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(a)Enteral conscious sedation may be induced and maintained by a permitted dentist licensed by the State of Texas and practicing in Texas, a physician anesthesiologist licensed by the Texas State Board of Medical Examiners, or a Certified Registered Nurse Anesthetist (CRNA) licensed in Texas. When a Certified Registered Nurse Anesthetist (CRNA) is permitted to function under the supervision of a dentist, in the dental office, provision of enteral conscious sedation by a CRNA shall require the operating dentist to be permitted for its utilization. (b)Enteral conscious sedation is indicated for use only for conscious sedation as defined in Rule 110.1 of this title (relating to Definitions). Enteral conscious sedation is not indicated for use to achieve deep sedation. (c)Administration of nitrous oxide/oxygen inhalation conscious sedation in combination with enteral administration of any agent used for any sedation procedure requiring a permit under board rules requires both an enteral conscious sedation permit and a nitrous oxide/oxygen inhalation conscious sedation permit. (d)Minor tranquilizers used for anxiolysis may be prescribed for administration outside of the dental office when pre-procedure instructions are likely to be followed. Medications such as chloral hydrate and all drugs included in the Drug Enforcement Administration (DEA) Controlled Substances Schedule II must not be administered outside of the dental office for sedation purposes. Medications other than minor tranquilizers used for anxiolysis administered outside of the office require a permit. (e)Standard of care requirements. Each dentist must maintain the minimum standard of care as detailed in board rules, and shall in addition: (1)adhere to the clinical requirements as detailed in subsection (f) of this section; (2)maintain under continuous direct supervision auxiliary personnel who shall be capable of reasonably assisting in procedures, problems, and emergencies incident to the use of enteral conscious sedation. (3)maintain current certification in basic cardiopulmonary resuscitation for the assistant staff by having them pass a course given by the American Heart Association or the American Red Cross; and (4)not allow an enteral conscious sedation procedure to be performed in his/her office by a Certified Registered Nurse Anesthetist (CRNA) unless the dentist holds a permit issued by the State Board of Dental Examiners for the procedure being performed. This provision addresses dentists and is not intended to address the scope of practice of persons licensed by any other agency. (f)Clinical Requirements. Each dentist must meet the following clinical requirements for utilization of enteral conscious sedation: (1)Patient Evaluation. Patients who are administered enteral conscious sedation must be suitably evaluated prior to the start of any sedative procedure. In healthy or medically stable individuals (ASA I, II), this may be simply a review of their current medical history and medication use. However, with individuals who may not be medically stable or who have a significant health disability (ASA III, IV) consultation with their primary care physician or consulting medical specialist regarding potential procedure risk is recommended. (2)Pre-Procedure preparation, informed consent: (A)the patient and/or guardian must be advised of the procedure associated with the delivery of the enteral conscious sedation. (B)equipment must be evaluated and maintained for proper operation. (C)baseline vital signs should be obtained at the discretion of the operator depending on the medical status of the patient and the nature of the procedure to be performed. (D)dentists administering enteral conscious sedation shall use sedative agents that he/she is competent to administer and shall administer such agents is a manner that is within the standard of care. (g)Personnel and Equipment: In addition to the dentist, at least one member of the assistant staff should be present during the administration of enteral conscious sedation. (h)Monitoring and Documentation: (1)Patients who have been administered enteral conscious sedation must be monitored during waiting periods prior to operative procedures. A responsible adult given appropriate written pre-procedural instruction may provide such monitoring. The patient should be monitored for alertness, responsiveness, breathing and skin coloration. (2)Dentists administering enteral conscious sedation must maintain direct supervision of the patient during the operative procedure and for such a period of time necessary to establish pharmacologic and physiologic vital sign stability. (A)Oxygenation. Color of mucosa, skin or blood shall be continually evaluated. Oxygen saturation must be evaluated continuously by pulse oximetry, except as provided in paragraph (4) of this section. (B)Ventilation. Must perform observation of chest excursions and/or auscultation of breath sounds. (C)Circulation. Must take and record an initial blood pressure and pulse and thereafter as appropriate except as provided in paragraph (4) of this section. (3)An appropriate time oriented anesthetic record must be maintained including documentation of individual administering the drug(s) and showing the name(s) of drug(s) and dosage(s) used. (4)In selected circumstances, enteral conscious sedation may be utilized without pulse oximetry or taking blood pressure and pulse. These circumstances include: sedation administered for brief procedures; extremely young children, patients who cooperate poorly due to unwillingness or inability to follow instructions, or patients whose level of anxiety will tend to be heightened by monitoring. When these situations occur, the dentist responsible for administering enteral conscious sedation must document the reasons preventing the recommended monitoring. (i)Recovery and Discharge: (1)recovery from enteral conscious sedation must include: (A)positive pressure oxygen and suction equipment must be immediately available in the recovery area and/or operatory; (B)continual monitoring of vital signs when the sedation/anesthesia is no longer being administered; i.e., the patient must have direct continuous supervision until oxygenation, and circulation are stable and the patient is appropriately responsive for discharge from the facility; (C)the dentist must determine and provide for documentation that oxygenation, circulation, activity, skin color and level of consciousness are appropriate and stable prior to discharge; (D)must provide explanation and documentation of written postoperative instructions to patient and/or a responsible adult at time of discharge; (E)the dentist must determine that the patient has met the following discharge criteria prior to leaving the office: (i)cardiovascular function satisfactory and stable; (ii)airway patency uncompromised and satisfactory; (iii)patient easily arousable and protective reflexes intact; (iv)state of hydration adequate; (v)patient can talk, if applicable; (vi)patient can sit unaided, if applicable; (vii)patient can ambulate, if applicable, with minimal assistance; (viii)For the child who is very young or disabled, and incapable of the usually expected responses, the pre-sedation level of responsiveness or the level as close as possible for that child should be achieved. (ix)Responsible individual is available. (2)patients who have unusual reactions to enteral conscious sedation must be assisted and monitored either in an operatory chair or recovery room until stable for discharge; (3)the dentist must determine that the patient is appropriately responsive prior to discharge. (j)Emergency Management. The dentist, personnel and facility must be prepared to treat emergencies that may arise from the administration of enteral conscious sedation, and must have the ability to provide positive pressure ventilation with 100% oxygen with an age appropriate device.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the
agency's legal authority to adopt.
Filed with the Office of
the Secretary of State, on November 27, 2000
TRD-200008185 Jeffry R. Hill
Executive Director
State Board of Dental Examiners
Earliest possible date of adoption: January 7, 2001
For further information, please call: (512) 463-6400
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