anesthetic agents and other adjunctive medications.
• Patient and family acceptance of procedure and understanding of outcomes.

Techniques
An individual patient’s medical conditions and physiology, responses to medications, the doses administered, andthe technique used influence the level of anesthesia. A variety of administration routes can be employed to achieve
PAGE 14 Office-based Anesthesia Provided by the Oral and Maxillofacial Surgeon

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the desired therapeutic goals, including local, enteral, parenteraland inhalation. Local, enteral, parenteral and inhalation routes ofadministration are utilized by the practitioner. It should be noted thatthe level of anesthesia achieved is independent of the administration
method. OMSs may personally administer medications and may delegate the administration of
medications by some routes to trained staff members under direct, continuous supervision, as
permitted by state regulations.

• Local Anesthetics: Ester and amide local anesthetics reversibly block sodium (Na+) channels, ultimately
denying nerve impulse propagation. Vasoconstrictors are often used in combination with local anesthetics
in order to maintain higher drug concentrations at the target site and minimizing surgical bleeding. Local
anesthetics minimize the amount of other anesthetic agents necessary to achieve therapeutic goals.
• Enteral Anesthetic Agents: Typically include benzodiazepines, non-benzodiazepine hypnotics, and alpha-2
agonists. There are many variables that confound the ability to accurately predict the pharmacokinetic andpharmacodynamic behavior of drugs when administered via the enteral route.
• Parenteral Anesthetic Agents: Include opioids, benzodiazepines, propofol, ketamine, barbiturates, andalpha-2 agonists. Parenteral routes include intravenous, intramuscular, and subcutaneous injection sites. The
intravenous route provides the most rapid onset and 100 percent bioavailability. However, all medications
administered via the parenteral routes should follow the guidelines of the Centers for Disease Control andPrevention (CDC) Safe Injection Practices to Prevent Transmission of Infection to Patients and labelling
guidelines set by the American Society of Anesthesiologists.
• Inhalation Agents: The final route of administration is inhalation of volatile gases. Inhalation agents include
nitrous oxide, sevoflurane, isoflurane and desflurane. The large surface area of the lungs allows for rapid accessof the agent to the systemic circulation.

Anesthesia Risks and Complications
Known risks and complications of the planned anesthetic for a procedure must be discussed with the patientand family preoperatively as a part of the Informed Consent Process, and all questions should be answered.
Fortunately, for reasonably healthy patients, office-based anesthesia is very safe. However, there are rare instanceswhere serious complications occur, and the anesthetic team must be prepared to recognize, diagnose and treat
them. Successful management of complications requires the entire office staff to function as a well-trained team.
Regular practice sessions for simulated emergencies are essential and prepare the entire team to manage a real
emergency. The AAOMS Office Anesthesia Evaluation Manual is an comprehensive resource for this training.
Anesthesia complications include the following:• Syncope• Nausea and vomiting, possible pulmonary aspiration• Venipuncture complications: hematoma, extravasation, phlebitis, intra-arterial injection• Medication overdose, allergic response, anaphylaxis• Hypoglycemia, hyperglycemia• Dental injury related to anesthesia administration• Oral or nasal injuries related to anesthetic administration• Airway complications: obstruction, laryngospasm, bronchospasm, foreign body displacement into upper airway
or bronchus
PAGE 15 Office-based Anesthesia Provided by the Oral and Maxillofacial Surgeon• Respiratory complications: hypoventilation, prolonged hypoxia
or hypercarbia, respiratory arrest, inability to ventilate, inability
to intubate

White Paper• Cardiovascular complications: hypotension, hypertension,arrhythmias, acute coronary syndrome, cardiac arrest/myocardial infarction• Seizures• Peripheral or central neurologic deficits• Ocular injuries• Local anesthetic systemic toxicity (LAST)• Thromboembolic events• Malignant hyperthermia• Unplanned hospital admission• Organ failure related to anesthesia administration• DeathIn summary, the oral and maxillofacial surgeon must continually stay focused on therapeutic goals andtherapeutic outcomes related to sedation and general anesthesia. Additionally, constant vigilance in patient
selection and appropriate anesthetic planning are essential in minimizing and preventing risks and complications
related to anesthesia.

Patient Evaluation
The care of the patient involves two considerations: the planned surgical procedure and the appropriate
management of the discomfort and anxiety that will accompany that procedure. Office-based surgeries are
typically minimally invasive with a low potential for significant blood loss and hemodynamic changes. However,the provision of local anesthesia, deep sedation or general anesthesia all involve the administration of agents withpotentially significant systemic effects. The responsibility of the oral and maxillofacial surgeon is to ensure thepatient can tolerate not only the surgical procedure but also, more importantly, the local and general anesthesia.
The provision of local anesthesia, sedation as well as deep and general anesthesia in any patient is not without
risk. The very essence of risk stratification is to identify patients with varying degrees of anesthesia risk andadjust the anesthesia plan accordingly. Most patients are relatively healthy and will require no modification to
the anesthesia plan. Other patients will require substantial modifications. This may include the choice of local
anesthetic, anesthesia medications, drug doses, duration of anesthesia and post-anesthesia recovery. On occasion,it also will necessitate that a patient be treated in an ambulatory surgical center or hospital operating room to
optimize patient safety.
It also is understood that individual patient variability to medication is significant. The provision of anesthesia
needs to appreciate some patients will have profound responses to even minimal doses of medications that canlead to acute respiratory compromise. The ability to rescue patients from unintended deeper levels of sedation
requires not only the skills of the anesthesia team but a patient who has the appropriate anatomy to provide
supplemental oxygenation. Patients also will vary in the amount of time they will tolerate hypoxemia andhypercarbia before decompensation occurs. Therefore, these two factors – individual patient anatomy and patient
reserves – need to be considered when determining who can be treated in an office setting.

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The five key elements to enable appropriate risk stratificationfor office-based anesthesia include:• American Association of Anesthesiology Physical Status

White Paper• Functional Status (METs)• Mallampati Classification• Body Mass Index (BMI)• Airway access in event of airway compromise
Patient evaluation begins with a thorough medical history that includes specific questions about previous
surgical and anesthetic experiences. The initial consultation with a patient provides the opportunity to obtain athorough medical, social and surgical history as well as perform an anesthesia-focused physical examination. This
allows the OMS to identify the appropriate surgical plan as well as comorbid medical conditions that allow risk
stratification prior to determining the most ideal anesthetic technique. On occasion, this will require that the OMS
consult with the patient’s other healthcare providers and/or request additional diagnostic testing to appropriately
risk stratify the patient.
It is ideal if patients can complete their medical history intake forms at home prior to presenting to the office. This
allows the patient to gather the information at home prior to the consultation. Furthermore, the documents can besubmitted electronically ahead of time to facilitate an initial review of the patient’s medical history.
The initial office visit should include obtaining vital signs, including blood pressure and heart rate. It may also be
advantageous to record the oxygen saturation (SpO2) that serves as a good surrogate monitor of cardiopulmonary
function. Staff who records these vital signs should have basic training in the recognition of abnormal rhythms,
including bradycardia, tachycardia and irregular rhythms. All abnormal values should be flagged for review by
the OMS. A review the patient’s past medical and surgical history will allow the patient to be classified using theAmerican Society of Anesthesiologists (ASA) physical status guidelines (Table 1).
Table 1. American Society of Anesthesiologists Physical Status Guidelines
ASA PS Classification
ASA I
ASA II

Definition
Normal healthy patient
Patient with MILD systemic disease

ASA III

Patient with SEVERE systemic disease

ASA IV

Patient with SEVERE systemic disease
that is a constant threat to life

ASA V

Moribund patient who will not survive
without the operation
Brain-dead patient having organs harvested

ASA VI

Explanation
No smoking and moderate alcohol
Mild disease without functional
limitations
Severe disease with functional
limitations
Severe disease (e.g., recent
myocardial infarction [MI],cerebrovascular accident [CVA]or transient ischemic attack [TIA],
acute coronary syndrome [ACS],
severe valvular heart disease,sepsis)N/A
N/A

In an ideal setting, patients within ASA I and II classes are the best candidates for office-based anesthesia as they
have acceptable cardiovascular and pulmonary reserves to undergo deep sedation and general anesthesia. OfficePAGE 17 Office-based Anesthesia Provided by the Oral and Maxillofacial Surgeon

based deep sedation and general anesthesia should be approachedwith caution for ASA III patients. This may require modifications
to the anesthesia plan to further reduce the potential risk of adverse
cardiovascular and pulmonary complications.

