Wyo. Code R. 034-0001-5
Dental Examiners, Board of
Chapter 5: Anesthesia Administration
Effective Date: 03/05/2003 to 01/08/2015
Rule Type: Superceded Rules & Regulations
Reference Number: 034.0001.5.03052003
Section 1. Definitions. For the purpose of these rules relative to the administration of local anesthesia, nitrous oxide inhalation analgesia, conscious sedation, deep sedation, and general anesthesia by licensed dentists the following definitions shall apply:
(a) Analgesia means the diminution or elimination of pain.
(b) Anxiolysis means the diminution or elimination of anxiety. The relief of patient anxiety or fear should produce minimum somnolence. The technique should be appropriately chosen to render the patient relaxed but have an adequate margin of safety so that excessive somnolence/unconsciousness is not likely.
(c) Competent means displaying special skill or knowledge derived from training and experience.
(d) Conscious Sedation means a minimally depressed level of consciousness that retains the patient's ability to independently and continuously maintain an airway and respond appropriately to physical stimulation and verbal command and that is produced by a pharmacological or non-pharmacological method or a combination thereof. 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. Further, patients whose only response is reflex withdrawal from repeated painful stimuli would not be considered to be in a state of conscious sedation.
(e) Combination Inhalation - enteral conscious sedation (combined conscious sedation) means using inhalation and enteral agents.
(i) Titration of oral medication for the purposes of sedation is unpredictable. Repeated dosing of orally-administered sedative agents may result in an alteration in the state of consciousness beyond the intent of the practitioner. Except in unusual circumstances, the Maximum Recommended Dose (MRD) of an oral medication should not be exceeded.
(ii) When the intent is anxiolysis only, and the appropriate dosage of agents is administered, then the definition of enteral and/or combination inhalation-enteral conscious sedation (combined conscious sedation) does not apply.
(f) Deep Sedation means an induced state of depressed consciousness accompanied by partial loss of protective reflexes, including the inability to continually maintain an airway independently and/or to respond purposefully to physical stimulation or verbal command, and is produced by a pharmacological or non-pharmacological method or a combination thereof.
(g) General Anesthesia means a controlled state of unconsciousness, produced by a pharmacological agent, accompanied by a partial or complete loss of protective reflexes, including inability to independently maintain an airway and respond appropriately to physical stimulation or verbal command.
(h) Local Anesthesia means the elimination of sensation, especially pain, in one part of the body by the topical application or regional injection of a drug.
(i) Nitrous Oxide 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 or verbal command. Nitrous Oxide/oxygen when used in combination with sedative agents may produce anxiolysis, conscious or deep sedation or general anesthesia.
(j) Sedation Levels:
Level 1 - Awake and calm, uninterrupted interactive ability, no evidence of drowsiness (anxiolysis)
Level 2 - Minimally depressed level of consciousness, eyes open or temporarily responds appropriately to verbal commands
Level 3 - Moderately depressed level of consciousness, mimics physiologic sleep (vitals not different from that of sleep), eyes closed most of the time, may or may not respond to verbal prompts alone, responds to mild/moderate stimuli(e.g. repeated trapezius pinching or needle insertion in oral tissues elicits reflex withdrawal and appropriate verbalization (complaint, moan, crying), airway only occasionally may require re-adjustment via chin thrust (Light Sedation)
Level 4 - Deep Sedation is a controlled, pharmacologically induced state of depressed consciousness from which the patient is not easily aroused which may be accompanied by a partial loss of protective reflexes, including the ability to maintain a patent airway independently and/or respond purposefully to physical stimulation or verbal command
Level 5 - General Anesthesia-Unconscious and unresponsive to surgical stimuli, partial or complete loss of protective reflexes including the airway, does not respond purposefully to physical or verbal command
(a) Enteral - any technique of administration in which the agent is absorbed through the gastrointestinal (GI) tract or mucosa [i.e., oral, rectal, or nasal].
(b) Parenteral - a technique of administration in which the drug bypasses the gastrointestinal (GI) tract [i.e., intramuscular (IM), intravenous (IV), intranasal (IN), submucosal (SM), subcutaneous (SC), or intraocular (IO)].
