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Regulations - Chapter 2, Article 5

TITLE 16. PROFESSIONAL AND VOCATIONAL REGULATIONS
DIVISION 10. DENTAL BOARD OF CALIFORNIA
CHAPTER 2. DENTISTS
ARTICLE 5. GENERAL ANESTHESIA AND (MODERATE) CONSCIOUS SEDATION

Section 1043. Definitions.
Section 1043.1. Permit Requirements.
Section 1043.2. Composition of Onsite Inspection and Evaluation Teams.
Section 1043.3. Onsite Inspections.
Section 1043.4. Evaluation Standards.
Section 1043.5. Cancellation of an Onsite Inspection and Evaluation.
Section 1043.6. Grading of Inspection and Evaluation.
Section 1043.7. Manner of Giving Notice of Evaluation.
Section 1043.8. Renewal.

Section 1043. Definitions.
(a) For purposes of this article, "direct supervision" of general anesthesia means the permittee is in the immediate presence of a patient while general anesthesia is being administered to that patient and that the permittee or a member of the permittee's staff directly monitors the patient at all times.
(b) For purposes of this article, "outpatient" means a patient treated in a treatment facility which is not accredited by the Joint Commission on Health Care Organizations or licensed by the California Department of Health Services as a "general acute care hospital" as defined in subdivision (a) of Section 1250 of the Health & Safety Code.

(c) For purposes of section 1682(a) of the code:
  1. (1) a patient under general anesthesia shall be considered "sedated" for that period of time beginning with the first administration of general anesthetic agents until that time when the patient is again conscious with a full return of protective reflexes, including the ability to respond purposely to physical stimulation and/or verbal command, when no additional agents will be administered, the dental procedures have been completed, and after the maximum effects of all agents have been experienced by the patient;
  2. (2) a patient under conscious sedation shall be considered "sedated" for that period of time beginning with the first administration of conscious sedation agents until that time when no additional agents will be administered, the dental procedures have been completed, and after the maximum effects of all agents have been experienced by the patient.
(d) For purposes of section 1682(b) of the code, a patient shall be deemed to be "recovering from" conscious sedation or general anesthesia from the time the patient is no longer "sedated" as that term is defined in subsection (c) above until the dentist has evaluated the patient and has determined the patient is responsive, alert, has stable vital signs and is ambulatory and/or capable of being safely transported.

(e) For purposes of this article, "applicant" refers to applicants without permits, as well as permit holders subject to re-evaluation.

Note: Authority cited: Section 1614, Business and Professions Code. Reference: Sections 1646.1 and 1682, Business and Professions Code.

HISTORY
  1. Amendment filed 4-1-91; operative 5-1-91 (Register 91, No. 18).
  2. Amendment of article heading and subsections (a), (b) and (c)(1) and new subsection (e) filed 2-27-2006; operative 3-29-2006 (Register 2006, No. 9).

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Section 1043.1. Permit Requirements.
(a) A licensed dentist does not need a general anesthesia or conscious sedation permit if the general anesthesia or conscious sedation administered in that dentist's office is directly administered by a licensed dentist or physician and surgeon who possesses a general anesthesia or conscious sedation permit, whichever is applicable to the type of anesthesia services being provided.
(b) An applicant for a permit to administer general anesthesia or order the administration of general anesthesia by a nurse anesthetist must be a licensed dentist in California who:
  1. (1)Has completed a residency program in general anesthesia of not less than one calendar year, that is approved by the board; or
  2. (2) Has completed a graduate program in oral and maxillofacial surgery which has been approved by the Commission on Dental Accreditation.
(c) An applicant for a permit to administer or order the administration of conscious sedation must be a licensed dentist in California who meets the requirements set forth in section 1647.3 of the code.

(d) The processing times for a general anesthesia or conscious sedation permit are set forth in section 1061.

Note: Authority cited: Sections 1614 and 1646.2, Business and Professions Code. Reference: Sections 1646.2, 1646.9, 1647.3 and 2827, Business and Professions Code.

HISTORY
  1. Amendment filed 2-22-88; operative 3-23-88 (Register 88, No. 10).
  2. Amendment filed 4-1-91; operative 5-1-91 (Register 91, No. 18).
  3. Editorial correction of subsection (d) (Register 95, No. 16).
  4. Amendment of subsections (a)-(c) and Note filed 2-27-2006; operative 3-29- 2006 (Register 2006, No. 9).