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Contemporary pre-anesthetic evaluation has greatly reduced the need for routine laboratory
testing. Significant information about pulmonary and cardiovascular reserve can be determining
by determining the patient’s Metabolic Equivalents (METs). This reflects the patients exercise tolerance with
one MET equivalent to 3.5 mL of oxygen per kilogram consumed per minute (3.5 mL O2/ kg/ minute). METs
offer the best insight into a patient’s ability to withstand changes in pulmonary and cardiovascular function that
may occur during anesthesia. Low METs or a recent decline in METs should alert the OMS to the potential foradverse anesthesia-related complication that requires further work-up and risk stratification. Patients who reporta functional status of less than 4 METs are not candidates for an office-based deep sedation or general anesthesia
due to their lack of cardiac and respiratory reserve (Table 2).
Table 2. Functional Status Assessment (METs) Examples
Excellent (>7 METs)
SquashTennis
Jogging
Cleaning floors

Moderate (4 – 7 METs)
Cycling
Climbing a flight of stairs
Walking 4 mph
Yardwork

Poor (≤ 4 METs)
Walking 2 mph
Activities of Daily Living

Adapted From: Hlatky MA, Boineau RE, Higginbotham MB, Lee KL, Mark DB, Califf RM, et al. A brief self-administered questionnaire
to determine functional capacity (the Duke Activity Status Index). Am J Cardiol. 1989;64:651–4.

The ability to establish an airway remains critical to office-based anesthesia. The Mallampati classification is atool for predicting difficulty related to establishing and maintaining an airway in addition to intubating patients.
Although it is not possible to adjust a patient’s Mallampati score, the anesthesia plan should be modified
according to the relative airway risk associated with different scores (Figure 1).
Figure 1. Mallampati Classification (1 – 4)

The BMI is a useful parameter to help predict anesthesia-related complications (Table 3). It is calculated by
dividing the patient weight (kg) by his/her height (m2). Patients who fall into a normal or overweight categorypose little anesthetic risk. A BMI that places a patient in the underweight category increases the anesthesia risk
due to electrolyte abnormalities and cardiac arrhythmias. A BMI that places a patient in the obese and morbidly
obese categories also places the patient at increased risk due to the potential for loss of airway; decrease
Functional Residual Capacity (FRC) and difficulty with establishing and airway or intubation. Adjusting
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the anesthesia regime by avoiding apnea-producing drugs may
be beneficial.
Table 3. Body Mass Index< 18.518.5 – 24.9
25 – 29.9
30 – 40> 40

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Underweight
NormalOverweight
Obese
Morbidly Obese

Challenges related to maintaining a patent airway or establishing one when
it is lost are compounded not only by the BMI but also by the length anddiameter of the neck. The sternomental distance extends from the sternal
notch to the menton with a distance of less than 12.5 cm having a positive
predictive value of 82% for a difficult intubation (Figure 2).
The checklist for patient evaluation for office-based anesthesia should
include:Figure 2. Sternomental Distance• Blood pressure, heart rate and rhythm• Height and weight (Body Mass Index)• Past medical, social, surgical and anesthesia history• Current medications including recent changes in medications• Allergies• Risk factor evaluation for obstructive sleep apnea• Salient laboratory result review
a. ECG for patients with cardiac disease (within 6-12 months)
b. Blood glucose levels and Hemoglobin A1C for diabetics (Type I and Type II)c. INR reports for patients taking warfarin (within five days of planned surgery) or suspected hepatic diseased. SpO2 on room air for patients with respiratory disease• Recording of ASA status• Recording of METs level
There are specific aspects of the patient physical examination that are critical for office-based anesthesia.
These include:• Focused airway examination
a. Mallampati score recorded
b. Maximum incisal openingc. Risk factors that contribute to difficulty with positive pressure ventilation, including facial hair, edentulism,
short and thick neck, increased BMI• Auscultation of lungs• Observation of extremities for venipuncture sites
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It remains controversial whether pregnancy testing is appropriate
for females of childbearing age who undergo office-based deep
sedation or general anesthesia. The AAOMS Parameters of Caredoes not endorse routine testing for pregnancy. Exceptions may
be indicated if there is an equivocal history of sexual activity with a possibility of pregnancy
due to an uncertainty regarding the time of the last menstrual period. A point of care (POC)
urine testing kit for pregnancy is available and usually positive within 14 days of conception.
Minors (< 18 years of age) can be offered a urine pregnancy test in the office after dismissing the parents
from the treatment room. The anesthetic should be postponed if the test is positive.

Body Systems and Disease
CARDIAC DISEASE

A history of cardiac disease will require further evaluation to appropriately risk stratify the patient. Many patients
who are good historians can provide adequate information about their status to allow the OMS to determine whatfurther information and/or tests are needed for review. Consultation with the patient’s primary care physician or
cardiologist may be indicated.
CORONARY ARTERY DISEASE AND MYOCARDIAL INFARCTION

The OMS should inquire about angina or shortness of breath (SOB) with exercise that may suggest Ischemic
Heart Disease (IHD). Determining the functional status of the patient using METs is particularly important toassess disease severity. The use of chronic and episodic vasodilator medications, including nitroglycerine, also
will provide insight. A history of myocardial infarction (MI) requires additional information. A history of an MI
within the last six weeks is a contraindication to all elective surgery. An MI that occurred more than six weeks
ago and that is not associated with reduced functional status can usually proceed. However, the longer the time
period since the MI, the less the risk related to adverse cardiac events. Many patients with a recent MI undergo
Percutaneous Coronary Angioplasty (PCA), which has significantly reduced mortality and morbidity. Following
PCA most patients are treated with dual anti-platelet therapy (DAPT). This involves the use of aspirin and either
a glycoprotein IIb/IIIa inhibitor (e.g., abciximab, eptifibatide) or an ADP antagonist (e.g., clopidogrel). The
glycoprotein IIb/IIIa inhibitor or ADP antagonist should be continued for a minimum period of 14 days, 30 days
and typically three months for balloon angioplasty, bare metal stents and drug eluting stents, respectively. ECG
monitoring is indicated and by using a modified V5 lead (move the left arm lead to the mid axillary position andset the machine to monitor lead I), a higher sensitivity for ST segment changes can be noted. Even with treatment
with just local anesthesia, supplemental oxygen with/w/o nitrous oxide may benefit the patient as well.
CARDIAC ARRHYTHMIAS

Cardiac arrhythmias can result in significant morbidity during anesthesia. The use of epinephrine containing local
anesthetics, endogenous epinephrine and certain anesthetic agents – such as ketamine and inhalational agents –can result in arrhythmias. Patients with Wolff Parkinson White syndrome, second-degree Type 2 and third-degree
heart blocks are not candidates for office-based deep sedation or general anesthesia. Atrial fibrillation (AF) is
common arrhythmia that should be recognized relatively easily upon taking vital signs. The use of medications
such as warfarin or other direct acting oral anticoagulants (DOACs) may provide further information regarding
the potential for AF. Concerns with AF relate to the potential for a rapid ventricular rate (RVR) that can lead toacute decompensation and heart failure. The anesthetic should plan should limit use of epinephrine and avoid
excessive fluid replacement. Patients with chronic AF and a rate greater than 90 BPM should be considered for
cardiology referral to achieve optimal rate control. Patients with implanted pacemakers and internal defibrillators(ICDs) warrant cardiac consultation and anesthesia should be considered in an ambulatory surgical center or
hospital OR.
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CONGESTIVE HEART FAILURE

