TSBDE update
What You Must Know If You
Administer Nitrous or Sedation
In Your Practice
by Dr. Shawn Seifikar
The Texas State Dental Board (TSBDE) has recently changed the rules governing the use of nitrous
oxide and all levels of sedation. This article will bring awareness to Texas dentists and try to rectify
confusion with the recently adopted rules. You may visit www.texas.gov for the list of all the
recently adopted rules.
Texas State Board of Dental Examiners (TSBDE) adopted rules
based on the findings of a Blue-Ribbon Panel (BRP) which was
commissioned to perform a comprehensive review of all the
adverse outcomes during fiscal years 2012-2016, where seda-
tion or anesthesia were administered.
Panel members reviewed, 78 cases with determination that 19
of these events were related to mishandled sedation/anesthesia.
BRP identified 13 of the 19 cases as mishaps, meaning the
adverse event occurred without permanent injury. Six cases
were identified as major events resulting in mortality or perma-
nent morbidity.
Every major event involved either young children or adults with
high risk factors such as obesity, compromised health, or the
elderly. All minimal and moderate sedation morbidities and
mortalities resulted from inadvertent deeper sedation. Sedation
is a continuum and patients can drift deeper than the practi-
tioner intended. This can occur as a result of over-medication
or subsequent to cessation of surgical stimulation leading to
unrecognized respiratory depression.
Poor pre-operative evaluation, nonadherence to current moni-
toring requirements were also prominent in these cases. There
was a paucity of training and preparation of dentists and staff
in responding to medical emergencies. Finally, the providers
were slow to activate the EMS.
In consideration of these findings, the BRP made the following
major recommendations and subsequently the legislature man-
dated these changes through the Senate Bill 313 directing the
14 HOUSTON DENTISTRY | www.houstondentistrymagazine.com
dental board to address these issues. A summary of the BRP rec-
ommendations is found below.
All Texas permit holders are required to have written emer-
gency protocols which must be specific to the permit holder and
practiced through emergency simulations with staff. All level 2,
3 and 4 permit holders providing sedation/anesthesia to chil-
dren and high-risk patients are required to receive sedation-
specific training or document to TSBDE specific training
regarding these groups of patients. Moreover, TSBDE has full
authority to inspect dental offices where any level of
sedation/anesthesia is provided, including nitrous oxide.
TSBDE rules 110.13, 110.14 and 110.15 were adopted in May
2018 and apply to all permit holders in Texas. Rules 110.16,
110.17 and 110.18 were adopted in September 2018 and
apply to level 2, 3 and 4 permit holders.
Preoperative Checklist for Administration of Nitrous Oxide
and Levels 1, 2, 3, and 4 Sedation/Anesthesia (Rule
110.13): This rule mandates all permit holders to create and
maintain a preoperative sedation/anesthesia checklist prior to
commencing a procedure for which the dentist will administer
any sedative agents including nitrous oxide. This checklist is in
addition to the permit holder’s sedation record and may be
paper or electronic. A dentist delegating the administration of
sedation to another provider must ensure the checklist is com-
pleted by that provider and subsequently maintained in the
patient’s dental record. For a complete list of the required items
on the pre-operative checklist, please visit www.tsbde.texas.gov.