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Section 1043.2. Composition of Onsite Inspection and Evaluation Teams.
(a) An evaluation team shall consist of two or more persons chosen and approved by the board.
(b) The evaluators must meet one of the criteria in subdivision (b) of section 1043.1 for general anesthesia or the criteria in section 1647.3 of the code for conscious sedation and must have utilized general anesthesia or conscious sedation, whichever is applicable, in a dental practice setting for a minimum of three years immediately preceding their application to be an evaluator, exclusive of any general anesthesia or conscious sedation training.
(c) At least one of the evaluators must have experience in evaluation of dentists administering general anesthesia or conscious sedation. At least one member of the team must have substantial experience in the administration of the method of delivery of anesthesia or sedation used by the dentist being evaluated.
(d) The board may appoint a licensee member of the board to serve as a consultant at any evaluation.

Note: Authority cited: Section 1614, Business and Professions Code. Reference: Sections 1646.4 and 1647.7, Business and Professions Code.

HISTORY
  1. Amendment filed 4-1-91; operative 5-1-91 (Register 91, No. 18).
  2. Amendment of subsection (b) filed 3-1-93 (Register 93, No. 10).
  3. Editorial correction of subsection (b) (Register 95, No. 16).
  4. Amendment of subsection (b) filed 2-27-2006; operative 3-29-2006 (Register 2006, No. 9).

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Section 1043.3. Onsite Inspections
All offices in which general anesthesia or conscious sedation is conducted under the terms of this article shall, unless otherwise indicated, meet the standards set forth below. In addition, an office may in the discretion of the board be required to undergo an onsite inspection. For the applicant who administers in both an outpatient setting and at an accredited facility, the onsite must be conducted in an outpatient setting. The evaluation of an office shall consist of three parts:
(a) Office Facilities and Equipment. The following office facilities and equipment shall be available and shall be maintained in good operating condition:
  1. (1) An operating theatre large enough to adequately accommodate the patient on a table or in an operating chair and permit an operating team consisting of at least three individuals to freely move about the patient.
  2. (2) An operating table or chair which permits the patient to be positioned so the operating team can maintain the airway, quickly alter patient position in an emergency, and provide a firm platform for the management of cardiopulmonary resuscitation.
  3. (3) A lighting system which is adequate to permit evaluation of the patient's skin and mucosal color and a backup lighting system which is battery powered and of sufficient intensity to permit completion of any operation underway at the time of general power failure.
  4. (4) Suction equipment which permits aspiration of the oral and pharyngeal cavities. A backup suction device which can operate at the time of general power failure must also be available.
  5. (5) An oxygen delivery system with adequate full face masks and appropriate connectors that is capable of allowing the administering of greater than 90% oxygen at a 10 liter/minute flow at least sixty minutes (650 liter "E" cylinder) to the patient under positive pressure, together with an adequate backup system which can operate at the time of general power failure.
  6. (6) A recovery area that has available oxygen, adequate lighting, suction, and electrical outlets. The recovery area can be the operating theatre.
  7. (7) Ancillary equipment:
  8. (A) Laryngoscope complete with adequate selection of blades and spare batteries and bulb. (This equipment is not required for conscious sedation.)
  9. (B) Endotracheal tubes and appropriate connectors. (This equipment is not required for conscious sedation.)
  10. (C) Emergency airway equipment (oral airways, laryngeal mask airways or combitubes, cricothyrotomy device).
  11. (D) Tonsillar or pharyngeal type suction tip adaptable to all office outlets.
  12. (E) Endotracheal tube forcep. (This equipment is not required for conscious sedation.)
  13. (F) Sphygmomanometer and stethoscope.
  14. (G) Electrocardioscope and defibrillator. (This equipment is not required for conscious sedation.)
  15. (H) Adequate equipment for the establishment of an intravenous infusion.
  16. (I) Precordial/pretracheal stethoscope.
  17. (J) Pulse oximeter.
  18. (K) Capnograph and temperature device. A capnograph and temperature measuring device are required for the intubated patient receiving general anesthesia. (This equipment is not required for conscious sedation.)
(b) Records. The following records shall be maintained:
  1. (1) Adequate medical history and physical evaluation records updated prior to each administration of general anesthesia or conscious sedation. Such records shall include, but are not limited to the recording of the age, sex, weight, physical status (American Society of Anesthesiologists Classification), medication use, any known or suspected medically compromising conditions, rationale for sedation of the patient, and visual examination of the airway, and for general anesthesia only, auscultation of the heart and lungs as medically required.
  2. (2) General Anesthesia and/or conscious sedation records, which shall include a time-oriented record with preoperative, multiple interaoperative, and postoperative pulse oximetry (every 5 minutes intraoperatively and every 15 minutes postoperatively for general anesthesia) and blood pressure and pulse readings, (both every 5 minutes intraoperatively for general anesthesia) drugs, amounts administered and time administered, length of the procedure, any complications of anesthesia or sedation and a statement of the patient's condition at time of discharge.
  3. (3) Written informed consent of the patient or if the patient is a minor, his or her parent or guardian.
(c) Drugs. Emergency drugs of the following types shall be available:
  1. (1) Epinephrine
  2. (2) Vasopressor (other than epinephrine)
  3. (3) Bronchodilator
  4. (4) Muscle relaxant (This is not required for conscious sedation.)
  5. (5) Intravenous medication for treatment of cardiopulmonary arrest (This is not required for conscious sedation.)
  6. (6) Appropriate drug antagonist
  7. (7) Antihistaminic
  8. (8) Anticholinergic
  9. (9) Antiarrhythmic (This is not required for conscious sedation.)
  10. (10) Coronary artery vasodilator
  11. (11) Antihypertensive (This is not required for conscious sedation.)
  12. (12) Anticonvulsant
  13. (13) Oxygen
  14. (14) 50% dextrose or other antihypoglycemic
(d) Prior to an onsite inspection and evaluation, the dentist shall provide a complete list of his/her emergency medications to the evaluator.