Congestive Heart Failure (CHF) is a progressive loss of the normal
cardiac output. Symptoms of non-compensated heart failure may
include shortness of breath, peripheral edema and/or fatigue. The
functional status (METs) provides valuable insight into disease severity. Many individuals cannot
tolerate acute changes in heart rate or blood pressure, and the anesthetic plan should include
monitoring of the patient’s blood pressure and lead II ECG even if treatment with just local
anesthesia is considered. Patients with moderate to severe CHF are not candidates for office-based deep sedationor general anesthesia.
VALVULAR HEART DISEASE AND PROSTHETIC VALVES

A patient may be referred for multiple extractions prior to a planned valve replacement and, depending on thecomplexity of the extractions, may not be suitable for treatment in an office-based setting. Consideration should
be given to scheduling multiple appointments. Once valve replacement has occurred, patients are typically morestable. Anticoagulant therapy will be continued after valve replacement when the valve is alloplastic. Xenograft(porcine) valves typically only require anticoagulation for six months. Consultation with the cardiologist as wellas the patient’s functional status will enable risk stratification and an appropriate anesthesia plan to be determined.
RESPIRATORY DISEASE

One of the major risks of an office-based anesthesia is the development of apnea/hypopnea due to the anesthetic
medications. The improvement in monitoring with end tidal carbon dioxide (ETCO2) monitoring and a precordial
stethoscope will alert the OMS to the development of apnea in real time. The time from the development of apnea
until the oxygen saturation declines depends on several factors, including pre-oxygenation and the functional
residual capacity (FRC). Obese patients, pediatric patients and those with comorbid medical conditions have
reduced FRC and will desaturate relatively rapidly (Figure 2).
Figure 2. Time to Desaturation

Adapted from: Benumof JF, Dagg
R, Benumof R: Critical Hemoglobin
Desaturation Will Occur before Return toan Unparalyzed State following 1 mg/kg
Intravenous Succinylcholine Anesthes.
1997;87(4):979-982

HEPATIC DISEASE

There are various causes of hepatic disease, including viral hepatitis, chronic alcoholism and hepatotoxicity fromdrugs. Many anesthetic drugs are bound to plasma proteins that are produced in the liver. Therefore, hepaticdisease may result in increased free drug within the circulation with the potential for enhanced and prolonged
drug activity. Additionally, as the liver is responsible for metabolism of many drugs including opioids and

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benzodiazepines, hepatic disease may result in an increased half-lifeand prolonged anesthetic effects. Rapidly redistributed drugs suchas propofol may be a better choice in these patients. Consultation
with the primary care physician or hepatologist as well as acomprehensive metabolic panel is required prior to risk stratifying the patient.
RENAL DISEASE

Renal disease presents another set of anesthesia challenges. Urinary excretion of drugs remains a majormechanism for drug elimination. Drug elimination will be reduced with renal disease that can result in prolonged
drug action, particularly when drug metabolites also have a therapeutic effect. Additionally, the kidney is
responsible for electrolyte and fluid homeostasis. Renal disease can therefore result in significant electrolyte
abnormalities and fluid shifts. This can result in a decreased cardiovascular reserve as well as cardiac arrhythmias.
Consultation with the primary care physician or nephrologist together with a comprehensive metabolic panel isrequired to enable risk stratification.
ASTHMAThe most common chronic respiratory disease that the OMS will encounter is asthma. The patient with asthma
requires particular attention in order to classify the asthma severity and control, hence the potential for anesthesiarelated complications (Table 3).
Table 3. Asthma Severity Classification (>12 years old)
Components of Severity

Intermittent

Mild

Moderate

SevereSymptoms< 2 days per week

> 2 days per
week but not
daily

Daily

Several times
per dayNocturnal awakenings< 2x per month3-4x per month> 1x per week but
not nightly

Often 7 nights per
week

SABA use for symptom control(not for prevention of exercise
induced bronchospasm)< days/week> 2 days per
week but not
daily

Daily

Several times per
day

Interference with normal activity

None

Minor limitation

Some limitation

Extremely limited

Lung function
Measured by FEV1 (% predicted)

> 80%

> 80%

60-80%< 60%

Exacerbations requiring use of oral
steroids

0-1 / year

> 2x per year

> 2x per year

> 2x per year

Medium dose ICS,+/- LABA, LTRAHigh dose ICS +LABA or LAMA,
LTRA, daily oralcorticosteroids*
Biologic agents**

Likely Medications

SABA as needed

Low dose ICS,LTRA*LABA: Long acting β agonist; SABA: Short acting β agonist; ICS: Inhaled Corticosteroids; LTRA: Leukotriene Receptor Antagonist;
LAMA: Long-acting muscarinic agent**Biologic medications are injectable or intravenous monoclonal antibodies targeting a specific axis in asthma either IgE, IL-5, IL5Receptor, IL-4/IL-13 Receptor based on asthma phenotype (allergic, eosinophilic). Available agents include omalizumab (Xolair),mepolizumab (Nucala), reslizumab (Cinquair), benralizumab (Fasenra), dupilumab (Dupixient). Note: This is a field with many new
agents due to come to market in coming years. Thus, this list will grow.

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It also is important to assess asthma control using the following
screening tool as poorly controlled asthma is a contraindication
to office-based deep sedation or general anesthesia.

White Paper• In the past four weeks, has the patient had:a. Daytime symptoms more than 2x per week?
b. Any night waking due to asthma?
c. SABA reliever use for symptoms more than 2x per week?
d. Any limitation of activity due to asthma?
Well-controlled Asthma: Report “no” to all of above questions.
Partly Controlled Asthma: Report “yes” to 1-2 of these questions.
Uncontrolled Asthma: Report “yes” to 3-4 of these questions.
Mild intermittent asthmatics and mild persistent asthmatics are reasonable candidates for office-based deep
sedation and general anesthesia. Moderate and severe asthmatics are better managed in an ambulatory surgicalcenter or hospital OR where complications such as bronchospasm are more readily managed. The avoidanceof known triggers for histamine release such as non-steroidal anti-inflammatory medications (NSAIDs) andmorphine is important. Patients with a recent (≤ 4 weeks) Upper Respiratory Infection (URI) are not goodcandidates for deep sedation or general anesthesia given the increased risk of bronchospasm. There is also
some evidence that asthmatic patients are at increased in post-anesthetic respiratory adverse events (PRADEs).

