Arkansas Administrative Code › Agency 038 - Board of Dental Examiners › Rule 038.00.09-001 - Article XIII: Rules of the Board governing Sedation and Anesthesia

Current through Register Vol. 49, No. 6, June, 2024
Article XIII
ANALGESIA, SEDATION, AND GENERAL
ANESTHESIA RULES FOR A DENTIST IN AN
AMBULATORY FACILITY
A.
DEFINITIONS
1.
Analgesia -
The diminution of
		  pain or production of increased tolerance to pain in the conscious
		  patient.
2.
Anesthesia
		  -
Partial or complete loss of sensation with or without the loss of
		  consciousness.
3.
Anesthesia
		  Period -
The period of time beginning with the placement of a needle,
		  mask, or solution into or onto the body until the patient has met the criteria
		  which are appropriate for dismissal.
4.
Levels of Supervision For Qualified
		  Staff -
a. Direct Supervision - The
		  dentist is in the dental office, authorizes the procedure, and remains in the
		  dental office while the procedures are being performed by the
		  auxiliary.
b. Personal Supervision
		  - The dentist is in the dental office, personally authorizes the procedure, and
		  before the dismissal of the patient, evaluates the patient.
c. Operative Supervision- The dentist is
		  personally operating on the patient and authorizes the auxiliary to aid the
		  treatment by concurrently performing a supportive procedure.
5.
Nitrous Oxide/Oxygen
		  Inhalation Analgesia -
The administration, by inhalation, of a
		  combination of nitrous oxide and oxygen producing an altered level of
		  consciousness that retains the patient's ability to independently and
		  continuously maintain an airway and respond appropriately to physical
		  stimulation and/or verbal command. Nitrous oxide/ oxygen inhalation analgesia,
		  when used alone, is not considered a form of sedation but is considered to be
		  an analgesic only.
6.
Qualified Staff -
An individual trained to monitor appropriate
		  physiological parameters and to help in any supportive or resuscitating
		  measures.
a. For dentists using Minimal or
		  Moderate Sedation, qualified staff must have a current Nitrous Oxide Permit
		  from the Board and be currently certified in health care provider
		  CPR.
b. For dentists using Deep or
		  General Sedation, qualified staff must have a current Nitrous Oxide Permit from
		  the Board and be currently certified in health care provider CPR AND have
		  completed a Board approved course as outlined in Section G. of this rule and be
		  registered with the Board as a Sedation Assistant.
7.
Minimal Sedation -
a
		  minimally depressed level of consciousness produced by a pharmacological
		  method, that retains the patient's ability to independently and continuously
		  maintain an airway and respond normally to tactile stimulation and verbal
		  command. The patient should be oriented to person, place and time. Although
		  cognitive function and coordination may be modestly impaired, ventilatory and
		  cardiovascular functions are unaffected. In accordance with this particular
		  definition, the drugand/or techniques used should carry a margin of safety wide
		  enough never to render unintended loss of consciousness. Further, patients
		  whose only response is reflex withdrawal from repeated painful stimuli would
		  not be considered to be in a state of minimal sedation. When the intent is
		  minimal sedation for adults, the appropriate initial dosing of a single enteral
		  drug is no more than the maximum recommended dose of a drug that can be
		  prescribed for unmonitored home use. When the intent is Minimal Sedation, only
		  one drug can be given in addition to nitrous oxide.
Pediatric Considerations: In addition to the physiologic
			 parameters for Minimal Sedation in children under 12 years of age, when the
			 intent is Minimal Sedation, only one drug can be given in addition to nitrous
			 oxide. A drug CANNOT be from the scheduled category of drugs II, III or IV. If
			 a child under 12 years of age is given any drug for sedation from Schedule II,
			 III or IV, that child is considered more than minimally sedated.
8.
Moderate Sedation-
a drug-induced depression of consciousness during which patients respond
		  purposefully to verbal commands, either alone or accompanied by light tactile
		  stimulation. No interventions are required to maintain a patent airway and
		  spontaneous ventilation is adequate. Cardiovascular function is usually
		  maintained. In accordance with this particular definition, the drugs and/or
		  techniques used should carry a margin of safety wide enough to render
		  unintended loss of consciousness unlikely. Repeated dosing of an agent before
		  the effects of previous dosing can be fully appreciated may result in a greater
		  alteration of the state of consciousness than is the intent of the dentist.
