North Texas Dentistry Volume 8 Issue 4 2018 ISSUE 4 DE | Page 26

What You Must Know If You Administer Nitrous or Sedation In Your Practice TSBDE update 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 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 26 NORTH TEXAS DENTISTRY | www.northtexasdentistry.com 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. Emergency Preparedness Policies and Procedures (Rule 110.14): This rule mandates all permit holders to develop writ- ten emergency preparedness policies and procedures which establish a plan for the management of medical and sedation emergencies. These developed policies must include training requirements specific to the permit holder’s equipment and drugs and must include individual office staff responsibilities in response to a medical emergency. Staff training logs, docu- menting simulation training in response to emergencies, and an emergency drug log are required per this rule. The permit holder must at least annually review all the above policies, pro- cedures and logs to document whether an update is necessary. Prevention of and Response to Sedation/Anesthesia Emer- gencies (Rule 110.15): This rule pertains to an equipment readiness log which needs to be reviewed and updated at least annually. Permit holders must have immediately available (eas- ily accessible) an adequate unexpired supply of reversal and