Geriatric Patients
Geriatric patients provide a unique set of challenges that must be anticipated. The function of all organ systems
decreases with advancing age. It becomes even more important to risk stratify geriatric patients to reduce
anesthesia related morbidity. Geriatric patients may have reduced cardiovascular, pulmonary, renal, hepaticand cognitive function.
General• ↓ Lean muscle mass
• ↑ Fat stores• ↓ Blood volume
CNS• Cerebral atrophy with cognitive impairment, confusion and dementia• Autonomic dysfunction with labile BP, impaired thermoregulation and delayed gastric emptying
Cardiovascular• Congestive heart failure and coronary heart disease• Atrial fibrillation• Hypertension• Increased circulatory time
Pulmonary• Diminished Functional Reserve Capacity (FRC)
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• Blunted response to ↑CO2 or ↓O2• Loss of protective cough and swallow reflexes

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Renal• ↓ Glomerular Filtration Rate
• Fluid and electrolyte imbalance• ↓ Capacity to excrete drugs and metabolites
Hepatic• ↓ Blood flow to the liver• ↓ Ability to metabolize drugs• ↓ Albumin and protein binding
The number of medical comorbidities associated with the geriatric patient also results in an increased number of
medications in this population. The combination of altered physiological responses and medications will attenuate
and blunt the usual pulmonary and cardiovascular responses to anesthesia. Furthermore, the medications are often
the source of potential drug interactions resulting in the need to carefully evaluate the choice of anesthesia drugs.
It is always advantageous to manage geriatric patients with local anesthesia alone to reduce the potential foranesthesia complications. Geriatric patients who require deep sedation to complete a surgical procedure should be
carefully risk stratified to ensure the planned anesthesia is appropriate and safe. Patients are generally encouraged
to maintain their regular medications with the exception of diabetic medications that require cessation or
adjustment. It is prudent to avoid drugs that tend to result in postoperative delirium. Accordingly, it is reasonable
to avoid benzodiazepines and ketamine where possible. Additionally, narcotics should be used judiciously
following weight-based guidelines. The combined use of fentanyl and propofol works well with few side effects
and little likelihood of apnea or cardiovascular changes. The following loading doses are considered conservative
but may be a reasonable staring point:• Fentanyl 0.25 – 0.5 µgms/kg (approximately 20 – 40 µgms)• Propofol 0.25 – 0.4 mgs/kg (approximately 15 – 30 mgs)
This should be followed by judicious titration to ensure vital signs and cardiovascular parameters remain stable.
The prolonged circulatory time in the geriatric patient does require that a longer time pass following injection ofanesthetic medications before deeming a dose inadequate.

Special Considerations
CONSIDERATIONS FOR PEDIATRIC ANESTHESIA IN OUTPATIENT FACILITIESIt is important to appreciate that children are not simply “small adults” – rather they have many unique andconstantly changing anatomic, physiologic, pharmacologic and psychologic differences. The anesthetic goals forthe pediatric patient are safety, cooperation, elimination of pain, reduction of anxiety and control of behavior toallow completion of the planned intervention.
The initial evaluation of the pediatric patient is unique in several ways. The history is derived almost completelyfrom the caregiver. Systemic diseases and prescription medications are uncommon, and past anesthetic
experiences may be rare. Instead, a family history of allergies and systemic disease can be of great importance.
A targeted physical exam should consist of an airway, heart and lung evaluation. Recent upper respiratory
infection, fever, mucopurulent nasal drainage, audible wheezing or a productive cough should prompt further
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evaluation. Congenital cardiac defects or the presence of a new
cardiac murmur should be evaluated completely prior to proceeding.

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Children have unique anatomical and physiologic characteristics
that must be considered during anesthesia. Their small nares, large tongue and enlarged tonsils/
adenoids can cause passive airway obstruction. Lower airway differences can hamper direct
laryngoscopy and present significant challenges during airway management. The pediatric airway
is far more reactive to stimuli such as secretions or foreign bodies than an adult airway. As a result, laryngospasm
must be expected, quickly identified and skillfully managed. Pediatric cardiac output can be maintained over awide range of preloads and rates without failing, but young pediatric patients rely almost solely on heart rate tomaintain blood pressure. As a result, bradycardia is an ominous sign during any pediatric anesthetic and must be
immediately detected and corrected.

Pharmacologic considerations demand a thorough knowledge of anesthetic and analgesic agents. Manyroutes of administration are available to the oral and maxillofacial surgeon providing pediatric anesthesia. All
pediatric patients should be weighed prior to drug dose selection. Intraoperative and postoperative monitoring is
instrumental in early detection of complications and corrective interventions. Because of the constantly changing
morphology of the pediatric patient, appropriately sized equipment is vital to the delivery of anesthesia and rescue
during an emergency. Also, prior to anesthetic administration, calculations of emergency dosages of the mostcommonly used drugs can facilitate a smooth, coordinated and successful outcome.
Safety is paramount to pediatric anesthetic care. Therefore, the age of the patient, preoperative evaluation,difficulty of the planned procedure, and the training and experience of the practitioner should guide the oral andmaxillofacial surgeon as to the choice of technique and most suitable environment to provide anesthetic care.
CONSIDERATIONS FOR ANESTHETIC MANAGEMENT
OF THE PREGNANT PATIENT IN OUTPATIENT FACILITIES

Although elective surgery can usually be delayed until postpartum, there are situations in which a pregnant female
will present to the office requiring urgent surgery. The consequences of not providing essential care may present
a greater risk than surgical intervention. The anesthetic goals in treating the pregnant patient include the ability tocontrol pain and anxiety. In addition to maternal safety, anesthetic management must maintain fetal safety, which
includes avoiding intrauterine fetal asphyxia and preterm labor.
A thorough knowledge pharmacologic agents is required. Most local anesthetics are considered safe during
pregnancy. Single exposure to the commonly used sedatives, benzodiazepines, opioids, and nitrous oxide haveundetermined risk of teratogenicity. The oral and maxillofacial surgeon also should counsel the patient about
analgesics, including over-the-counter medications, because certain medications may not be acceptable during
specific stages of pregnancy. Also, consultation with the practitioner already managing the pregnant patient’s
prenatal care may be helpful in determining the most appropriate timing for surgery and the optimal perioperative
anesthetic care.
CONSIDERATIONS FOR ANESTHETIC MANAGEMENT OF THE OBESE PATIENT IN OUTPATIENT FACILITIESThe obese patient presents with special anatomic and physiologic problems that must be addressed whenproviding outpatient anesthesia. Obesity can be defined by Body Mass Index (BMI) and is classified as ClassI (BMI 30 – 34.9), Class II (BMI 35 – 35.9) and Class III (BMI >40). These classes are associated withincreasing risk for type 2 diabetes, hypertension and cardiovascular disease relative to normal weight andwaist circumference.
Airway management in the obese patient may be difficult due the overabundance of soft tissue or anatomic
deficiencies. Anesthetic techniques that do not utilize an adjunctive airway can be challenging. Comorbid
conditions decreased functional residual capacity, complex airways and even difficult intravenous access can place
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the obese patient at higher risk for anesthetic complications. If deep
sedation/general anesthesia is to be provided in the office setting,the practitioner should be experienced in airway management,
including endotracheal intubation and supraglottic device placement.
Postprocedural and post-discharge use of opioids should be considered with caution, as the riskof respiratory depression in the patient who already has obstructive sleep apnea (OSA) or sleep
disordered breathing may be increased.
CONSIDERATIONS FOR ANESTHETIC MANAGEMENT
OF THE GERIATRIC PATIENT IN OUTPATIENT FACILITIESThe U.S. population is aging. As a result, the anesthesia team should expect an increase in geriatric patientsseeking surgical care. Although chronologic age does not always predict physiologic age, it is prudent to consider
age, frailty and comorbid disease as anesthetic risk factors. The goal of geriatric anesthesia is to provide safe andeffective care in this increasingly medically complex population.
Medical consultation may be necessary to complete the medical history or optimize function. Determination of thegeriatric patient’s mental status is valuable, as postoperative delirium is more common in patients with dementia
or preoperative mental status changes. Assessing the level of exercise tolerance can be integral to estimating
the patient’s ability to tolerate the combined stress of anesthesia and surgery. This is best communicated using
metabolic equivalents for aerobic activity (METs), with 4 METs (climbing a flight of stairs without rest or
shortness of breath) generally considered adequate.
Practitioners should plan for reduced dosing requirements and expect longer elimination half-lives of anesthetic
drugs. This reflects the time proven adage – “start low and go slow.” Medications with anticholinergic effects
should be limited or avoided, and preference should be given to reversible anesthetic agents. Prolonged recovery
should be anticipated. Consideration should be given to anesthetic techniques that will cause the least disruption
to a geriatric patient’s routine, when available.

