As used in this part:

1. (1) “Analgesia” means the diminution of pain or production of increased tolerance to pain in the conscious patient;
2. (2) “Anesthesia” means partial or complete loss of sensation with or without the loss of consciousness;
3. (3) “Anesthesia period” means the period of time beginning with the placement of a needle, mask, or solution into or onto the body until the patient has met the criteria that are appropriate for dismissal;

4. (4)

   1. (A) “Deep sedation” means a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation.
   2. (B) The ability to independently maintain ventilatory function may be impaired.
   3. (C) Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate.
   4. (D) Cardiovascular function is usually maintained;

5. (5) “Direct supervision” means the dentist:

   1. (A) Is in the dental office;
   2. (B) Authorizes the procedure; and
   3. (C) Remains in the dental office while the procedures are being performed by the auxiliary;
6. (6) “Enteral” means any technique of administration in which the agent is absorbed through the gastrointestinal tract or oral mucosa (i.e., oral, rectal, sublingual);

7. (7)

   1. (A) “General anesthesia” means a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation.
   2. (B) The ability to independently maintain ventilatory function is often impaired.
   3. (C) Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function.
   4. (D) Cardiovascular function may be impaired;
8. (8) “Incremental dosing” means administration of multiple doses of a drug until a desired effect is reached, but not to exceed the MRD;

9. (9) “Inhalation” means a technique of administration:

   1. (A) In which a gaseous or volatile agent is introduced into the lungs; and
   2. (B) Whose primary effect is due to absorption through the gas/blood interface;
10. (10) “Maximum recommended dose (MRD)” means the maximum United States Food and Drug Administration-recommended dose of a drug as printed in Food and Drug Administration-approved labeling for unmonitored home use;

11. (11)

    1. (A) “Minimal sedation” means a minimally depressed level of consciousness produced by a pharmacological method that retains the patient’s ability to independently and continuously maintain an airway and respond normally to tactile stimulation and verbal command.

    2. (B) The patient should be oriented to:

       1. (i) Person;
       2. (ii) Place; and
       3. (iii) Time.
    3. (C) Although cognitive function and coordination may be modestly impaired, ventilatory and cardiovascular functions are unaffected.
    4. (D) In accordance with this particular definition, the drug and/or techniques used should carry a margin of safety wide enough never to render unintended loss of consciousness.
    5. (E) Further, patients whose only response is reflex withdrawal from repeated painful stimuli would not be considered to be in a state of minimal sedation.
    6. (F) When the intent is minimal sedation for adults, the appropriate initial dosing of a single enteral drug is no more than the maximum recommended dose of a drug that can be prescribed for unmonitored home use.
    7. (G) When the intent is minimal sedation, only one (1) drug can be given in addition to nitrous oxide.

    8. (H) Pediatric considerations.

       1. (i) In addition to the physiologic parameters for minimal sedation in children under twelve (12) years of age, when the intent is minimal sedation, only one (1) drug can be given in addition to nitrous oxide.
       2. (ii) A drug cannot be from the scheduled category of drugs II, III, or IV with the exception of diazepam.
       3. (iii) If a child under twelve (12) years of age is given any drug for sedation from Schedule II, III, or IV, with the exception of diazepam, that child is considered more than minimally sedated;

12. (12)

    1. (A) “Moderate sedation” means a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation.
    2. (B) No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate.
    3. (C) Cardiovascular function is usually maintained.
    4. (D) In accordance with this particular definition, the drugs and/or techniques used should carry a margin of safety wide enough to render unintended loss of consciousness unlikely.
    5. (E) Repeated dosing of an agent before the effects of previous dosing can be fully appreciated may result in a greater alteration of the state of consciousness than is the intent of the dentist.
    6. (F) Further, a patient whose only response is reflex withdrawal from a painful stimulus is not considered to be in a state of moderate sedation;

13. (13)

