{ rules & regulations } provided by the Missouri Dental Board
New Rule Changes: Sedation and EFDA
significant rule changes regarding sedation and anesthesia and expanded functions for dental auxiliaries (EFDA). Many of these changes became effective February 28, 2013.
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By now, most of you should have received a series of emails from the MDA outlining some of the significant changes. The purpose of this article is to delve a little deeper into these changes. Licensees should not rely solely on these informational articles and communications to ensure compliance with the requirements. Licensees are expected to comply with all rules and statutes in their entirety.
SEDATION & ANESTHESIA
When you look at the changes to the seda- tion/anesthesia rules you will notice that there are several changes in terminology. These changes were made to make the language in Missouri’s rules consistent with the language used in the American Dental Association (ADA) Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students as adopted by the October 2007 ADA House of Delegates. For example, the term conscious sedation is now referred to as moderate sedation. And the term anx- iolysis has been replaced by the term minimal sedation. As it was with the previous rules, licensees will need to obtain a permit from the Board to perform moderate (conscious) sedation. A permit is not needed for minimal sedation (anxiolysis).
Some of the more common questions and complaints that the Board received about the previous sedation rules were regarding
16 focus | MAR/APR 2013 | ISSUE 2
s most of you probably know, over the past six years, the Mis- souri Dental Board has been working on promulgating several
a lack of a clear definition of anxiolysis and confusion regarding the difference between anxiolysis and conscious sedation. The new rules more clearly define minimal sedation (anxiolysis) as:
a minimally depressed level of consciousness produced by a pharmacological method, which retains the patient’s ability to independently and continuously maintain an airway and respond normally to tactile stimulation and verbal command. Although cognitive function and coordination may be modestly impaired, ventilatory and cardiovascular functions are unaffected. In accord with this particular definition, the drug(s) and/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.
The new rule goes on to clarify that when minimal sedation is the intent, the initial dose of an enteral drug should not be more than the maximum recommended dose (MRD) of a drug that can be prescribed for unmonitored home use. The MRD is defined as the maximum United States Food and Drug Administration (FDA) recommended dose of a drug, as printed in FDA approved labeling for unmonitored home use.
A similar change clarifies that when the intent is moderate sedation, the amount of drugs used for enteral moderate sedation shall not exceed 1.5 times the maximum recommended dose (MRD) for a period of 12 hours before and after the patient appoint- ment.
A significant change in the moderate seda- tion rule establishes a new pediatric moder- ate sedation permit. The new rule requires that a dentist providing moderate sedation to a patient 12 years of age or younger must obtain training specific to sedating pediatric patients and must obtain a pediatric sedation permit from the Board. A dentist possessing a pediatric moderate sedation permit may administer moderate sedation using either enteral or parenteral techniques.
Probably the most significant change to the deep sedation/general anesthesia rules is a requirement that all members of the anesthesia team complete a board-approved course in monitoring sedated patients. This has always been a requirement for sedation teams working under the requirements of the moderate (conscious) sedation rules. This change makes the requirements for the two teams more consistent.
Another change in the deep sedation/general anesthesia rule changes the requirement for obtaining and renewing a site certificate to include a facility inspection instead of an on-site evaluation. Each individual holding a deep sedation/general anesthesia permit still will be required to undergo an on-site evaluation in order to obtain or renew their individual permit; however they will no longer be required to repeat that process for each individual site certificate for each office they practice at.
One change common to both the moderate sedation rule and the deep sedation/general anesthesia rule is that if the administra- tor of the sedation/anesthesia is a certified registered nurse anesthetist (CRNA), the operating dentist, under whose supervision the CRNA is working, must possess the ap-
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