Monitoring
Despite the technical nature of modern, computerized physiological monitors, the maxim of “treat the patient not
the monitor” continues to support patient safety. For the anesthetic team, treating the patient means coordinating
patient-focused anesthetic and surgical care through the use of multiple systems, or intentional strategies,
including the team model of anesthesia delivery.
The team model of anesthesia delivery incorporates an OMS team leader working together with well-trained
staff members. This team shares in the patient safety responsibilities and must utilize effective communication
skills, with all members empowered to speak up if/when they detect something that may forecast a problem. The
continuous real-time monitoring of each patient’s physiological response to anesthesia and the surgical procedure
supports a culture of shared patient safety responsibilities.
PERIOPERATIVE MONITORING

Patient monitoring includes the continuous, time-sensitive assessment of a patient’s physiological responseto anesthesia and a surgical procedure including the monitoring of the following:• Blood pressure with automated time determined capability and data recording.
• Continuous electrocardiographic (ECG) for visualization of cardiac rhythms.
• Continuous pulse oximetry for blood oxygen saturation assessment.
• Continuous capnography for continuous assessment of exhaled carbon dioxide in patients undergoing moderate
or deep sedation or general anesthesia.
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Pre-operative clinical patient evaluations – consisting of a physicalexamination and interpretation of initial monitor readings – help
to determine a patient’s baseline physiology and support theintended level of sedation for each patient. In the event there are
any questions about the patient’s physical condition, elective care should be delayed until
the presenting questions are resolved.

Multiple factors can impact the performance and utility of perioperative monitoring. These include thetechnical capabilities of a commercial monitoring system and decisions related to monitor implementation;
electronic medical record integration; monitor data printing, recording and storage; monitor calibration; monitor
maintenance; and system updates.
STAFF TRAINING

For the anesthesia team model, patient safety is based on the shared responsibilities related to patient selection,
anesthesia techniques, patient monitoring and anesthetic depth limit setting. The OMS can support patient safety
through monitoring by implementing staff training related to monitor use and maintenance. The following
topics are provided as general training suggestions. Given the variation in monitor systems, practice models
and regulatory requirements, OMSs should consider which training topics are appropriate for their practice.
Staff training could consist of training on the following:• Monitor use, calibration, troubleshooting and maintenance.
• The purpose of perioperative monitors and alarms.
• The importance of staff’s role in speaking up about changes in monitor readings during procedures
or during recovery.
• Alarm management and the setting of appropriate alarm ranges.
• Monitor data recording, exporting and any other required processing after a procedure.
• The use of monitoring during medical emergencies or patient transport.
• Monitor data recovery after inadvertent monitor shut down.
PROCEDURAL AND RECOVERY CONSIDERATIONS

At appropriate and regular intervals, it is important to confirm the accuracy of the date and time on the monitors
and to synchronize the monitor timestamp with other equipment such as other monitors, the EMR or wall clocks.
Without completing this step, the records may not accurately reflect the time when care was provided, especiallywhen compared to a paper anesthesia or emergency record.
A few additional procedural considerations include confirming the following for each patient:• Which monitors are required for the procedure based on the patient’s condition, planned anesthesia technique,professional standards and applicable regulations.
• The appropriate blood pressure cuff size for the patient.
• The compatibility of any disposable supplies such as a pulse oximetry probe.
• That the alarms are on and the alarm ranges are appropriate for the patient given their baseline vital signs
and medical condition.
• That the printing, data-recording and data-saving features of the monitor are functioning appropriately.
• That the monitor data is printed, saved or otherwise secured at the end of the procedure.
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After a procedure, patient monitoring should be continued during
the recovery phase with the alarms on. The decision to discontinue
patient monitoring and discharge the patient should be based on
objective, clinical assessments and comparison to the patient’s preoperative vital signs and status. The Modified Aldrete Scoring tool or other clinical resources canbe used for evaluating a patient’s physical activity, respiration, circulation, consciousness andoxygen saturation.

To optimize the patient safety benefits with patient monitoring, office emergency drills should reflect
the importance of the following:• Having staff identify changes in a patient’s physiological status.
• Silencing alarms without disconnecting the patient from the monitor or without the loss of monitor data.
• Changing alarm parameters.
• Saving monitor printouts and preserving monitor data, especially in the event of common emergency scenarios
such as leads being disconnected by EMS and/or the monitors manually shut off. Avoid using the equipment tomonitor another patient until there is confirmation the data from the emergency response has been preserved.
However, monitor readings do not independently support the emergency response efforts made by the anesthesia
team during an emergency. These efforts can be contemporaneously documented on an emergency record, such as
the one available for download from OMSNIC.com.
The clinical monitors available today – together with the team concept of anesthesia delivery – provide OMSs
with the kind of accurate patient data from start to finish that supports safe clinical care.

Office Anesthesia Evaluation
The Office Anesthesia Evaluation (OAE) is a unique peer review process that has been in existence since 1975.
The OAE was conceived, developed, implemented and mandated by AAOMS through its component statesocieties to benefit the public, whom its members serve. To maintain AAOMS membership, all member oral andmaxillofacial surgeons must complete this mandatory program at least every five years. The process involves
a thorough and factual inspection of the member’s practice location(s), team, equipment and patient care skills
especially as it pertains to anesthesia and emergencies in the office. The inspection is typically conducted byan outside surgeon(s) or a designate of the state dental board. The AAOMS office anesthesia evaluation digitalapplication (AAOMS OAE App on Apple Store or Google Play) can be used to assist with this process.
The AAOMS Office Anesthesia Evaluation Manual is published periodically and is used to guide the OAE
process. Among other things, the manual provides sample forms; checklists; emergency scenarios such as
laryngospasm, syncope, venipuncture, bronchospasm, emesis and aspiration of foreign material, airway
obstruction by foreign body, angina pectoris, myocardial infraction, and cardiac arrest; cardiopulmonary
resuscitation (CPR); management of blood pressure problems; drug allergies; hyperventilation; convulsions;malignant hyperthermia; and anesthesia for patients suspected of substance abuse among others.
The AAOMS OAE program consist of four parts:• Part I – An evaluation of the office facilities, emergency medications and emergency equipment.
• Part II – A demonstration by the oral and maxillofacial surgeon and team of the management of simulated
office emergencies.
• Part III – A debriefing between the evaluator(s) and the oral and maxillofacial surgeon of the emergency
demonstrations and/or facility.
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• Part IV – An observation of the anesthesia/surgeries performedin the office (subject to state laws and patient consent).

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Mobile Anesthesia
The information outlined in this section is applicable to OMSs and other anesthetic providers,regardless of their practice model. Anyone considering the mobile anesthesia provider model
should be mindful of applicable state laws, rules and regulations, professional resources – such as the AAOMSParameters of Care and the AAOMS Office Anesthesia Evaluation Manual – and the scope of their state dental
licenses, training and experience.
PATIENT RELATIONSHIPS AND SELECTION

Patient safety is supported when the provider is appropriately familiar with the patient and anticipated procedure.
The provider’s responsibility includes determining the patient’s appropriateness for the planned outpatientanesthesia treatment. The mobile anesthesia provider’s responsibilities include, but are not limited to:• Performance of a patient assessment, including a medical history and a physical examination prior
to performing surgery.
• Documentation of the patient’s physical status in their record using the American Society of Anesthesiologists’physical status classification prior to surgery.
• Documentation of a diagnosis indicating the need for surgical care.
An established patient selection process should be applied to meet to the specific needs of each patient. In
the event there are any questions about the patient selection process, elective care should be delayed until thepresenting questions are resolved. The sample questions below are offered to help mobile anesthesia providers
identify the type of information that can support a safe patient selection process.
• When is advanced access to the patient’s medical history available?
• What is the process to obtain a medical consultation?
• Where will the pre-operative physical exam be performed?
• Will access be provided to the office medical record to document the patient pre-operative assessment?
• Who is responsible for selecting candidates for in-office anesthesia and the level of anesthesia basedon a patient’s specific risks?
• What options are available on the day of surgery if the independent assessment of the patient indicatesa different level of anesthesia would be in the best interest of the patient?
• What is the process to obtain the patient’s informed consent for the anesthesia and for the procedure?
FACILITY RESOURCES AND SAFETY

Anesthesia should be delivered in a safe and suitably equipped facility. State and federal regulations andprofessional resources have identified the facility requirements for anesthesia delivery, including when
intravenous sedation and/or general anesthesia is delivered. At a minimum, each location where anesthesia
is administered should have its own vital sign monitoring equipment for:
• ECG
• Blood pressure• Pulse oximetry• End-tidal CO2
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All patient monitoring equipment should receive regularly scheduled
maintenance to ensure proper calibration and functioning.

