Individual Permit C: Administration of Nitrous Oxide-oxygen Alone or in Conjunction with Local

Anesthesia (1) Initial Application Requirements. An applicant shall submit an accurate and complete application on forms provided by the Board and accompanied by a fee established annually by the Executive Office of Administration and Finance, and includes documentation that demonstrates proof that the applicant: (a) Is a dentist licensed under M.G.L. c. 112, § 45 to practice in the Commonwealth; (b) Has current certification in BLS, ACLS or PALS; (c) Has successfully completed between 14 hours of didactic and clinical training in the administration of nitrous oxide-oxygen only; or (d) An advanced education program accredited by the ADA Commission on Dental Accreditation that affords comprehensive and appropriate training necessary to administer and manage nitrous oxide-oxygen only. (2) Auxiliary Personnel Required. A qualified dentist inducing minimum sedation shall have at least one additional individual trained in BLS present during the administration of the anesthesia. (3) Patient Evaluation Required. Patients considered for nitrous oxide-oxygen sedation must be suitably evaluated prior to the start of any sedative procedure. In healthy or medically stable individuals (ASA I, II) this shall consist of at least a review of their current medical history and medication use. For patients with significant medical considerations (e.g., ASA III, IV) may require consultation with their primary care physician or consulting medical specialist. (4) Pre-operative Preparation for Patients Required. Pre-operative preparation for the administration of nitrous oxide-oxygen sedation shall include the following: (a) The patient or legal representative shall be advised regarding the procedure associated with the delivery of any sedative or anesthetic agents and signed informed consent pursuant to 234 CMR 5.15(3)(f) for the proposed sedation/anesthesia shall be obtained prior to the administration of nitrous oxide-oxygen; (b) Determination of adequate oxygen supply and equipment necessary to deliver oxygen under positive pressure must be completed; (c) Baseline vital signs must be obtained and documented in the patient record. If the patient's behavior prohibits such determination, this must be documented in the patient record; (d) A focused physical evaluation must be performed as deemed appropriate; (e) Specific dietary instructions must be provided to the patient based upon the type of sedative/anesthetic technique prescribed and patient's physical status; and (f) Pre-operative verbal and written instructions must be given to the patient. (5) Requirements for Patient Monitoring and Documentation. (a) A qualified dentist, or at the qualified dentist's direction, an appropriately trained dental auxiliary, must remain in the operatory during active dental treatment to monitor the patient continuously until the patient meets the criteria for discharge to the recovery area. The appropriately trained dental auxiliary must be familiar with monitoring techniques and equipment. (b) Anesthesia Chart. The Anesthesia Chart shall contain documentation of all events related to the administration of the sedative or anesthetic agents, including but not limited to the following: 1. The color of mucosa, skin or blood (monitoring only); 2. The qualified dentist and/or appropriately trained dental auxiliary must observe chest excursions continually; 3. Blood pressure, respirations, and heart rate should be evaluated pre-operatively, post-operatively and intra-operatively as necessary. If the patient is uncooperative or cannot tolerate such monitoring, this must be documented in the patient record. (6) Requirements for Recovery and Discharge. (a) Oxygen and suction equipment must be immediately available; (b) The qualified dentist or appropriately trained dental auxiliary must monitor the patient during recovery until the patient is ready for discharge; (c) The qualified dentist must determine and document that level of consciousness, oxygenation, ventilation and circulation are satisfactory for discharge; (d) Post-operative verbal and written instructions must be given to the patient and responsible person. (7) Requirements for Management of Pediatric Patients. The Board adopts the American Academy of Pediatrics/American Academy of Pediatric Dentistry's Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation of Diagnostic and Therapeutic Procedures, and the American Dental Association's guidance on pediatric and special needs patients as contained in its Policy Statement on The Use of Sedation and General Anesthesia by Dentists (2007). (8) Requirements for Emergency Management for Patients. The qualified dentist is responsible for the sedative management, adequacy of the facility and staff, diagnosis and treatment of emergencies related to the administration of sedation and providing and maintenance of the equipment, drugs and protocol for patient rescue. If a patient enters a deeper level of sedation than the qualified dentist is permitted to provide, the dentist must stop the dental procedure until the patient returns to the intended level of sedation.