(c) Transdermal/transmucosal - a technique of administration in which the drug is administered by patch or iontophoresis.
(d) Inhalation - a technique of administration in which a gaseous or volatile agent is introduced into the pulmonary tree and whose primary effect is due to absorption through the pulmonary bed.
Section 3. Prohibitions. The following are hereby prohibited:
(a) General Anesthesia: Effective July 1, 1991, dentists licensed in this state shall not administer general anesthesia in the practice of dentistry unless they have complied with the provisions of this rule.
(b) Parenteral Sedation: Effective July 1, 1991, dentists licensed in this state shall not administer parenteral sedation in the practice of dentistry unless they have complied with the provisions of this rule.
(c) Nitrous Oxide Inhalation Analgesia: Effective July 1, 1991, dentists licensed in this state shall not administer nitrous oxide inhalation analgesia in the practice of dentistry unless they have complied with the provisions of this rule.
(d) Conscious Sedation: Effective January 1, 2003, dentists licensed in this state shall not engage in the use of conscious sedation in the practice of dentistry unless they have complied with the provisions of this rule.
(e) Deep Sedation: Effective January 1, 2003, dentists licensed in this state shall not engage in the use of deep sedation in the practice of dentistry unless they have complied with the provisions of this rule.
Section 4. Standard of Care. These guidelines are designed to encourage a high level of quality care in the dental office setting. It should be recognized that emergency situations may require that these standards be modified based on the judgment of the clinician(s) responsible for the delivery of the anesthesia care services. Changing technology and Wyoming rules, regulations or laws may also modify the standards listed herein.
(a) Before the administration of analgesia, sedation, or general anesthesia, a complete written medical history must be obtained which shall include previous medications, allergies and sensitivities. The recording of appropriate vital signs [blood pressure, pulse and oxygen saturation (q 5 min.)] is required in conscious sedation (Level 3), deep sedation (Level 4), and general anesthesia (Level 5). The patient's weight should be recorded when appropriate.
(b) During the anesthesia period the oxygenation, ventilation, and circulation of the patient must be continually evaluated by qualified staff assigned by the dentist.
(c) Each licensed dentist must provide for training in basic life support to his or her qualified staff.
(d) A dentist who administers any type of sedation or general anesthesia shall maintain emergency equipment and medications appropriate for patient resuscitation. That dentist shall be proficient in handling emergencies and complications to include the maintenance of respiration, circulation, and the immediate establishment of a patent airway, and cardiopulmonary resuscitation. The dentist shall maintain appropriate emergency equipment and medications in the dental facility.
(e) The patient must be continually observed during the anesthesia period either by the dentist or qualified staff.
(f) In the licensee uses repeated dosing (multi-dosing) or doses beyond the Maximum Recommended Dose (MRD) for sedating a patient, this automatically places the sedation at level 3.
(g) Direct supervision is required for conscious sedation (Level 3). Operative supervision is required for deep sedation (Level 4) and general anesthesia (Level 5). Qualified staff must continuously monitor post-surgical patients before final evaluation and discharge by the dentist.
(a) Anxiolysis: (Levels 1 and 2): Does not require a permit or registration with the Board.
(b) Nitrous oxide/oxygen inhalation analgesia: (Levels 1 and 2): Does not require a permit or registration with the Board.
(i) A dentist may use nitrous oxide/oxygen inhalation analgesia on an out-patient basis for dental patients provided the dentist:
(A) Has completed a Board approved course of training; or
(B) Has training equivalent to that required of a student in an accredited School of dentistry, and
(C) Has adequate equipment with fail-safe features and 25% minimum oxygen flow.
(ii) A dentist and qualified licensed dental hygienists utilizing nitrous oxide/oxygen inhalation analgesia who monitor its use shall be trained and capable of administering basic life support. This certification must be renewed in compliance with the standards set forth by the American Heart Association.
(iii) A licensed dentist who has been utilizing nitrous oxide/oxygen inhalation analgesia in a competent manner for the twelve month period preceding the effective date of this rule, but has not had the benefit of formal training outlined in subsections (A) or (B), may continue such use provided the dentist fulfills the requirement of (C) above and is trained and capable of administering basic life support.