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Having a suitably equipped facility for anesthesia also includes
being prepared for potential crisis events. Emergency response planning that includes theidentification and condition of emergency medications, equipment and supplies will support
management of an emergency event. The sample questions below are offered to help mobile
anesthesia providers identify the suitability of a facility for anesthesia administration and may provide insight into
the facility’s emergency medical response resources.
• Does the facility follow applicable laws, rules, regulations and professional standards related to the deliveryof anesthesia?
• Are pre-procedure crash cart checklists regularly used to ensure that emergency equipment and medications
are readily available and fully functioning? Who is responsible for completing these checklists?
• Is the anesthesia team familiar with the location and function of the monitoring equipment and the emergency
response equipment offered in each office?
• Are pre-procedure “time outs” performed before each procedure to identify any patient-specific risks related
to the proposed surgical procedure or anesthetic technique?
• Does local EMS have the pertinent facts related to emergency facility access – such as which elevator or door
to use in an emergency – and are hallways and operatories appropriately sized for easy EMS access?
STAFF PERFORMANCE AND SAFETY

As with facility resources, staffing levels and staff training requirements should follow the applicable regulations
and professional standards. One foundation of the team model is to establish a culture of patient safety where
all team members seek to reduce risk in all aspects of patient care. Examples of risk-reduction strategies for the
trained anesthesia team, which are also applicable with mobile anesthesia providers include the following:• Training for anesthesia patient management through programs such as DAANCE.
• Conducting regular and realistic office emergency drills.
• Utilizing standardized communication tools to improve the staff’s communication skills regarding patient safety
matters.
• Empowering staff to improve patient safety through the establishment of a “just culture.”
The sample questions below are offered to help mobile anesthesia providers identify the suitability of staff training
and emergency responses in any location they are providing services.
• What level of CPR certification has the staff achieved?
• What other training is required of staff who will assist in mobile anesthesia related procedures?
• Is the staff trained on how to operate the vital sign monitors, configure the alarms and create a recording
or printout?
• How frequently are medical emergency drills conducted?
• Have specific emergency responses roles been identified for each staff member?
• What roles do staff play in the event of an emergency and are staff members cross-trained in emergency
responses?

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CARE COORDINATIONWhite Paper

The treating OMS should retain the responsibility for postoperative
care and maintain communication to ensure that each patient
receives appropriate care continuity. This may include the ability andprivilege to admit patients to an extended care hospital for surgical care and/or other management.
To assist with identifying the care coordination opportunities, a few questions for mobile
anesthesia providers to consider include the following:• Do patients know how to contact the OMS after-hours?

• What resources are available to conduct a postoperative patient examination including after hours if necessary?
• If someone other than the OMS is responsible for triaging postoperative phone calls from patients, at what pointis the OMS notified of postoperative complications?
• Were patient-specific pre-operative instructions provided, including the need for a patient escort?
• What resources are available when a patient requires an extended postoperative recovery?
• What is the discharge process?

Emergency Preparedness
Despite the best effort of all concerned, crisis events can and do occur. Therefore, it is important for the anesthesia
team to make intentional efforts to prevent as well as recognize and respond effectively to potential crisis events.
OMS SYSTEMS AND PATIENT SAFETY

Systems are intentional strategies to limit risk and enhance safety outcomes. Incorporating accepted professional
resources, such as the AAOMS Office Anesthesia Evaluation Manual or the AAOMS Parameters of Care, canhelp OMSs establish systems that support the delivery of patient-focused care and a safe and effective anesthetic
experience for their patients. A few examples of systems which promote patient safety include are as follows:• Establishing written patient assessment protocols to identify patient risk factors before surgery.
• Utilizing standardized clinical documentation forms and electronic medical record templates to improve
the reliability of clinical information.
• Conducting pre-procedure time out checklists to identify any patient-specific risks related to the proposed
surgical procedure or anesthetic technique.
• Performing regular crash cart checks to ensure that emergency equipment, supplies and medications are readily
available and fully functioning.
• Conducting interdisciplinary emergency drills to assist with the recognition of and response to potential crisis
events.
MOCK DRILLS/PRACTICE SESSIONS

Learning experiences that embrace an interactive component have been shown to be the most effective approachto improving outcomes in healthcare. One way to incorporate such learning is to conduct thoughtful, regular andrealistic practice sessions with feedback. In keeping with its commitment to safety, AAOMS requires members
and their teams to conduct mock drills/crisis practice sessions at least four times per year.
The goals of practice such as mock drills include: 1) developing cohesion as members of a team, understandingof the roles and responsibilities for each, 2) making sure everyone knows where equipment and medications arelocated and how they are used, 3) identifying areas that need improvement with a plan to correct them, and most
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importantly, 4) moving through stages of learning, from unconscious
incompetence (“you are not able to do something and have little ofidea what you are supposed to do”) to conscious incompetence(“you understand what needs to be done but are not able to do it”)
to conscious competence (“you are aware of what needs to be done and are able to do it withconscious effort”) to unconscious competence (“you both know what to do and are able to act
without conscious effort”).

Practice can be considered as having two major components: drills and scrimmages. Drills are activities thatdevelop and grow the skills necessary to perform effectively. Scrimmages are activities that involve applying
knowledge and skills into simulated challenges. Scrimmages should be as realistic and meaningful as possible,
mimicking the kinds of challenges seen in a crisis event. In the effort to develop effective practice sessions, teamleaders should recognize the value and role of each of these elements.
MAKING PRACTICE EFFECTIVE

While simulation‐based scrimmages run by an outside administrator are desirable, they may not be feasible.
Fortunately, less “high-fidelity” practice types have been shown to be effective approaches to team training withactive engagement in the learning process. Regardless of the variation of the type employed, practices should
be conducted on a regular basis, planned with the needs of the team in mind, be challenging physiologically andmentally, mimic real-life situations, incorporate a level of stretch for the team, include constructive feedback(de-briefing), employ a “growth mindset” (challenge embraced as desirable and an opportunity to learn) andincorporate an element of engaging team building.
Common versions of practice include the following:• The “traditional” approach is for the team to follow the lead of the OMS, working through algorithms ofcommon crisis events. This allows for the team to rehearse actions, identify shortcomings and experience
how to successfully work together.
• Bring in an outside expert to create/conduct scenarios, observe performance and provide feedback. This puts
the anesthesia team “under the microscope” in a good way.
• Either of the above can be enhanced with videotaping, which allows participants to see what actually took placecompared with what they thought took place.
• Talking around a conference table about what individuals or the team might do. This allows clarification of
responsibilities and identification of challenges that might arise, which in essence is a form of mental rehearsal.
Scenarios used to guide scrimmages should emphasize the types of patients the office typically treats, including
age, medical and physical status, and procedure types. While scenarios should generally focus on events occurringin the office operating room(s), where anesthetics are most commonly administered, they also should include
other areas of the office such as the recovery area, waiting room, hallway and bathroom. Algorithms for specificcrisis events should be creative rather than formulaic and allow for progression through a variety of possible
solutions to presenting problems. They should provide an opportunity for the team to discuss risk factors and an
opportunity to consider how pre-operative assessments might have prepared the team in advance. In the effort
to make sessions as realistic as possible, the team should use a CPR/airway manikin and carry out tasks in amanner that approximates reality, such as performing CPR, managing the airway, connecting IV tubing, drawing
up “mock” drugs, etc. As much as possible, sessions should allow participants to experience the thoughts andemotions they face during a true crisis, including mental and physical stress. One way to do so is to incorporate
elements of stress, such as setting time limits to complete a given task.