Note: Authority cited: Section 1614, Business and Professions Code. Reference: Sections 1646.2, 1646.3, 1647.3 and 1647.6, Business and Professions Code.

HISTORY
  1. Amendment filed 4-1-91; operative 5-1-91 (Register 91, No. 18).
  2. Editorial correction of subsection (a)(4) (Register 95, No. 16).
  3. Amendment filed 2-27-2006; operative 3-29-2006 (Register 2006, No. 9).
Section 1043.4. Evaluation Standards.
The evaluation of an applicant for a permit shall consist of two parts:
(a) Demonstration of a General Anesthesia. A dental procedure utilizing general anesthesia administered by the applicant must be observed and evaluated. Any anesthesia technique that is routinely employed can be demonstrated. The patient shall be monitored while anesthetized and during recovery from anesthesia in the manner prescribed by section 1682 of the code.
The applicant for a permit must demonstrate that he or she has knowledge of the uses of the equipment required by section 1043.3(a) and is capable of using that equipment.
(b) Demonstration of a Conscious Sedation. A dental procedure utilizing conscious sedation administered by the applicant must be observed and evaluated. Any conscious sedation technique that is routinely employed can be demonstrated. The patient shall be monitored while sedated and during recovery from sedation in the manner prescribed by section 1682 of the code. The applicant for a permit must demonstrate that he or she has knowledge of the uses of the equipment required by section 1043.3(a) and is capable of using that equipment.
(c) Simulated Emergencies. Knowledge of and a method of treatment must be physically demonstrated by the dentist and his or her operating team for the following emergencies:
  1. (1) Airway obstruction
  2. (2) Bronchospasm
  3. (3) Emesis and aspiration of foreign material under anesthesia
  4. (4) Angina pectoris
  5. (5) Myocardial infarction
  6. (6) Hypotension
  7. (7) Hypertension
  8. (8) Cardiac arrest
  9. (9) Allergic reaction
  10. (10) Convulsions
  11. (11) Hypoglycemia
  12. (12) Syncope
  13. (13) Respiratory depression

Note: Authority cited: Section 1614, Business and Professions Code. Reference: Sections 1646.4 and 1647.7, Business and Professions Code.

HISTORY
  1. Amendment filed 4-1-91; operative 5-1-91 (Register 91, No. 18).
  2. Amendment of subsections (a) and (b) filed 2-27-2006; operative 3-29-2006 (Register 2006, No. 9).

