Chapter 150-13 SEDATION PERMITS

Rule 150-13-.01 Conscious Sedation Permits

When the intent is minimal sedation (anxiolysis), which is defined as a minimally depressed level of consciousness that retains the patient's ability to independently and continuously maintain an airway with unaffected ventilatory and cardiovascular function and respond normally to tactile and verbal stimulation, a permit for conscious sedation is not required.

(a)

When the intent is minimal sedation for adults, the initial dosing is no more than the maximum recommended dose (MRD) of a drug that can be prescribed for unmonitored home use. Nitrous oxide/oxygen may be used in combination with a single enteral drug in minimal sedation. For adults, supplemental dosing that may be necessary for prolonged procedures should not exceed one-half of the initial drug dose and should not be administered until the dentist has determined that the clinical half-life of the initial dosing has passed. The total aggregate dose must not exceed 1.5x the MRD on the day of treatment.

(b)

The use of preoperative sedatives for children (age 12 and under) except in extraordinary situations must be avoided due to the risk of unobserved respiratory obstruction during transport by untrained individuals. Children can become moderately sedated despite the intended level of minimal sedation. Should this occur, the guidelines for moderate sedation apply. For children, the American Dental Association supports the use of the American Academy of Pediatrics/American Academy of Pediatric Dentists Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures.

(2)

No dentist shall administer conscious sedation at the moderate level in Georgia in accordance with the definition of conscious sedation as defined by O.C.G.A. 43-11-1 unless such dentist possesses a permit based on a credentials review. The permits issued are Moderate Enteral Conscious Sedation or Moderate Parenteral Conscious Sedation.

(3)

Moderate Conscious Sedation is defined as 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.

(4)

Moderate Enteral Conscious Sedation is any technique of administration in which the drugs are absorbed through the gastrointestinal tract or oral mucosa, i.e. oral, rectal, and sublingual.

(a)

To obtain a Moderate Enteral Conscious Sedation Permit for adults, a dentist must provide certification of the following:

1.	Completion of an ADA-accredited postdoctoral training program, which affords comprehensive training necessary to administer and manage moderate enteral conscious sedation; or

2.

Completion of a continuing education course of a board approved organization, which consists of a minimum of twenty-four (24) hours of didactic instruction plus management of at least ten (10) adult case experiences which provides competency in moderate enteral conscious sedation which may include simulated cases.

(b)

To obtain a Moderate Enteral Conscious Sedation Permit for pediatric patients (age 12 and under) a dentist must provide certification of a continuing education course of a board approved organization in pediatric sedation including twenty-four (24) hours of pediatric-specific instruction after adult training and ten (10) pediatric patient experiences to include supervised administration of sedation of at least five (5) patients; or completion of an ADA-accredited postdoctoral training program that provides pediatric sedation experience commensurate with these guidelines.

(5)

Moderate Parenteral Conscious Sedation is any technique utilizing multiple sedation modalities, including intravenous, enteral, parenteral, and inhalation.

(a)

To obtain a Moderate Parenteral Conscious Sedation Permit for adults, a dentist must provide certification of the following:

(1)	Completion of an ADA-accredited postdoctoral training program, which affords comprehensive training to administer and manage moderate parenteral conscious sedation; or

(2)	Completion of a continuing education course of a board approved organization consisting of a minimum of sixty (60) hours of didactic instruction plus management of at least twenty (20) patients, which provides competency in moderate parenteral conscious sedation.

(b)

To obtain a Moderate Parenteral Conscious Sedation Permit for pediatric patients (age 12 and under) a dentist must provide certification of a continuing education course of a board approved organization in pediatric sedation including not less than sixty (60) hours didactic and supervised administration of sedation of twenty (20) patients; or completion of an ADA-accredited postdoctoral training program that provides pediatric sedation experience commensurate with these guidelines.