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DELIBERATE PRACTICE AND FLOW

Two things have been identified as making high performance more
likely: 1) deliberate practice and 2) flow.

White Paper

Deliberate practice is characterized by intentional design, graduated difficulty (stretch), clear
goals, immediate and constructive feedback and repetition to correct shortcomings with targeted
reinforcement. Flow is a highly productive state of consciousness when individuals/teams
become highly effective and in their actions. For these purposes, the most important element conducive to flow
is a balance between the challenge and the skills that the individual has, clear goals and the ability to tune out
distractions.
Given that principles of effective practice are well-established in other disciplines (aviation, military and sport),
the OMS team should borrow from what is known to increase the effectiveness of their own practices. For
example, there is value in focusing 80 percent of the allotted time and attention to the 20 percent of knowledge
and skills that have the most impact on outcomes. Focus should include practicing skills both in isolation as wellas in a version that approximates the “real thing” environment. Objectives for practices should be measurable,
such as intubating a manikin or accessing and activating an AED within a specific time. Modeling – which means
demonstrating how to perform specific actions effectively – should be employed with practices conducted in acontext as similar as possible to the one in which team members are expected to perform, such as positioning theoperating chair in a position that would allow CPR to be performed. “Inter-leaving” – shifting back and forth fromone skill being developed to another – should be incorporated as it enhances long-term skill retention. Sessions
should allow for feedback in a manner that is specific to identified shortcoming(s) and provided in a supportive
environment.
STRESS AND CRISIS EVENTSThe literature reveals several things about performing under duress in a healthcare environment: 1) stress iscommon, 2) stress degrades performance, 3) most practitioners who have “figured out” how to perform well understress have done so through experiential learning, 4) practice offers an opportunity to engage trainees in individual
and team learning experiences that provide a foundation for effective performance, and 5) the value of practice isclosely related to the quality and, to a lesser degree, the quantity of the simulations/drills/scrimmages.
It is important that individuals have acquired an appropriate level of knowledge and skills in their area of
responsibility that they be able to access and apply them in the face of distractions/stress. An important way to
do so is through the application of productive mental skills. While many mental skills have be identified, twostraightforward approaches are learning to control breathing patterns (exhaling longer than inhaling reduces
heart rate and improves focus) and re-framing the moment in a way that turns “stress” in “challenge.” Practicesessions provide individuals an opportunity to try out and develop mental skills when the stakes are theoreticalrather than actual.
OFFICE EMERGENCY MANAGEMENT PLAN

What needs to be done? A detailed management plan for how the team works together when an emergency
occurs must be carefully established and practiced in advance. In addition, there should be ready access to
information that supports care management such as algorithms for common crisis events.
Who is going to do what needs done? In advance, the details of how the team operates, such as who andhow many people stay with the patient, who meets EMS and where, how does EMS enter the office if it is nota standalone facility, who maintains records, etc., must be worked out and understood. Examples include thefollowing:

PAGE 33 Office-based Anesthesia Provided by the Oral and Maxillofacial Surgeon• Recommended Staffing◦ Procedural

White Paper▪ State and/or AAOMS guidelines▪ May vary based upon the depth/level of anesthesia, procedure and other factors• Office Staff Preparation◦ Dental Anesthesia Assistant National Certification Examination (DAANCE) staff Certification/Recertification
or equivalent◦ Documented Staff Ongoing Training/Continuing Education▪ Online Anesthesia Review for Dental Anesthesia Assistants▪ Anesthesia Simulation Training▪ Competency Assessment• Provider and Office Staff Anesthesia Ongoing Training/Continuing Education◦ Office-Based Emergency Airway Management (OBEAM)◦ Advanced Protocols for Medical Emergencies in the Oral and Maxillofacial Surgery Office (APME)◦ Anesthesia Simulation Training◦ Anesthesia-specific CE – Maintenance of Proficiency Section• Dental Anesthesia Reporting◦ Dental Anesthesia Incident Reporting System (DAIRS)

Provider Training/Continuing Education
It is known that knowledge will decline as time passes from the educational aspect of health profession training.
In addition, there will always be an inevitable expansion of the field with new knowledge and developments overtime. Accordingly, an important component of providing safe and effective care is the continuous learning process
known as being a “lifelong learner.” The field of oral and maxillofacial surgery is not static and new monitoring
equipment, medications and understanding of patient factors have led to improved outcomes throughout theyears. Many “older” practitioners recall learning to change from methohexital to propofol as their primary
general anesthetic agent and integrating end tidal carbon dioxide monitoring into their practice after leaving theirresidency programs. Continuing educational opportunities have provided the primary means for dissemination ofthis information.
All 50 states and the District of Columbia have requirements for permits to administer anesthesia by the OMS
in the office and these requirements vary from state to state, especially in the number of hours of continuing
education. These are specific anesthesia-focused topics and set hours on a yearly or biannual basis. Practitioners areoften responsible for logging their hours with either submission during the renewal of their permit or to maintain on
file in anticipation of a potential audit. These CE courses are required to be certified by an independent organizationsuch as ACCME (Accreditation Council for Continuing Medical Education) of the American Medical Associationor the American Dental Association CERP program, among other recognized providers.
The American Medical Association defines two different CE categories, Category 1 and 2. Category 1 credits
are those programs that have applied for certification and have been credentialed.

PAGE 34 Office-based Anesthesia Provided by the Oral and Maxillofacial Surgeon

White Paper• Category 1 – Includes these activities as defined by the AMA:
1) live activities, such as specialty society annual meetings,
2) enduring materials, such as a CME activity on a DVD, 3)
journal-based CME, such as the CME articles available throughthe JAMA Network, 4) test item writing, such as writing questions for a certification exam of amember board of the American Board of Medical Specialties (ABMS), 5) manuscript review,
such as participating in the pre-publication peer review process for articles submitted to JAMA,6) performance improvement (PI) CME, such as a performance in practice (Part IV) activity for an ABMSmember board and 7) internet point-of-care, such as physicians using databases vetted by a CME provider toengage in self-directed learning to answer a question relevant to their clinical practice.

