SEDATION and GENERAL ANESTHESIA - Minnesota Board of ...

MINNESOTA BOARD OF DENTISTRYUniversity Park Plaza, 2829 University Avenue SE, Suite 450Minneapolis, MN 55414-3249 www.dentalboard.state.mn.usPhone 612.617.2250 Fax 612.617.2260MN Relay Service for Hearing Impaired 800.627.3529SEDATION and GENERAL ANESTHESIACREDENTIAL AND SELF-EVALUATION GUIDEAn inspection is required for each Minnesota-licensed dentist who holds a sedation/anesthesia permit.The inspection document, “Credential Review and Self-Evaluation for Dentists & Dental Offices OfferingModerate Sedation, Deep Sedation, and/or General Anesthesia,” has been designed for this purpose. Weapologize for the delay in getting these materials produced.ELIGIBILITY:Dentists who received their initial sedation/anesthesia certification from the Board AFTER March 17, 2007,must have an in-person, on-site inspection conducted by a Board-approved inspector within 2 years of obtainingthe certificate.Dentists who received their initial sedation/anesthesia certification for the Board BEFORE March 17, 2007, arecurrently considered eligible (Board-approved) to conduct their own inspections by completing the additional“Credential Review and Self-Evaluation…” form.According to Minnesota Rule or those who are eligible to complete “Credential and Self-Evaluation…” form,the completed form should be submitted directly to the Minnesota Board of Dentistry for review by theSedation Committee by March 19, 2009.♦ Sedation Dentists (SD) providing Moderate Sedation, Deep Sedation and/or General Anesthesia are toprovide a completed copy of the Credential and Self-Evaluation form to the Board with all sections exceptSection 8 completed. Those dentists who contract with another professional to administer the sedation oranesthesia (CSS) while they provide the dental care are strongly encouraged to complete the form.Section 1: Indicate the type of sedation that you will be providing. If you are not the sedation provider, butprovide dental services while the patient is sedated, please indicate the level of anesthesia that patients will beunder for those dental services.Section 2: Provide information about yourself and your practice.Section 3: Indicate and attach a copy of your current ACLS or PALS certification.Section 4: Initial checklist items to indicate compliance with each requirement, and indicate expiration date ofmedications as requested. Rationale for absent or substituted items should be provided on a separate sheet.Section 5: Select a random sample of records for patients who have received dental services that includedsedation/anesthesia, and thoroughly examine the patient and clinic records to determine compliance withrecordkeeping expectations.Section 6: Discuss each of the emergency scenarios indicated with staff, and indicate the clinic protocolestablished for each.Section 7: Sign to indicate completeness and accuracy of the Credential Review and Self-Evaluation.

MINNESOTA BOARD OF DENTISTRYUniversity Park Plaza, 2829 University Avenue SE, Suite 450Minneapolis, MN 55414-3249 www.dentalboard.state.mn.usPhone 612.617.2250 Fax 612.617.2260MN Relay Service for Hearing Impaired 800.627.3529Credential Review and Self-Evaluation for Dentists & Dental Offices OfferingModerate Sedation, Deep Sedation, and/or General AnesthesiaA. THE SELF-EVALUATION: All sedation dentists (SD) qualified by training and education to administer moderate sedation,deep sedation and/or general anesthesia, must complete the attached Credential Review and Self-Evaluation form. Any dentist whocontracts with another provider to perform sedation services (CSS) is strongly encouraged to complete the attached Credential Reviewand Self-Evaluation form. Completion of the forms is to be done at least once every five (5) years.Sedation Dentists providing Moderate Sedation will provide a copy of this form to the Board of Dentistry with all sectionscompleted.Sedation Dentists providing Deep Sedation and/or General Anesthesia are to provide a copy of this form to the Board of Dentistrywith all sections completed. The facility, equipment, medication, record keeping, and emergency preparedness will be evaluated byusing the current “Office Anesthesia Evaluation Manual” of the American Association of Oral and Maxillofacial Surgeons. Items ofdifference between this manual and the Board of Dentistry’s rules and regulations will be resolved according to the Board ofDentistry’s determination. The Board of Dentistry may modify, supplement or eliminate all or parts of this document at the Board’sdiscretion.B. TIME FRAME: Initial – An initial inspection must be completed within one (1) year of the SD obtaining MN certification inmoderate sedation, deep sedation, or general anesthesia.Renewal – Both the sedation certificate and the inspection are subject to expiration and renewal. The certificates must be renewedbiennially, concurrent with the dentist’s license renewal. A Credential Review must be completed at least once every (5) years. Thefive (5) year cycle will expire on the last day of the birth month of the licensee’s renewal year.C. MULTIPLE OFFICES: All offices where sedation is performed must comply with the minimum standards established by theBoard for a sedation practice. An SD or CSS who travels to other office locations to administer sedation will be responsible forensuring that each office location has the equipment and emergency medications required by this guideline and that the staff isproperly trained to handle sedation-related emergencies.D. INSPECTION FEES: The fee for the inspection may not exceed $250 plus the cost of travel expenses. Fees are to be paid bythe applicant directly to the inspector. The Minnesota Board of Dentistry does not receive any fees for the sedation inspection.E. TERMINATION: Late certificate renewals result in the SD certificate expiring, and require the dentist to apply for areinstatement of the certificate. If certification has expired, sedation services MUST be suspended until a reinstatement is completedand formally approved by the Board.F. COMPLETENESS/ACCURACY: Failure to complete any portion of the Credential Review or Renewal requirements, i.e.application/renewal forms, proof of emergency management course certification, proof of sedation training, completion of selfevaluationor the submission of appropriate fees, etc. could result in disciplinary action.G. DEFINITIONS:Minimal Sedation – a drug-induced state during which patients respond normally to verbal commands (also referred to as anxiolysis)Moderate Sedation – a drug-induced depression of consciousness during which patients respond purposefully to verbal commands,either alone or accompanied by light tactile stimulation (also referred to as conscious sedation)Deep Sedation – a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefullyfollowing repeated or painful stimulationGeneral Anesthesia – a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation.Requirements – defined by Rule 3100.3600Recommendation – determined by dentist/s skill and knowledgeWrongful Event Prevention – protocol by the dentist to prevent the event of wrong treatment, anesthesia, sedation, patient, medicationAdverse Reaction/Reporting of Incidents (3100.3600 Subp.8) – “… any incident that arises from the administration of nitrous oxideinhalation analgesia, deep sedation, general anesthesia, moderate sedation, local anesthesia, analgesia or minimal sedation (anxiolysis)that results in: A. serious or unusual outcome; …. B. a sedation state becoming a deeper stage than originally intended …”Please Complete the Attached Pages

