1. (a) Nitrous oxide inhalation analgesia.

   1. (1) Permit. A permit is not required for the dentist.

   2. (2) Qualified staff. All patients shall be monitored continuously by personnel who hold a current:

      1. (A) Permit with the Arkansas State Board of Dental Examiners to induce and monitor nitrous oxide/oxygen inhalation analgesia; and
      2. (B) Certification in healthcare provider-level CPR.
   3. (3) Equipment. Fail-safe nitrous oxide equipment with nitrous oxide scavenging.
   4. (4) Documentation. The use of nitrous oxide and oxygen analgesia must be properly recorded on each individual patient's record.
   5. (5) Emergency care. The dental office shall maintain emergency equipment and medications to perform basic life support.
   6. (6) Patient monitoring. The dentist or qualified staff must remain in the operatory while a patient is receiving nitrous oxide inhalation analgesia.

2. (b) Minimal sedation.

   1. (1) Permit. A permit from the board is not required for minimal sedation.

   2. (2) Qualified staff. All patients shall be monitored continuously by qualified staff who hold a current:

      1. (A) Permit with the board to induce and monitor nitrous oxide/oxygen inhalation analgesia; and
      2. (B) Certification in healthcare provider-level CPR.

   3. (3) Equipment.

      1. (A)
3. (i) The nitrous oxide and patient monitoring equipment listed below must be used for every patient being sedated:
4. (a) (a) Fail-safe nitrous oxide equipment;
5. (b) (b) Scavenging system for nitrous oxide;
6. (c) (c) Pulse oximeter for pediatric minimal sedation; and

7. (d) (d) Blood pressure cuff and stethoscope.

   1. (ii) If multiple patients are being sedated simultaneously, each piece of equipment listed must be available for every patient being sedated.

      1. (B) The emergency equipment listed below must be available in any office where minimal sedation is administered:

         1. (i) Oral airways;
         2. (ii) Appropriate emergency drugs;
         3. (iii) Automated external defibrillators; and
         4. (iv) Positive pressure oxygen delivery system with appropriately sized mask.

   2. (4) Documentation.

      1. (A) The use of minimal sedation must be properly recorded on each individual patient's record.

      2. (B) Documentation should include but not be limited to:

         1. (i) Informed consent;
         2. (ii) Health history;
         3. (iii)
8. (a) (a) For pediatric minimal sedation, heart rate and respiratory rate must be recorded preoperatively, intraoperatively, and postoperatively as necessary.

9. (b) (b) Blood pressure must be recorded preoperatively, intraoperatively, and postoperatively as necessary unless the patient is unable to tolerate such monitoring (i.e., a small child with a blood pressure cuff).

   1. (c) (c) Oxygen saturation must also be recorded preoperatively, intraoperatively, and postoperatively;

      1. (iv) Names of all drugs administered including dosages and the weight of patients under the age of twelve (12);

         1. (v) Local anesthetic record;
         2. (vi) Record of all procedures;
         3. (vii) Post-operative instructions; and
         4. (viii) Record that level of consciousness was satisfactory prior to discharge.

   2. (5) Emergency care.

      1. (A) The dental office shall maintain emergency equipment and medications to perform basic life support.
      2. (B) Dentists intending to produce minimal sedation must be able to diagnose and manage the physiologic consequences (rescue) for patients whose level of sedation enters that of a higher level than minimal.
      3. (C) The dentist must have the training to identify and manage such an occurrence until either assistance arrives (emergency medical services) or the patient returns to the intended level of minimal or lower level of sedation without airway or cardiovascular complications.

   3. (6) Patient monitoring.

      1. (A) The dentist or qualified staff 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.
      2. (B) The dentist or qualified staff must monitor the patient during recovery until the patient is ready for discharge by the dentist.

      3. (C) The dentists must determine and document that levels of consciousness, oxygenation, ventilation, and circulation are satisfactory prior to discharge.

         1. (c) Moderate sedation.

   4. (1) Permit.

      1. (A) A permit from the board is required.
      2. (B) A Facility Permit is also required.
      3. (C) In facilities where more than one (1) dentist provides services to moderately sedated patients, the dentist who is personally providing the dental service to the moderately sedated patient must personally hold a valid moderate sedation permit, unless the sedation is being provided by a contracted anesthesia provider under subsection (f) of this section.
   5. (2) Qualified staff. All patients shall be monitored continuously by qualified staff who hold a current permit with the board to induce and monitor nitrous oxide/oxygen inhalation analgesia and a current certification in healthcare provider-level CPR.

   6. (3) Equipment.

      1. (A) An operating theater large enough to adequately accommodate the patient on a table or in an operating chair and allow an operating team consisting of at least three (3) individuals to freely move about the patient.