(c) Conscious Sedation: (Level 3): Enteral Conscious Sedation: After January 1, 2003, enteral conscious sedation (Level 3) may only be administered by a licensed dentist who has received an enteral conscious sedation (Level 3) permit from the Board. Permits will be issued by the Board only after the following requirements have been met:
(i) Proof of Proficiency: A licensed dentist can show proof of proficiency in administering enteral conscious sedation (Level 3) by successfully passing an appropriate examination which includes:
1. Discussion and review of three surgical cases including anesthetic technique
2. Review of records
3. Demonstration of managing emergencies
In addition, a dentist must provide:
(A) Proof that he is a licensed dentist who has documented experience at the graduate level, acceptable to the Board, specifying the type, the number of hours, the length of training and the number of patient contact hours, including documentation of the number of supervised enteral conscious sedation (Level 3) cases; or
(B) Proof that he is a licensed dentist who has successfully completed a formal training program approved by the Board which includes a minimum of sixty hours of didactic instruction and ten cases of clinical experience involved with enteral conscious sedation (Level 3). The training program must include physical evaluation, enteral conscious sedation (Level 3), airway management monitoring, advanced cardiac life support and emergency management; or
(C) Those licensed dentists who hold permits for parenteral conscious sedation, deep sedation, or general anesthesia may administer enteral conscious sedation (Level 3).
(ii) A dentist utilizing enteral conscious sedation (Level 3) shall maintain a properly equipped facility for the administration of enteral conscious sedation (Level 3), staffed with supervised auxiliary personnel capable of reasonably handling procedures, problems, and emergency incidences thereto.
(iii) A dentist using enteral conscious sedation (Level 3) shall be trained and capable of administering advanced cardiac life support. This certification shall be renewed in compliance with the standards set forth by the American Heart Association.
(iv) A dentist using enteral conscious sedation (Level 3) shall employ auxiliary personnel who are trained and capable of administering basic life support. This certification shall be renewed in compliance with the standards set forth by the American Heart Association.
(v) A dentist who is performing a procedure for which enteral conscious sedation (Level 3) is being employed shall not administer the pharmacologic agents and monitor the patient without the presence and assistance of trained and qualified auxiliary personnel.
(vi) Enteral conscious sedation (Level 3) equipment of permitted dentists shall be inspected every five years beginning from the date of the initial permit as designated by the Board to insure the equipment is of the appropriate type and is in working order.
(A) Enteral Conscious Sedation (Level 3) equipment includes:
...Oxygen and supplemental gas-delivery system and backup system ...Suction and backup system ...Auxiliary lighting system ...Gas storage facilities ...Suitable operating suite ...Recovery areas ...Emergency anesthetic equipment including a defibrillator and appropriate emergency medications ...Monitoring equipment
1. Pulse oximeter
2. Blood pressure cuff and precordial stethoscope
3. EKG
(B) Inspection of offices where enteral conscious sedation (Level 3) is administered shall be conducted every five (5) years.
(C) Inspections shall be done by at least two qualified experts as determined by the Board.
(D) Any malfunctioning equipment shall be called to the attention of the applicant and a permit will not be issued until the experts determine all equipment is operating satisfactorily.
(E) The annual permit fee shall be determined by the Board and is to be paid at the time of license renewal. The renewal license shall indicate when the five (5) year inspection is due.
(F) A dentist shall apply to the Board who will arrange with the qualified experts and the applicant dentist for an on-site inspection.
(G) Any permitted dentist who operates with malfunctioning equipment as determined by the Board, shall cease administering enteral conscious sedation (Level 3) until such equipment has been repaired. A copy of the work order showing satisfactory repair completed shall be sent to the Board office.
(vii) Any dentist using enteral conscious sedation (Level 3) without a permit may have his license revoked or suspended.
(viii) The Board shall establish fees as necessary to carry out this section.