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Section 1043.5. Cancellation of an Onsite Inspection and Evaluation.
(a) Whenever a conscious sedation or general anesthesia permittee or applicant cancels an onsite inspection and evaluation, that permittee or applicant shall provide the board with a written reason for the cancellation. If the first cancellation occurs 14 calendar days or more before the date of the scheduled inspection and evaluation, the fee paid shall be applied toward the next scheduled inspection and evaluation. If the cancellation occurs less than 14 calendar days before the scheduled inspection and evaluation, the fee shall be forfeited and a new fee shall be paid before the inspection and evaluation will be rescheduled.
(b) If a permittee or applicant cancels the inspection and evaluation for a second time, all fees are forfeited and the permit shall be automatically suspended or denied unless a new fee has been paid and an onsite inspection and evaluation has been completed within 30 calendar days from the date of the second cancellation.
(c) If a permittee or applicant cancels the scheduled onsite inspection and evaluation for a third time, all fees are forfeited and that cancellation shall be deemed a refusal to submit to an inspection and evaluation, and in accordance with Sections 1646.4 and 1647.7 of the code, the permit shall be automatically revoked or denied as of the date of the third cancellation.

Note: Authority cited: Section 1614, Business and Professions Code. Reference: Sections 1646.4 and 1646.7, Business and Professions Code.

HISTORY
  1. Repealer filed 4-8-87; effective upon filing (Register 87, No. 15).
  2. New section filed 9-8-95; operative 10-8-95 (Register 95, No. 36).

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Section 1043.6. Grading of Inspection and Evaluation.
(a) The inspection and evaluation shall be graded on a pass/fail system. The grade shall be determined by the board, based upon a recommendation of the evaluators, who shall make independent evaluations and recommendations.
(b) An applicant who has failed the evaluation may appeal that decision to the board and request a reevaluation. This appeal must be made in writing to the board stating the grounds for the appeal within thirty (30) days after the date on which the evaluation results were mailed. However, pursuant to sections 1646.4(a) and 1647.7(a) of the code, the permit of any applicant who has failed an onsite inspection and evaluation shall be automatically suspended 30 days after the date on which the board notifies the applicant of the failure unless, within that time period, the applicant has retaken and passed an onsite inspection and evaluation.
Upon receipt of the appeal request and an additional evaluation fee, the board will schedule an independent reevaluation of the appellant. If an applicant has failed two evaluations, the board will decide the matter and may grant or deny a permit or request further evaluation of the appellant with a board member or other board appointed representative being present.
(c) An applicant who has failed the inspection and evaluation solely on the basis of a failure to demonstrate knowledge and ability in recognition and treatment of any or all of the simulated emergencies may be reevaluated only on the simulated emergencies provided the reevaluation is within 30 days.

Note: Authority cited: Section 1614, Business and Professions Code. Reference: Sections 1646.4 and 1647.7, Business and Professions Code.

HISTORY
  1. Amendment filed 4-1-91; operative 5-1-91 (Register 91, No. 18).
  2. Amendment of subsection (b) filed 2-8-96; operative 3-9-96 (Register 96, No. 6).
  3. Amendment of subsection (b) and new subsection (c) filed 2-27-2006; operative 3-29-2006 (Register 2006, No. 9).

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Section 1043.7. Manner of Giving Notice of Evaluation.
Upon receipt of either an application for a general anesthesia permit or a conscious sedation permit or where the board determines in any other case that there shall be an onsite inspection and evaluation, the board shall determine the date and time of such evaluation and shall so inform the dentist.

Note: Authority cited: Section 1614, Business and Professions Code. Reference: Sections 1646.4 and 1647.7, Business and Professions Code.

HISTORY
  1. Amendment filed 4-1-91; operative 5-1-91 (Register 91, No. 18).

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Section 1043.8. Renewal.
A general anesthesia or conscious sedation permit shall be renewed biennially upon certification by the permit holder that he/she has met all applicable continuing education requirements for the particular permit, payment of the required fee and if required, successful completion of an onsite inspection and evaluation.

Note: Authority cited: Section 1614, Business and Professions Code. Reference: Sections 1646.1, 1646.5, 1646.6, 1647.2, 1647.5 and 1647.8, Business and Professions Code.

HISTORY
  1. Amendment filed 4-1-91; operative 5-1-91 (Register 91, No. 18).