      2. (B) An operating table or chair that permits the patient to be positioned so the operating team can:

         1. (i) Maintain the airway;
         2. (ii) Quickly alter patient position in an emergency; and
         3. (iii) Provide a firm platform for the management of cardiopulmonary resuscitation.
      3. (C) A lighting system that is adequate to permit evaluation of the patient's skin and mucosal color and a back-up lighting system that is battery powered and of sufficient intensity to permit completion of any operation underway at the time of general power failure.

      4. (D)

         1. (i) Suction equipment that permits aspiration of the oral and pharyngeal cavities and accepts a tonsillar suction.
         2. (ii) A backup suction device must also be available.
      5. (E) An oxygen delivery system with adequate full-face masks and appropriate connectors that are capable of delivering oxygen to a patient under positive pressure, together with an adequate backup system.

      6. (F)

         1. (i) A recovery area that has available oxygen, adequate lighting, suction, and electrical outlets.
         2. (ii) The recovery area can be the operating theater.
         3. (iii) The patient must be able to be observed by qualified staff at all times during the recovery period.

      7. (G) Ancillary equipment must include the following:

         1. (i)

10. (a) (a) The nitrous oxide and patient monitoring equipment listed below must be used for every patient being sedated:

    1. (1) (1) Fail-safe nitrous oxide equipment;
    2. (2) (2) Scavenging system for nitrous oxide;
    3. (3) (3) Pulse oximeter; and
    4. (4) (4) Blood pressure cuff and stethoscope.

11. (b) (b) If multiple patients are being sedated simultaneously, each piece of equipment listed must be available for every patient being sedated; and

    1. (ii) The emergency equipment listed below must be available in any office where moderate sedation is administered:
12. (a) (a) Oral airways;

13. (b) (b) Appropriate emergency drugs;

    1. (c) (c) Automated external defibrillators; and

       1. (d) (d) Positive pressure oxygen delivery system with appropriately sized mask.

    2. (4) Documentation.

       1. (A) The use of moderate sedation must be properly recorded on each individual patient's record.

       2. (B) Documentation should include but not be limited to:

          1. (i) Informed consent;
          2. (ii) Health history;
          3. (iii)
14. (a) (a) Heart rate, oxygen saturation, and respiratory rate must be recorded preoperatively, intraoperatively, and postoperatively as necessary.

15. (b) (b) Blood pressure must be recorded preoperatively, intraoperatively, and postoperatively as necessary unless the patient is unable to tolerate such monitoring (i.e., a small child with a blood pressure cuff);

    1. (iv) Names of all drugs administered including dosages and the weight of any patient under twelve (12) years of age;

       1. (v) Local anesthetic record;

          1. (vi) Record of all procedures;
          2. (vii) Post-operative instructions;
          3. (viii) Record that level of consciousness was satisfactory prior to discharge; and
          4. (ix) Time-oriented anesthetic record.

    2. (5) Emergency care.

       1. (A) The dental office shall maintain emergency equipment and medications to perform basic life support.
       2. (B) Dentists intending to produce moderate sedation must be able to diagnose and manage the physiologic consequences (rescue) for patients whose level of sedation enters that of a higher level than moderate.

       3. (C) The dentist must have the training to identify and manage such an occurrence until either:

          1. (i) Assistance arrives (emergency medical services); or
          2. (ii) The patient returns to the intended level of moderate or lower level of sedation without airway or cardiovascular complications.
       4. (D) The dentist must be trained in and capable of providing, at the minimum, bag-valve-mask ventilation so as to be able to oxygenate any patient who develops airway obstruction or apnea.
       5. (E) The equipment listed in subdivision (c)(3) of this section is the minimal requirement for offices where moderate sedation is provided.

    3. (6) Patient monitoring.

       1. (A) The dentist or qualified staff must remain in the operatory to monitor the patient continuously until the patient meets the criteria for recovery.
       2. (B) When active treatment concludes and the patient recovers to a minimally sedated level, qualified staff may remain with the patient and continue to monitor them until they are discharged from the facility.

       3. (C) The dentists must not leave the facility until the patient:

          1. (i) Meets the criteria for discharge; and
          2. (ii) Is discharged from the facility.

       4. (D) The dentist must determine and document that levels of consciousness, oxygenation, ventilation, and circulation are satisfactory prior to discharge.

          1. (d) Deep sedation.
    4. (1) Permit. A permit issued to the dentist from the board to administer deep sedation is required as well as a Facility Permit.

    5. (2) Qualified staff. The technique for deep sedation requires the following three (3) individuals:

       1. (A) A dentist holding a current permit for deep sedation from the board;
       2. (B) An individual to assist with observation and monitoring of the patient and who may administer drugs if appropriately licensed; and

       3. (C)

          1. (i) Qualified staff to assist the operator as necessary.
          2. (ii) All individuals assisting at this level must hold a current:
16. (a) (a) Permit from the board to monitor and administer nitrous oxide;

17. (b) (b) Permit from the board as a sedation assistant; and

    1. (c) (c) Certification in healthcare provider-level of CPR.