(d) Conscious Sedation (Level 3): Parenteral Sedation: After July 1, 1991, parenteral sedation may only be administered by a licensed dentist who has received a parenteral sedation permit from the Board. Permits will be issued by the Board only after the following requirements have been met:
(i) Proof of Proficiency: A licensed dentist can show proof of proficiency in administering parenteral sedation by successfully passing an appropriate examination which includes:
1. Discussion and review of three surgical cases including anesthetic technique
2. Review of records
3. Demonstration of managing emergencies
In addition, a dentist must provide:
(A) Proof that he is a licensed dentist who has documented experience at the graduate level, acceptable to the Board, specifying the type, the number of hours, the length of training and the number of patient contact hours, including documentation of the number of supervised parenteral sedation cases; or (B) Proof that he is a licensed dentist who has successfully completed a formal training program, approved by the Board, which included physical evaluation, IV sedation, airway management, monitoring, advanced cardiac life support and emergency management; or
(C) Proof that he is a licensed dentist who has been utilizing parenteral sedation on an out-patient basis in a competent manner for five (5) years preceding the effective date of this rule, but has not had the benefit of formal training as outlined in this rule. He may continue such use provided the licensed dentist fulfills the provisions set forth in (ii), (iii), (iv) and (v) below.
(ii) A dentist utilizing parenteral sedation shall maintain a properly equipped facility for the administration of parenteral sedation, staffed with supervised auxiliary personnel, capable of reasonable handling procedures, problems, and emergencies incident thereto.
(iii) A dentist using parenteral sedation shall be trained and capable of administering advanced cardiac life support. This certification shall be renewed in compliance with the standards set forth by the American Heart Association.
(iv) A dentist using parenteral sedation shall employ auxiliary personnel who are trained and capable of administering basic life support. This certification shall be renewed in compliance with the standards set forth by the American Heart Association.
(v) A dentist who is performing a procedure for which parenteral sedation is being employed shall not administer the pharmacologic agents and monitor the patient without the presence and assistance of trained and qualified auxiliary personnel.
(vi) Dentists qualified to administer parenteral sedation may administer nitrous oxide inhalation analgesic.
(vii) If parenteral sedation results in a general anesthetic state, the rules for general anesthesia apply.
(viii) Parenteral sedation equipment of permitted dentists shall be inspected on a regular basis as designated by the Board to insure the equipment is of the appropriate type and is in working order.
(A) Parenteral Sedation equipment includes:
...Oxygen and supplemental gas-delivery system and backup system ...Suction and backup system ...Auxiliary lighting system
...Gas storage facilities
...Suitable operating suite
...Recovery areas
...Emergency anesthetic equipment including a defibrillator
and
appropriate emergency medications
...Monitoring equipment
1. Pulse oximeter
2. Blood pressure cuff and precordial stethoscope
3. EKG
(B) Inspection of offices where parenteral sedation is administered shall be conducted every five (5) years.
(C) Inspections shall be done by at least two qualified experts as determined by the Board.
(D) Any malfunctioning equipment shall be called to the attention of the applicant and a permit will not be issued until the experts determine all equipment is operating satisfactorily.
(E) The annual permit fee shall be determined by the Board which includes the general anesthesia fee and is to be paid at the time of the license renewal. The renewal license shall indicate when the five (5) year inspection is due.
(F) A dentist shall apply to the Board who will arrange with the qualified experts and the applicant dentist for an on-site inspection.
(G) Any permitted dentist who operates with malfunctioning equipment as determined by the Board, shall cease administering parenteral sedation until such equipment has been repaired. A copy of the work order showing satisfactory repair completed shall be sent to the Board office.
(ix) Any dentist using parenteral sedation without a permit may have his license revoked or suspended.
(x) The Board shall establish examination fees as necessary to carry out this section.