• Category 2 – Includes those activities obtained from home self-designated study programs, journal reading,etc. In totaling the required number of hours for licensing and maintenance of certification, there may be limits
on the number of Category 2 credits that can be reported. Category 2 credits are not “certified” by a third party
and are self-reported only. Examples of Category 2 credits are: 1) unstructured online searching and learning(i.e., not internet point-of-care), 2) reading authoritative medical literature, 3) consultation with peers andmedical experts, 4) self-assessment activities, 5) medical writing, 6) preceptorship participation and 7) peer
review and quality assurance participation.
Obtaining continuing education in anesthesia can be obtained in a variety of formats. The classic “in-person”
attendance at state, regional and national meetings allow the practitioner to choose topics directly applicable totheir delivery of anesthesia in the OMS office setting. The benefits of in-person meetings also permit the doctors
and potentially their anesthesia team as well to interact with the lecturer and other participants.
Live webinar format presentations allow for much of the value of in-person events without the need for travel andother costs. Although not as facile a way to interact with speakers and other attendees, chat features and scheduled
Q&A sessions may assist in the learning process. Locally, the doctor and the anesthesia team can all be together
to gain some of the benefits of specific team discussions directly relevant to their unique practice. Webinars may
be recorded and thus allow subsequent review of the material and/or presentation to members that may have
had a conflict during the original presentation. Other formats such as podcasts, review articles and maintenanceof certification programs also confer CE credits available to the anesthesia team. Validation of attendance andassimilation of the material by post-course testing are typically required for credits to be received. Also, thecollection of feedback for the course developers is required for these and in-person events so that continuous
quality improvement is occurring.
Participation in continuing education programs throughout one’s career is not only a licensing and possibly board
certification requirement, but one that is necessary to provide optimum patient care. All practitioners need to belifelong learners as they progress in their practices. The potential isolation of the OMS in an independent practicesetting only makes this a more critical aspect.
Continuing education (CE) requirements not only satisfy licensure requirements on the state level for dental andmedical licensing boards, but several states across the country have specific anesthesia CE requirements for theirstate and regional OMS societies. Additionally, AAOMS hosts webinars and conferences focused on anesthesia
for members and OMS office staff. This includes the biannual Patient Safety Conference that includes expert
presenters from within and outside the specialty of oral and maxillofacial surgery.
In addition, the Committee on Continuing Education and Professional Development (CCEPD) and the Committee
on Anesthesia (CAN) consistently provide offerings on anesthesia topics at the AAOMS Annual Meeting andScientific Sessions, and AAOMS supports a Special Interest Group (SIG) on anesthesia to assist in the creationof recurring CE programs for AAOMS members and their office staff. One example of AAOMS-sponsored CE
is the pre-conference course on Anesthesia Update held at the AAOMS Annual Meeting. Examples of courses
PAGE 35 Office-based Anesthesia Provided by the Oral and Maxillofacial Surgeon

White Paper

intended for staff members include Advanced Protocols for
Medical Emergencies in the OMS Office, Anesthesia Assistants
Skills Lab and the Anesthesia Assistants Review Course. OMSs
are also encouraged to access to anesthesia-related CE from sisterorganizations such as the American Dental Society of Anesthesia (ADSA),
the American College of Oral and Maxillofacial Surgeons (ACOMS) and local, state and regional
OMS society offerings.

The newly created Daniel M. Laskin Institute For OMS Education and Innovation is a centralized classroom anda state-of-the-art simulation center at AAOMS headquarters in Rosemont, Ill., near Chicago, and the Institutehas become the destination for members and their staff seeking simulation training in Office-Based Airway
Emergency Management (OBEAM).

Simulation Training
AAOMS has created an extensive program intended to provide every OMS and their staff training in Office-Based
Airway Emergency Management (OBEAM) and Office-Based Crisis Management (OBCM). Modules in the
National Simulation Program include didactic and hands-on mastery-based skills training and adult cooperative
learning modules that allow participants to learn and update their airway skills as well as improving teamdynamics. As of 2026, AAOMS members will need to complete simulation training to maintain their membershipin the organization.
Maintenance of proficiency by all members of the team is an integral part of quality care and patient safety
in oral and maxillofacial surgery. Lifelong learning from multiple sources consistently enhances the efficiency
and effectiveness of both OMSs and their staff in the interest of patient safety.

Ongoing Quality Assessment and Lifelong Learning
In order to provide optimal patient care, it is important to know where OMSs are and identify areas for
improvement. In that effort, it is important to be involved in performance improvement activities that aresystematically organized and implemented in such a way as to monitor, assess and improve the quality andsafety of healthcare.
Quality Assessment is a dynamic process that must be ongoing to provide actionable information to optimize
necessary actions, responses and decisions. Because oral and maxillofacial surgeons have been trained across both
medicine and dentistry, ongoing Quality Assessment has been an integral part of the specialty from both a Process
Improvement (PI) and Quality Improvement (QI) perspective. Sometimes utilized interchangeably, PI and QI arein fact different.
In the effort to appropriately implement Quality Assessment, one must understand what PI and QI are and thesometimes subtle, but important, differences between them. Although both take a systems’ view, PI places theemphasis on human performance while QI places the emphasis on the actual process the human is attempting
to perform. They are intricately linked and must be accomplished together to achieve wanted and expected
outcomes.
LIFELONG LEARNING

Lifelong learning is an integral tool to the delivery of safe, efficient, effective and quality healthcare. It is selfmotivated continuous learning that extends beyond the completion of formal education resulting in the ongoingdevelopment of knowledge and skills. Continued knowledge and improvement, both didactic and task-based
performance, is the hallmark of this process. AAOMS and ABOMS are related organizations that fully support
the importance of this concept/process.
PAGE 36 Office-based Anesthesia Provided by the Oral and Maxillofacial Surgeon

CHARACTERISTICS OF ONGOING QUALITY ASSESSMENT
AND LIFELONG LEARNINGWhite Paper

Performance must be observed, measure, analyzed, critiqued,
improved and practiced. Quality Assessment and Lifelong Learning
together are key to improved mishap prevention, positive outcomes, quality care and patient
safety.
KEY ASPECTS• Physical Requirements – The actual hands-on, how to do and what to do related to a particular process or
situation. The physical performance of a task. Can the provider and staff perform the task when stressed?
• Didactic Requirements – What does the provider and their staff need to know? What needs to be memorybased and what needs to be on a readily available reference?
• State Requirements – Many states have specific requirements and qualifications for the delivery of officebased anesthesia. Providers and staff must be aware of current requirements, stay abreast of changing
requirements and be engaged when changes are suggested or discussed.
• Record Keeping – Among recommendations:◦ Anesthesia Record Recommendations: See OAE section.
◦ Training Record Recommendations: See OAE section.
◦ Drills: A record should be kept of drill scenarios, actions by each member of the team, a performance critiqueand recommendations for improvement in performance if warranted.
◦ Additional Quality Assessment forms if needed.
Ongoing Quality Assessment and Lifelong Learning are the signature elements in practice efficiency, procedural
effectiveness, the delivery of high-quality state of the art patient care and optimized patient safety and emergency
response. Oral and maxillofacial surgery as a specialty must do all it can, and OMSs must do all they can to utilize
and optimize these principals when building and training staff, evaluating practice and providing care.

Conclusion
AAOMS expects this white paper will be revised over time as warranted, as is the case where there is ongoing
evolution of knowledge, technology and practice preferences. Reality informs AAOMS that there is a necessarybalance between what is ideal and what is practical, particularly in communities where resources are limited andaccess to care is challenged. While it is understood the choice of agents and techniques is dependent upon theexperience, training and preferences of individual practitioners, safety can never be sacrificed.

Suggested Readings
Accreditation Standards for Advanced Dental Education Programs in Oral and Maxillofacial Surgery. Available at https://coda.ada.org/~/
media/CODA/Files/oms.pdf?la=en
American Association of Oral, & Maxillofacial Surgeons. Committee on Anesthesia. (2018). Office Anesthesia Evaluation Manual,
9th edition. American Association of Oral and Maxillofacial Surgeons.
American Association of Oral, & Maxillofacial Surgeons. Committee on Anesthesia. (2017). Parameters of Care to Clinical Practice,
6th edition. Sections: Patient Assessment, Miloro, Basi, Halpern, Kang, and Anesthesia in Outpatient Facilities, Rollert, Busaidy, Krishnan,
Van Heukelom, published in Journal of Oral and Maxillofacial Surgery, 75 (8), e15-49.
American Dental Association. (2016). Guidelines for the use of sedation and general anesthesia by dentists. Adopted by the ADA Houseof Delegates.

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American Society of Anesthesiologists (ASA). Continuum of depth of sedation:
definition of general anesthesia and levels of sedation/analgesia. (Approved by the
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American Society of Anesthesiologists (ASA). Standards for basic anesthetic monitoring. Developed By: Committee
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© 2022 American Association of Oral and Maxillofacial Surgeons. No portion of this publication may be used or reproduced without theexpress written consent of the American Association of Oral and Maxillofacial Surgeons.

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