    1. (A) “Nitrous oxide/oxygen inhalation analgesia” means the administration, by inhalation, of a combination of nitrous oxide and oxygen producing an altered level of consciousness that retains the patient's ability to independently and continuously maintain an airway and respond appropriately to physical stimulation and/or verbal command.
    2. (B) Nitrous oxide/oxygen inhalation analgesia, when used alone, is not considered a form of sedation but is considered to be an analgesic only;
14. (14) “Operative supervision” means the dentist is personally operating on the patient and authorizes the auxiliary to aid the treatment by concurrently performing a supportive procedure;
15. (15) “Parenteral” means a technique of administration in which the drug bypasses the gastrointestinal tract (i.e., intramuscular, intravenous, intranasal, submucosal, subcutaneous, intraosseous);

16. (16) “Patient physical status classification”, as defined by the American Society of Anesthesiologists, means:

    1. (A) ASA I: A normal, healthy patient;
    2. (B) ASA II: A patient with mild systemic disease;
    3. (C) ASA III: A patient with severe systemic disease;
    4. (D) ASA IV: A patient with severe systemic disease that is a constant threat to life;
    5. (E) ASA V: A moribund patient who is not expected to survive without the operation;
    6. (F) ASA VI: A declared brain-dead patient whose organs are being removed for donor purposes; and
    7. (G) E: Emergency operation of any variety used to modify one (1) of the above classifications, i.e., ASA III-E;
17. (17) “Pediatric sedation” means any level above nitrous oxide analgesia on patients under the age of twelve (12) years;

18. (18)

    1. (A) “Permit reclassification” means all Level 3 permits currently held by any dentists on the date of adoption of this part will be reclassified to Moderate Sedation Permits.
    2. (B) All Level 4-General Anesthesia permits currently held by any dentists on the date of adoption of this part will be reclassified to Deep Sedation-General Anesthesia Permits;

19. (19) “Personal supervision” means the dentist:

    1. (A) Is in the dental office;
    2. (B) Personally authorizes the procedure; and
    3. (C) Before the dismissal of the patient, evaluates the patient;

20. (20)

    1. (A) “Qualified staff” means an individual trained to:

       1. (i) Monitor appropriate physiological parameters; and
       2. (ii) Help in any supportive or resuscitating measures.

    2. (B) For dentists using minimal or moderate sedation, qualified staff must:

       1. (i) Have a current Nitrous Oxide Permit from the Arkansas State Board of Dental Examiners; and
       2. (ii) Be currently certified in healthcare provider CPR.

    3. (C) For dentists using deep or general sedation, qualified staff must:

       1. (i) Have a current Nitrous Oxide Permit from the Arkansas State Board of Dental Examiners;
       2. (ii) Be currently certified in healthcare provider CPR; and
       3. (iii) Have completed an Arkansas State Board of Dental Examiners-approved course as outlined in 17 CAR § 115-1307 and be registered with the Arkansas State Board of Dental Examiners as a sedation assistant;

21. (21)

    1. (A) “Supplemental dosing” means, during minimal sedation, a single additional dose of the initial drug that may be necessary for prolonged procedures.

    2. (B) The supplemental dose should not:

       1. (i) Exceed one-half (1/2) of the initial total dose; and
       2. (ii) Be administered until the dentist has determined the clinical half-life of the initial dosing has passed.
    3. (C) The total aggregate dose must not exceed one and one-half (1 ½) times the MRD on the day of treatment;

22. (22)

    1. (A) “Titration” means administration of incremental doses of a drug until a desired effect is reached.
    2. (B) Knowledge of each drug’s time of onset, peak response, and duration of action is essential to avoid over sedation.
    3. (C) Although the concept of titration of a drug to effect is critical for patient safety, when the intent is moderate sedation one must know whether the previous dose has taken full effect before administering an additional drug increment;
23. (23) “Transdermal” means a technique of administration in which the drug is administered by patch or iontophoresis through skin; and

24. (24) “Transmucosal” means a technique of administration in which the drug is administered across mucosa, such as:

    1. (A) Intranasal;
    2. (B) Sublingual; or
    3. (C) Rectal.

Codification Notes: "CPR" means cardiopulmonary resuscitation. This section as promulgated prior to codification into the Code of Arkansas Rules contained the following as a heading to the definitions of "enteral", "inhalation", "parenteral", "transdermal", and "transmucosal": "12. Routes of Administration Defined". This section as promulgated prior to codification into the Code of Arkansas Rules contained the following as a heading to the definitions of "direct supervision", "operative supervision", and "personal supervision": "4. Levels of Supervision For Qualified Staff".