(6)

The dentist issued a permit in either Moderate Enteral Conscious Sedation or Moderate Parenteral Conscious Sedation shall maintain a properly equipped facility for the administration of such sedation, staffed with appropriately trained and supervised personnel. The facility must have equipment capable of delivering positive pressure oxygen ventilation, a pulse oximeter, suction equipment that allows aspiration of the oral and pharyngeal cavities, an operating table or chair that allows for the patient to be positioned to maintain an airway, a firm platform for cardiopulmonary resuscitation, a fail-safe inhalation system if nitrous oxide/oxygen is used, equipment necessary to establish intravascular access, equipment to continuously monitor blood pressure and heart rate, appropriate emergency drugs per ACLS or PALS protocol, a manual or automatic external defibrillator, and a recovery area with available oxygen and suction. All of the aforementioned equipment, drugs, and supplies must be stationary and not subject to transfer from one facility to another. The applicant must submit verification that the facility meets the above requirements and shall be subject to an on-site inspection. The dentist and all support personnel must be certified in cardiopulmonary resuscitation at the basic life support healthcare provider level given by a board approved sponsor with update not to exceed two years per board rules 150-3-.08, 150-3-.09, 150-5-.04, 150-5-.05. Additionally, the dentist must have current certification in advanced cardiovascular life support (ACLS) for adult permits or pediatric advanced life support (PALS) for pediatric permits or an appropriate dental sedation/anesthesia emergency management course as approved by the board.

(a)

The dentist must take four (4) hours of continuing education every two (2) years in pharmacology, anesthesia, emergency medicine or sedation, as part of the 40 hour requirement for license renewal, to maintain certification for the Enteral and/or Parenteral Conscious Sedation Permits. Certification of this continuing education must be submitted at renewal.

(b)	The Georgia Board of Dentistry shall be given a written, thirty (30) day advance notification of the relocation of a facility, the addition of a facility or significant change to the facility.

(c)

When a Certified Registered Nurse Anesthetist (CRNA) is permitted to function under the direction and responsibility of a dentist for the administration of conscious sedation, the operating dentist must have completed training and hold a valid conscious sedation permit issued by the board that incorporates the level and mode of sedation administered by the CRNA.

(d)

The dentist must be certified in cardiopulmonary resuscitation at the basic and advanced levels and all support personnel who provide direct hands-on patient care must be certified in cardiopulmonary resuscitation at the basic life support level given by a board approved provider with an update not to exceed two years. While any conscious sedation procedure is underway, a minimum of two support personnel certified in basic cardiopulmonary resuscitation must be present.

(7)

The requirements as set forth in this rule apply to all new permit applicants upon its effective date. Current, active sedation permit holders are grandfathered for educational requirements and will have until December 31, 2011 to comply with facility requirements including monitoring and emergency equipment, drugs, and supplies, and periodic emergency training requirements for the dentist and all support personnel.

(8)	Permit fees: As shown in the schedule of fees adopted by the Board of Dentistry.

(9)	Renewal Fees: As shown in the schedule of fees adopted by the Board of Dentistry.

(10)	Late Renewal Fees: As shown in the schedule of fees adopted by the Board of Dentistry.

Rule 150-13-.02 Deep Sedation/General Anesthesia Permits

(1)	The educational requirements for a permit to use deep sedation/general anesthesia in Georgia shall be equal to those set forth in O.C.G.A. § 43-11-21.1.

(2)

The following guidelines shall apply to the administration of deep sedation/general anesthesia in the dental office or a site approved by the Board:

(a)

When administration of deep sedation/general anesthesia is provided by another qualified dentist holding a current (Georgia) deep sedation/general anesthesia permit or by a physician anesthesiologist, the operating dentist and the staff must be certified in cardiopulmonary resuscitation at the basic life support level given by a board-approved sponsor with an update not to exceed two years per board Rules 150-3-.08, 150-3-.09, 150-5-.04, and 150-5-.05.

(b)

When a certified Registered Nurse Anesthetist (CRNA) is permitted to function under the direction and responsibility of a dentist, administration of deep sedation/general anesthesia by a CRNA shall require the operating dentist to have completed training in deep sedation/general anesthesia, commensurate with these guidelines.

(c)	A dentist administering deep sedation/general anesthesia must document current successful completion of an advanced cardiac life support (ACLS) course (or an appropriate equivalent).

(d)	All staff must be certified in cardiopulmonary resuscitation at the basic life support level given by a board-approved sponsor with an update not to exceed two years per board Rules 150-3-.08, 150-3-.09, 150-5-.04, and 150-5-.05.

(3)

In all areas in which this level of anesthesia is being conducted, the dentist shall maintain a properly equipped facility for the administration of deep sedation/general anesthesia, staffed with appropriately trained and supervised personnel. The facility must have equipment capable of delivering positive pressure oxygen ventilation, a pulse oximeter, suction equipment that allows aspiration of the oral and pharyngeal cavity, an operating table or chair that allows for the patient to be positioned to maintain an airway, a firm platform for cardiopulmonary resuscitation, a fail-safe inhalation system if nitrous oxide/oxygen is used, equipment to continuously monitor blood pressure and heart rate and rhythm, EKG monitor, appropriate emergency drugs per ACLS protocol including reversal agents for narcotics and/or benzodiazepines depending on which is actually utilized, a manual or automatic external defibrillator, and a recovery area with available oxygen and suction. The facility shall have continual monitoring of end tidal CO2 (expired carbon dioxide) unless invalidated by the nature of the patient, procedure or equipment. "Continual" shall mean "repeated regularly and frequently in steady rapid succession." All of the aforementioned equipment and supplies must be stationary and not subject to transfer from one facility to another. The applicant must submit verification that the facility meets the above requirements and shall be subject to an on-site inspection.

(a)

The dentist must be certified in cardiopulmonary resuscitation at the basic and advanced levels and all immediate support personnel who provide direct hands-on patient care must be certified in cardiopulmonary resuscitation at the basic life support level given by a board approved provider with an update not to exceed two years. While any deep sedation/general anesthesia procedure is underway, a minimum of two immediate support personnel certified in basic cardiopulmonary resuscitation must be present.

(4)

The Georgia Board of Dentistry shall be given a written thirty (30) day advance notification of the relocation of a facility, the addition of a facility or significant changes in the facility. Changes in the method of administration of deep sedation/general anesthesia should also be brought to the attention of the Board. The permit holder shall be subject to an on-site inspection.

(5)

The dentist must take four (4) hours of continuing education every two (2) years in pharmacology, anesthesia, emergency medicine or sedation as part of the forty (40) hour requirement for license renewal to maintain certification for the deep sedation/general anesthesia permit. Certification of this continuing education must be submitted at renewal.

(6)	Permit fees: As shown in the schedule of fees adopted by the Board.

(7)	Renewal fees: As shown in the schedule of fees adopted by the Board.

(8)	Late renewal fees: As shown in the schedule of fees adopted by the Board.

Rule 150-13-.03 Renewal of Conscious Sedation and Deep Sedation/ General Anesthesia Permits

(1)

Conscious sedation and deep sedation/general anesthesia permits shall be renewable biennially, on or prior to December 31st of all odd-numbered years, and upon payment of the renewal fee as provided in Rule 150-12-.01. The permit shall be administratively revoked for failure to renew on July 1st of the following even-numbered year. Permits, which have been administratively revoked, shall be reinstated only in the discretion of the Board, upon completion of a reinstatement application. The former permit holder may also be subject to an on-site inspection prior to renewal of the permit.

(2)

The dentist must be certified in cardiopulmonary resuscitation at the basic and advanced levels and all support personnel who provide direct hands-on patient care must be certified in cardiopulmonary resuscitation at the basic life support level given by a board approved provider with an update not to exceed two years.

(3)

The dentist must take four (4) hours of continuing education every 2 years to stay current on sedation/general anesthesia techniques, patient risk assessment courses, new medications, improved monitoring devices, and any other developing trends to insure that current knowledge and competency are maintained so that sedation/general anesthesia can be most safely provided. These four hours will be part of the total forty (40) hour CE requirement.

(4)	CPR, ACLS, and PALS are required to rescue patients from untoward events and do count toward the total of forty (40) CE hours every two years, but do not satisfy the four (4) hour CE requirement referenced in subsection (3) above.

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