		  Further, a patient whose only response is reflex withdrawal from a painful
		  stimulus is not considered to be in a state of moderate sedation.
9.
Deep Sedation-
a drug-induced
		  depression of consciousness during which patients cannot be easily aroused but
		  respond purposefully following repeated or painful stimulation. The ability to
		  independently maintain ventilatory function may be impaired. Patients may
		  require assistance in maintaining a patent airway, and spontaneous ventilation
		  may be inadequate. Cardiovascular function is usually maintained.
10.
General Anesthesia -
a
		  drug-induced loss of consciousness during which patients are not arousable,
		  even by painful stimulation. The ability to independently maintain ventilatory
		  function is often impaired. Patients often require assistance in maintaining a
		  patent airway, and positive pressure ventilation may be required because of
		  depressed spontaneous ventilation or drug-induced depression of neuromuscular
		  function. Cardiovascular function may be impaired.
11.
Titration-
administration of
		  incremental doses of a drug until a desired effect is reached. Knowledge of
		  each drug's time of onset, peak response and duration of action is essential to
		  avoid over sedation. Although the concept of titration of a drug to effect is
		  critical for patient safety, when the intent is moderate sedation one must know
		  whether the previous dose has taken full effect before administering an
		  additional drug increment.
12.
Routes of Administration Defined-
a. Enteral: any technique of administration
		  in which the agent is absorbed through the gastrointestinal tract or oral
		  mucosa (i.e. oral, rectal, sublingual).
b. Parenteral: a technique of administration
		  in which the drug bypasses the gastrointestinal tract (i.e. intramuscular,
		  intravenous, intranasal, submucosal, subcutaneous, intraosseous).
c. Transdermal: a technique of administration
		  in which the drug is administered by patch or iontophoresis through
		  skin.-
d. Transmucosal: a technique
		  of administration in which the drug is administered across mucosa such as
		  intranasal, sublingual or rectal.
e. Inhalation: a technique of administration
		  in which a gaseous or volatile agent is introduced into the lungs and whose
		  primary effect is due to absorption through the gas/blood interface.
13.
Patient Physical Status
		  Classification
(as defined by the American Society of
		  Anesthesiologists)-
a. ASA I: A normal healthy
		  patient
b. ASA II: A patient with
		  mild systemic disease
c. ASA III: A
		  patient with severe systemic disease
d. ASA IV: A patient with severe systemic
		  disease that is a constant threat to life
e. ASA V: A moribund patient who is not
		  expected to survive without the operation
f. ASA VI: A declared brain-dead patient
		  whose organs are being removed for donor purposes
g. E: Emergency operation of any variety
		  (used to modify one of the above classifications, i.e. ASA III-E)
14.
Maximum Recommended Dose
		  (MRD) -
maximum FDA- recommended dose of a drug as printed in
		  FDA-approved labeling for unmonitored home use.
15.
Incremental Dosing-
administration of multiple doses of a drug until a desired effect is reached,
		  but not to exceed the MRD.
16.
Supplemental Dosing-
during minimal sedation, supplemental dosing
		  is a single additional dose of the initial drug that may be necessary for
		  prolonged procedures. The supplemental dose should not exceed one-half of the
		  initial total dose and should not be administered until the dentist has
		  determined the clinical half-life of the initial dosing has passed. The total
		  aggregate dose must not exceed 1.5 x the MRD on the day of treatment.
17.
Pediatric Sedation-
Any
		  level above nitrous oxide analgesia on patients under the age of twelve (12)
		  years.
18.
Permit
		  reclassification-
All Level 3 permits currently held by any dentists on
		  the date of adoption of this rule will be reclassified to Moderate Sedation
		  permits. All Level 4- General Anesthesia permits currently held by any dentists
		  on the date of adoption of this rule will be reclassified to Deep
		  Sedation-General Anesthesia permits.