    2. (3) Equipment.

       1. (A) Requirements are the same as the first six (6) requirements for moderate sedation listed in subdivision (c)(3) of this section.

       2. (B) In addition to those previously listed requirements, the following ancillary equipment is required:

          1. (i)

18. (a) (a) The nitrous oxide and patient monitoring equipment listed below must be used for every patient being sedated:

    1. (1) (1) Fail-safe nitrous oxide equipment;
    2. (2) (2) Scavenging system for nitrous oxide;
    3. (3) (3) Pulse oximeter;
    4. (4) (4) Blood pressure cuff and stethoscope;
    5. (5) (5) Electrocardioscope; and
    6. (6) (6) Automatic blood pressure monitoring device.

19. (b) (b) If multiple patients are being sedated simultaneously, each piece of equipment listed must be available for every patient being sedated; and

    1. (ii) The emergency equipment listed below must be available in any office where deep sedation or general anesthesia is administered:
20. (a) (a) Oral airway;

21. (b) (b) Appropriate emergency drugs;

    1. (c) (c) Automated external defibrillators;

       1. (d) (d) Positive pressure oxygen delivery system;
22. (e) (e) Tonsillar and pharyngeal-type suction tip;
23. (f) (f) Laryngoscope complete with adequate selection of blades, batteries, and bulb;
24. (g) (g) Endotracheal tubes and appropriate connectors;

25. (h) (h) Adequate equipment for the establishment of an intravenous infusion;

    1. (i) (i) McGill forceps;
26. (j) (j) Appropriate emergency drugs for advanced cardiac life support (ACLS); and

27. (k) (k) Thermometer.

    1. (4) Records. Anesthesia records must be maintained as a permanent portion of the patient file and shall include at a minimum:

       1. (A) Informed consent;
       2. (B) Health history;

       3. (C) Vital signs, recorded:

          1. (i) Preoperative;
          2. (ii) Intraoperative; and
          3. (iii) Postoperative;
       4. (D) Names of all drugs administered including dosages;
       5. (E) Local anesthetic record;
       6. (F) Record of all procedures;
       7. (G) Postoperative instructions;
       8. (H) Record that level of consciousness was satisfactory prior to discharge;
       9. (I) Time-oriented anesthetic record; and
       10. (J) Pulse oximetry readings.

    2. (5) Emergency care.

       1. (A) The dental office shall maintain emergency equipment and medications to perform ACLS.
       2. (B) Dentists intending to produce deep sedation must be able to diagnose and manage the physiologic consequences (rescue) for patients whose level of sedation enters that of general anesthesia.

       3. (C) The dentist must have the training, skills, drugs, and equipment to identify and manage such an occurrence until either:

          1. (i) Assistance arrives (emergency medical services); or
          2. (ii) The patient returns to the intended level of deep or lower level of sedation without airway or cardiovascular complications.

    3. (6) Patient monitoring.

       1. (A) The dentist must remain in the operatory to monitor the patient continuously until the patient meets the criteria for recovery.
       2. (B) When active treatment concludes and the patient recovers to a minimally sedated level, qualified staff may remain with the patient and continue to monitor them until they are discharged from the facility.
       3. (C) The dentist must not leave the facility until the patient meets the criteria for discharge and is discharged from the facility.
       4. (D) The dentist must determine and document that levels of consciousness, oxygenation, ventilation, circulation, and temperature are satisfactory prior to discharge.
28. (e) General anesthesia. All requirements for permits, qualified staff, equipment, records, emergency care, and patient monitoring are exactly the same as for deep sedation.

29. (f) Contracting anesthesia.

    1. (1)

       1. (A) A dentist whose dental office meets the facility requirements and has obtained a Facility Permit from the board may contract with a licensed physician with a specialty in anesthesiology, certified registered nurse anesthetist, or a dentist holding an anesthesia permit for in-office deep sedation or general anesthesia.
       2. (B) The board holds the contracting dentist ultimately responsible for the quality of the anesthesia given and the patient care delivered.
    2. (2) A dentist may admit or have a patient admitted to an outpatient surgery center approved by the Department of Health, The Joint Commission (outpatient facilities), AAAHC, or other nationally recognized accreditation agency or a hospital and utilize any appropriate level of sedation or general anesthesia as provided by a licensed physician with a specialty in anesthesiology or a certified registered nurse anesthetist without the dentist holding a board permit for that level of anesthesia or sedation or a Facility Permit.

Codification Notes: "CPR" means cardiopulmonary resuscitation. "AAAHC" means Accreditation Association for Ambulatory Health Care.