(e) Deep Sedation(Level 4) and General Anesthesia (Level 5): After July 1, 1991, general anesthesia may only be administered by a licensed dentist who has received a general anesthesia permit from the Board. Permits will be issued by the Board only after the following requirements have been met:
(i) Proof of Proficiency: A licensed dentist can show proof of proficiency in administering deep sedation and/or general anesthesia by successfully passing an appropriate examination which includes:
1. Discussion and review of three surgical cases including anesthetic technique
Review of records
Demonstration of managing emergencies
In addition, a dentist must provide:
(A) Proof that he has completed a minimum of one year of advanced training in anesthesiology and related academic subjects beyond the under graduate dental school level in a training program approved by the Board; or
(B) Proof that he is a diplomate of the American Board of Oral and Maxillofacial Surgery; or
(C) Proof that he is eligible for examination by the American Board of Oral and Maxillofacial Surgery; or
(D) Proof that he is a member of the American Association of Oral and Maxillofacial Surgeons; or
(E) Proof that he is a fellow of the American Dental Society of Anesthesiology; or
(F) Proof that he is a licensed dentist who has been utilizing general anesthesia in a competent manner for the five (5) year period preceding the effective date of this rule.
(ii) A dentist using deep sedation and/or general anesthesia shall provide and maintain proper equipment for the administration of general anesthesia staffed with supervised auxiliary personnel, capable of reasonable handling procedures, problems and emergencies incident thereto.
(iii) A dentist using deep sedation and/or general anesthesia shall be trained and capable of administering advanced cardiac life support. This certification shall be renewed in compliance with the standards set forth by the American Heart Association.
(iv) A dentist using deep sedation and/or general anesthesia shall employ auxiliary personnel who are trained and capable of administering basic life support. This certification shall be renewed in compliance with the standards set forth by the American Heart Association.
(v) A dentist who is performing a procedure for which deep sedation and /or general anesthesia is to be used shall not administer deep sedation and/or general anesthetic without the presence and assistance of trained auxiliary personnel and patient monitoring.
(vi) A dentist qualified to administer deep sedation and/or general anesthesia under this rule may administer parenteral sedation and nitrous oxide inhalation analgesia.
(vii) General anesthetic equipment of permitted dentists shall be inspected on a regular basis as designated by the Board to insure the equipment is of the appropriate type and is in working order.
(A) Deep Sedation and General Anesthesia equipment includes:
...Oxygen and supplemental gas-delivery system and backup system
...Suction and backup system
...Auxiliary lighting system
...Gas storage facilities
...Suitable operating suite
...Recovery areas
...Emergency anesthetic equipment including a defibrillator
and appropriate emergency medications
...Monitoring equipment
1. Pulse oximeter
2. Blood pressure cuff and precordial stethoscope
3. EKG
(B) Inspection of offices where deep sedation and/or general anesthesia is administered shall be conducted every five (5) years.
(C) Inspections shall be done by at least two qualified experts as determined by the Board.
(D) Any malfunctioning equipment shall be called to the attention of the applicant and a permit will not be issued until the experts determine all equipment is operating satisfactorily.
(E) The annual deep sedation and/or general anesthesia permit fee shall be determined by the Board. This fee will include the parenteral sedation fee and will be paid at the time of the license renewal. The renewal license shall indicate when the five (5) year inspection is due.
(F) A dentist shall apply to the Board who will arrange with the qualified experts and the applicant dentist for an on-site inspection.
(G) Any permitted dentist who operates with malfunctioning equipment as determined by the Board, shall cease administering general anesthesia until such equipment has been repaired. A copy of the work order showing satisfactory repair completed shall be sent to the Board office.
(viii) Any dentist using general anesthesia without a permit may have his license revoked or suspended.
(ix) The Board shall establish examination fees as necessary to carry out this section.
(a) All licensed dentists in the practice of dentistry in this state should submit a report within a period of thirty (30) days to the Board of any mortality or other incident which results in temporary or permanent physical or mental injury requiring hospitalization of said patient during, or as a result of, anesthesia administration related to Chapter V of the rules and regulations. The report shall include, at the minimum, responses to the following:
(i) Description of dental procedure.
(ii) Description of preoperative physical condition of patient.
(iii) List of drugs and dosage administered.
(iv) Description, in detail, of techniques utilized in the administration of the above listed drugs.
(v) Description of adverse occurrence.
(A) Describe in detail symptoms of any complications, to include but not limited to onset, and type of symptoms in patient.
(B) Treatment instituted on the patient.
(C) Response of patient to treatment.
(vi) Describe patient's condition on termination of any procedures undertaken.