Type of Sedation To Be Provided (check all that apply):Moderate SedationSECTION 1Enteral Sedation (Oral)Parenteral Sedation (IV)Deep SedationGeneral AnesthesiaSECTION 2I. Dentist Information – (SD/CSS)Dentist Name: _____________________________________ License Number: _______________*If the dentist is NOT providing the sedation, Section 2/Part II below must be completed, and a copy of the contractedindividual’s licensure must be supplied to the Board.II. Sedation Provider Information –Nurse AnesthetistOMFSDentist Certified in SedationOther: ___________________SedationProvider Name: _____________________________________ License Number: _______________Signature: _____________________________________III. Location Information –Location Name: _____________________________________Inspection Date: _______________Address: _____________________________________ Telephone: _____________________________________________________________If the SD or the CSS provides sedation at more than one location, the SD or CSS certifies that each of theoffices/clinics have the required emergency equipment and emergency medication.Yes No SD/CSS Signature: _____________________________________ Date: _______________*Please attach supplemental information indicating other sedation locations.*SECTION 3Attach a copy of Emergency Management Course Certification for the Professional Providing SedationProof of ACLS CertificationExpiration Date: _______________ORProof of PALS CertificationORProof of Board Approved EquivalentEmergency Management CourseCertificationExpiration Date: _______________Course Name: ____________________Expiration Date: __________________2

II. Emergency Medications –A. Enteral and Parenteral Emergency Medications or Equivalents – RecommendationsThese drugs may be included in the emergency cart/kit in forms/doses that the dentist can knowledgeablyadminister, and in typical routes of administration for enteral/parenteral sedation. These drugs are listed bycategory, not by order of importance. These medications must be used appropriately for both pediatric andadult emergency situations. Please attach a separate sheet (if needed) with rationale for absent or substitutedmedications.B. ___ Documentation that all emergency medications are checked and maintained on a prudent andregularly scheduled basis.*Please indicate the expiration date of the following medications available in your practice.*Recommended Enteral SedationEmergency Medications or Current Equivalents*Recommended Parenteral SedationEmergency Medications or Current Equivalents*____Analgesic (nitrous oxide/oxygen, morphine sulfate IM)____Analgesic (morphine sulfate)____Anticonvulsant (diazepam IM)____Anticonvulsant (diazepam)________Antihypoglycemic (oral glucose/sucrose, glucagon HClIM or SC)Anti-inflammatory Corticosteroid (sodium succinate inIM form)________Antihypoglycemic (glucagon HCl, 50% dextrose)Allergic Reaction, Anaphylaxis____ epinephrine IM or SC____ epinephrine (ana-guard, epi-pen auto injector)________________________________________Endogenous Catecholamine____ epinephrine IM or SC for cardiac resuscitation____ epinephrine IM for allergic reaction (ana-guard,epi-pen auto-injector)____ epinephrine SC for asthmatic pediatric patientsVasodilator, Antianginal, Antihypertensive(nitroglycerin SL, SC, IM, PO)Bronchodilator (albuterol inhalant)Respiratory Stimulant (ammonia inhalant)Histamine Blocker (benadryl PO or IM)Vasopressor (methoxamine IM)Anticholinergic Antiarrhythmic (atropine IM or SC)ASA (acetylsalicylic acid, aspirin)Narcotic Antagonist (naloxone IM or SC)Benzodiazepine Antagonist (flumazenil SL)____________________________Corticosteroid (anti-inflammatory hydrocortisone,sodium succinate)Bronchodilator (albuterol)Respiratory Stimulant (ammonia inhalant)Histamine Blocker (diphenhydramine-benadryl,chlorpheniramine)Narcotic Antagonist (naloxone)Benzodiazepine Antagonist (flumazenil)Cardiac Medications____ endogenous catecholamine (epinephrine)____ anticholinergic, antiarrhythmic (atropine)____ vasopresssor (methoxamine)____ vasodilator____ antianginal____ antihypertensive (nitroglycerin)____ antiarrhythmics (lidocaine, verapamil)____ tachycardia (adenosine)____ ventricular fibrillation (aminodarone)____ antihypertensive, antianginal, beta-adrenergicblocker (esmolol)____ ASA (acetylsalicylic acid, aspirin)____Alkalinizing agent (sodium bicarbonate)____Calcium Salt (calcium chloride)____Neuromuscular Blocker (succinylcholine)• Specific medications are provided above as examples, and are subject to changebased on currently published ACLS or Board approved standardsList any deficiencies, substitutions, and rationale (may continue on back):5

