Section 1 simplifies the definition to just an official, signed request from a dentist to a laboratory.
Section 2 eliminates the prescribed format for the dental laboratory work authorization and simplifies the requirements to include the patient’s name or id number, the dentist’s name and the prescription information.
Sections 3, 5, 7, and 15 repeal definitions no longer utilized in the chapter.
Section 4 defines ASA as the American Society of Anesthesiologists.
Section 6 amends the definitions for Class 1, Class 2 and Class 3 permits. Currently the permits are issued based upon method of sedation and this proposed rule bases the permits on level of sedation which is in line with the American Dental Association’s guidelines. A Class 1 is no longer being issued or valid as minimal sedation is being considered as part of the scope of dentistry that does not require a sedation permit. A Class 2 permit allows the dentist to do moderate sedation. A Class 3 permit allows a dentist to do deep sedation or general anesthesia.
Section 8 defines continual to mean repeated regularly and frequently in a stead succession and continual to mean prolonged without interruption.
Section 9 redefines deep sedation as a drug induced depression of consciousness. A patient cannot be easily aroused but respond to repeated painful stimulation. A patient may require assistance in maintaining an airway and spontaneous ventilation may be inadequate. Cardiovascular function usually is maintained.
Section 10 creates a definition for enteral for agents which are absorbed through the gastrointestinal tract or through the oral, rectal or nasal mucous membranes.
Section 11 redefines general anesthesia as a drug-induced loss of consciousness. The patient is not arousable. The patient often requires assistance to maintain an airway and ventilation is required. Cardiovascular function may be impaired.
Section 12 defines immediately available as the person is actually in the dental office or facility and can immediately available to respond.
Minimal sedation is defined as a depressed level of consciousness allowing the patient to maintain an airway and respond to stimulation or command. Ventilatory and cardiovascular functions are unaffected.
Moderate sedation is defined as a drug-induced depression of consciousness which the patient can respond to oral commands either alone or with a light stimulation. No interventions are necessary to maintain airway or ventilation. Cardiovascular function is maintained. If more than one enteral drug is administered or it is administered at a dosage that exceeds the maximum recommended dose during one appointment, it is considered moderate sedation instead of minimal.
Section 13 revises the term being defined to “nitrous oxide” and defines it as a combination of nitrous oxide and oxygen in a patient.
Section 14 creates a definition for parenteral which means the administration of a drug which bypasses the gastrointestinal tract. It is administered into a muscle, vein, nasal structurers, areolar connective tissue lying beneath a mucous membrane, interocular, or under the skin.
The definition of a pediatric patient is a patient who is 12 years or younger.
Section 16 indicates a permit is not required for minimal sedation. A Class 2 is required for moderate sedation and a Class 3 is required for moderate or deep sedation or general anesthesia. A person applies for a permit by submitting the following: an application; fee; verification of any permit or credential for anesthesia or sedation held by the application; disclosure of any previous adverse incident involving anesthesia or sedation; evidence of current Wisconsin dentistry licensure; evidence of certification in advanced cardiovascular life support or pediatric advanced life support; and approved education. Class 2 permit requires one of the following: board certification or a candidate for board certification by the American Board of Oral and Maxillofacial Surgery; diplomate or candidate of the American Dental Board of Anesthesiology; or successful completion of a Board approved education program. Class 3 permit requires one of the following: board certification or a candidate for board certification by the American Board of Oral and Maxillofacial Surgery; diplomate or candidate of the American Dental Board of Anesthesiology; or postdoctoral residency in an accredited dental program in dental anesthesiology.
Section 17 clarifies that nitrous oxide when used in combination with a sedative agent may produce minimal, moderate or deep sedation. If a patient enters a deeper level of sedation than the dentist is authorized to provide, the dentist must stop the sedation and procedures until the patient returns to the intended level of sedation.
Section 18 provides the education requirements approved by the Board for Class 2 permit. The program shall be at least 60 hours in administration and management of moderate sedation and include:
- Aspects of anxiety and pain control.
- Patient evaluation and selection based upon review of medical history, physical diagnosis and psychological profiling.
- Use of patient history and examination for ASA classification, risk assessment and fasting instructions.
- Definitions and descriptions of physiological psychological aspects of anxiety and pain.
- Description of the sedation anesthesia continuum.
- Review of adult respiratory and circulatory physiology and related anatomy.
- Pharmacology of local anesthetics and agents used in moderate sedation.
- Indications and contraindications for use of moderate sedation.
-Review of dental procedures possible under moderate sedation.
-Patient monitoring using observation and monitoring equipment.
-Maintaining proper records with accurate chart entries.
-Prevention, recognition and management of complications and emergencies.
-Description, maintenance and use of moderate sedation monitors and equipment.
-Discussion of abuse potential.
-Intravenous access anatomy, equipment and technique.
-Prevention, recognition and management of complications of venipuncture and other parenteral techniques.
-Description and rationale for the technique to be employed.
-Prevention, recognition and management of systemic complications of moderate sedation.
20 individually managed cases.
Section 19 repeals the sections on requirements for anxiolysis, conscious sedation-enteral, conscious sedation-parenteral, and deep sedation and general anesthesia sue to being obsolete.
Section 20 creates a requirement for a dentist holding a sedation permit must complete 2 hours of continuing education on the topic of sedation and anesthesia each biennium. The continuing education can count toward the general continuing education requirements for dentists.
Section 21 repeals the office facilities and equipment section as it is addressed under the standards of care section.
Section 22 requires auxiliary personnel to be certified in basic life support for the health care provider. A dentist administering moderate sedation must have one additional person present during the procedure and another person on the premises and available to respond to a patient emergency. A dentist administering general anesthesia or deep sedation must have two additional persons present during the procedure. If the dentist is both performing the dental procedures administering moderate or deep sedation, or general anesthesia, then an auxiliary person must be designated to only monitor the patient.
Section 23 delineates the standards of care. A dentist administering anesthesia or sedation must be in the room to continuously monitor the patient until the patient meets the criteria for transfer to recovery. The dentist may not leave the dental office or facility until the patient meets the criteria for discharge and is discharged from the dental office or facility.
Preoperative preparation includes:
-Determine the adequacy of the oxygen supply and equipment necessary.
-Take and record the patient’s baseline vital signs.
-Complete medical history and a focused physical evaluation.
-Instruct the patient on specific dietary limitations based upon the sedative and anesthetic technique to be used and patient’s physical status.
-Provide pre-operative instructions to the patient.
-Notify and require a patient to arrive and leave with a vested escort.
-Establish and secure, an intravenous line throughout the procedure.
-Advise the patient of fasting requirements.
Utilizing moderate or deep sedation or general anesthesia, a dentist must continuously monitor and evaluate:
-Level of consciousness.
-Oxygenation saturation by pulse oximetry.
-Chest excursions.
-Ventilation monitored by end-tidal carbon dioxide.
-Auscultation of breath sounds by precordial or pretrachial stethoscope.
-Respiration rate.
-Heart rate and rhythm via electrocardiogram.
-Blood pressure.
-Color of mucosa, skin or blood.
-Body temperature whenever triggering agents associated with malignant hyperthermia are administered.
Utilizing minimal sedation, a dentist must continuously monitor and evaluate:
-Level of consciousness.
-Chest excursions.
-Ventilation by either auscultation of breath sounds or by verbal communication with the patient.
-Color of mucosa, skin or blood.
-Blood pressure, heart rate, and oxygenation saturations by pulse oximetry pre-operatively and post0perative and intraoperatively.
A dentist shall maintain and implement recovery and discharge procedures which must include:
