The very structure and nature of the US health care system engenders many challenges, several of which arise from the fact that each state determines its respective rules and regulations, including those that pertain to dentistry. It comes as no surprise, then, that no universally accepted set of laws exists to provide oversight for the use of office-based sedation and general anesthesia for dentistry. This has led to many states enacting rules and regulations that lack fairness, equity, and, quite frankly, common sense.
Some states have very strict rules governing dentists providing sedation and/or general anesthesia (ie, dentist anesthesia providers) while physician anesthesiologists or nurse anesthetists (ie, nondentist anesthesia providers) operating in the same dental office environment are not held to the same standards, or any standard at all. For instance, many states require dentist anesthesia providers to undergo onsite evaluations while nondentist anesthesia providers working in dental offices have no such requirements. In many cases, nondentist anesthesia providers appear to fall into a “no man’s land,” where no board assumes regulatory control for fear of overstepping their presumed jurisdictional bounds. This would not be an issue were it not for patient safety concerns that are not being adequately addressed by this lack of oversight.
In an ideal world, dental, medical, and nursing boards would work together to ensure the existence of appropriate safety measures and fair regulatory oversight covering all providers of anesthesia services in the dental office. However, those steps have clearly not yet been taken, and the regulatory game of “hot potato” persists.
In response to this issue, the American Society of Dentist Anesthesiologists (ASDA) developed a template of sensible rules and regulations intended to be used by state dental boards when updating their sedation and general anesthesia rules for dental offices. The proposal was shared among dental organizations representing Commission on Dental Accreditation training programs with sedation and/or general anesthesia requirements. These specialty and general dentistry organizations were all initially quite supportive, and many offered helpful comments. The American Association of Oral and Maxillofacial Surgeons (AAOMS) was particularly interested in the deep sedation/general anesthesia (DS/GA) provisions, which of course only applied to them and the ASDA. Thus, these 2 groups collaborated to further refine the proposed Rules Template before circling back to the other groups. It was realized early on no one groups’ Parameters of Care could be followed completely, but acceptable common ground was found despite some notable differences as helping to promote patient safety was the overarching goal.
After review, the approved ASDA-AAOMS document was further supported by the American Academy of Periodontology (AAP). The ASDA-AAOMS-AAP Rules Template (https://www.asda.org/wp-content/uploads/2023/10/Model-Regulations-ASDA.-AAOMS.AAP-Final_9.20.2023.pdf) has continued to gain momentum as evident by the ongoing dialogue with several other dental organizations including the American Association of Pediatric Dentistry (AAPD) and the American Dental Association (ADA). The document has been shared with other anesthesia communities of interest beyond dentistry such as the American Society of Anesthesiology (ASA), the Society of Ambulatory Anesthesia (SAMBA), and the American Association of Nurse Anesthetists (AANA), encompassing the variety of providers currently delivering dental anesthesia services across the country.
The Rules Template is intended to help improve safety for sedation and general anesthesia in dental settings (ie, nonhospital/nonambulatory surgery center environments) by including all types of providers who deliver dental anesthesia services and seemingly addresses the problems of regulatory equitability. The document provides a mechanism for a dentist without sedation or general anesthesia training to utilize a nondentist anesthesia provider who will follow the same rules as a dentist anesthesia provider. The nonsedation dentist may obtain a permit to use a nondentist anesthesia provider which requires the nondentist anesthesia provider to agree to a dental board-approved written contract attesting that they will follow the same staffing, equipment, training, and other requirements the dental board requires of dentist anesthesia providers. An in-office evaluation of the nondentist anesthesia provider is required every 5 years in only one office in which they will work, just like dentist anesthesia providers, although a contract is required for each different office in which they provide anesthesia services. If an adverse event does occur and the dental board rules are not followed, it will be the onus of the anesthesia provider to explain this discrepancy.
Specific language addresses the use of certified registered nurse anesthetists (CRNAs) in states where they are allowed to work without a delegating order or supervision, which is the same as applies to physician anesthesiologists. In states requiring CRNA supervision, the depth of sedation must be commensurate with the supervising dentist’s level of advanced anesthesia training. This latter aspect of the proposed legislation helps prevent a scenario where a dentist without appropriate advanced anesthesia training is supervising a CRNA and could be held liable for advanced anesthesia treatment they are not licensed/permitted to provide.
The proposed legislation also discusses other requirements geared toward improving patient safety. A special pediatric endorsement documenting 50 cases every 2 years to utilize sedation or general anesthesia for children 8 years of age and younger is included. Lastly, the document also details emergency preparedness, facility, armamentarium, and support personnel requirements, initial and periodic onsite evaluations, educational requirements for obtaining and maintaining a moderate sedation or DS/GA permit, and reporting requirements for adverse outcomes. All these aspects are to be applied universally regardless of the type of dental anesthesia provider.
The current Rules Template endorsed by ASDA, AAOMS, and AAP is a living document likely to undergo further refinement as other dental organizations endorse it and as other states borrow its language. As uniform rules for all anesthesia providers was one of the principles used in the document’s development, we hope that anesthesia groups outside of dentistry (ie, ASA, SAMBA, AANA) also support it. However, the most interesting aspect of this collaborative endeavor will be how states and dental boards ultimately respond.
Dentistry has historically been a proud, self-regulating profession. It must continue to ensure we have effective, fair, and progressive rules and regulations that promote patient safety and access to care including the use of dental anesthesia services. This Rules Template works to promote those aims and serves as guidance developed collaboratively from within the profession for states as they seek to improve their respective dental rules and regulations for the provision of sedation and general anesthesia in dental facilities.