List Any Deficiencies:SECTION 6Emergency PreparednessPART I. Emergency Scenarios ― Complete protocols for all scenarios. Attach additional pages ifneeded.The SD/CSS and his/her clinical team must indicate competency in treating the following emergencies. If any areas of theMock Emergency Scenarios need immediate correction, then the SD or CSS must keep a record of the systems’ failures andwrite a plan to amend the staff protocol. A second mock drill should be conducted and subsequently evaluated.* Reminder: Clinical staff involved in the delivery of sedation dental services must be CPR/BLS certified *ALLERGY1. Immediate Allergic Reaction/Anaphylaxis― less than one hourAre you and your staff competent and prepared to recognize and treat Immediate Allergic Reaction/Anaphylaxis?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________2. Delayed Allergic Reaction― greater than one hourAre you and your staff competent and prepared to recognize and treat Delayed Allergic Reaction?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________RESPIRATORY3. Asthmatic Attack (Bronchospasm)Are you and your staff competent and prepared to recognize and treat Asthmatic Attack?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________4. HyperventilationAre you and your staff competent and prepared to recognize and treat Hyperventilation?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________5. Apnea – Airway ManagementAre you and your staff competent and prepared to recognize and treat Apnea?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________6. Foreign Body Obstruction/EmesisAre you and your staff competent and prepared to recognize and treat Foreign Body Obstruction/Emesis?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________7. LaryngospasmAre you and your staff competent and prepared to recognize and treat Laryngospasm?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________CARDIOVASCULAR8. SyncopeAre you and your staff competent and prepared to recognize and treat Syncope?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________9. Angina Pectoris (Chest Pain)Are you and your staff competent and prepared to recognize and treat Angina Pectoris?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________10. Myocardial Infarction (Heart Attack)/Sudden Cardiac ArrestAre you and your staff competent and prepared to recognize and treat Myocardial Infarction/Sudden Cardiac Arrest?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________11. Hypotensive CrisisAre you and your staff competent and prepared to recognize and treat Hypotensive Crisis?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________12. Hypertensive CrisisAre you and your staff competent and prepared to recognize and treat Hypertensive Crisis?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________13. Stroke (Cerebrovascular Accident) *OptionalAre you and your staff competent and prepared to recognize and treat Stroke?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________8

NEUROLOGICAL14. Seizures (Convulsions)Are you and your staff competent and prepared to recognize and treat Seizures?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________DRUG OVERDOSE15. Local Anesthetic OverdoseAre you and your staff competent and prepared to recognize and treat Local Anesthetic Overdose?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________16. Narcotic OverdoseAre you and your staff competent and prepared to recognize and treat Narcotic Overdose?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________17. Benzodiazepine OverdoseAre you and your staff competent and prepared to recognize and treat Benzodiazepine Overdose?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ENDOCRINE18. HypoglycemiaAre you and your staff competent and prepared to recognize and treat Hypoglycemia?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________SECTION 7Personal Attestation – SD/CSSI attest that I have reviewed the information in this document, and that the information is complete and accurate.Signature: _____________________________________Date: ____________________9

SECTION 8: Board/Sedation Committee (for office use only)Summary of Inspection/EvaluationComments/Concerns:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Recommendations:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Sedation Committee Approval: _____________________Signature: _____________________________________Date: _______________*Pursuant to Minnesota Rule 3100.3600, Supt. 11: On-site inspection; requirements and procedures, and Rule 3100.3600,Subp.9,B,(4) and (6).The Minnesota Board of Dentistry greatly appreciates the material provided for thisdocument by:• The American Association of Oral and Maxillofacial Surgeons (AAOMS)• The Institute of Medical Emergency Preparedness ( IMEP)10