6.2 Facility Equipment, Staffing, Administration Standards & Pediatric Safeguards

Facility Standards, Administration, and Pediatric Safeguards

Baseline equipment and staffing for every sedation facility — Den 304.07(a)

Added requirements while moderate, deep, or general anesthesia is administered — Den 304.07(b)

• Gas delivery: oxygen fail-safe valve on the anesthesia machine or nitrous flowmeter; size-dissimilar fittings and color-coded hoses for oxygen, nitrous oxide, and medical air.
• Suction: pulmonary suction catheter; portable suction usable during a power failure.
• Airway: endotracheal tubes with stylets (adult, plus pediatric if under-13 patients are treated); cuff syringe; Ambu bag able to deliver positive pressure through the tube; video laryngoscope with blades and spare batteries or bulbs if deep sedation or GA is provided; Magill forceps; tongue-grasping forceps; oral and nasopharyngeal airways; supraglottic airways such as laryngeal mask or King airways; and an emergency cricothyrotomy kit if deep sedation or GA is provided.
• Monitoring: continuous ECG, capnography, and a stethoscope.
• Emergency drugs: IV supplies and fluids; epinephrine 1:10,000 (cardiac arrest) and 1:1,000 (allergic reaction); a pressor for hypotension; an antiarrhythmic; adenosine; naloxone; flumazenil; an antihypertensive; an injectable steroid; dextrose; atropine; injectable diphenhydramine; a rapid-onset neuromuscular blocker for laryngospasm; an albuterol inhaler; an injectable benzodiazepine for seizure; non-enteric-coated aspirin; and sublingual nitroglycerin.

Den 304.07(c): when inhaled volatile anesthetics are used, or succinylcholine routinely, add an anesthetic gas analyzer, dantrolene for malignant hyperthermia, and sterile water to dilute it.

Administration standards — Den 304.08(a)–(d)

1. Follow Part IV B or C of the ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists (2016) or the American Academy of Pediatrics sedation guidelines (2019), matched to the patient's age, including history, pre-operative evaluation, and preparation.
2. For moderate sedation, deep sedation, or GA, an IV catheter is in place before administration, or equipment to establish IV or intraosseous access is immediately available until the patient meets discharge criteria.
3. For moderate sedation, with or without inhalation agents, drugs are limited to a single dose (initial, repeated, or maintenance dose per manufacturer guidelines in the FDA label repository) of one or more drugs, or multiple doses of a single drug.
4. A dentist may not delegate to an assistant or hygienist any task outside that person's scope, such as placing an IV catheter, drawing up medications, or administering medications. PALS certification does not expand an auxiliary's duties.

Statutory safety rules — RSA 317-A:17, II(k)–(n) and Den 407.01(m)–(p)

Violating these is professional misconduct:

• One patient at a time: more than one outpatient under moderate sedation, deep sedation, or GA at once is prohibited unless each is continuously monitored one-to-one by the dentist or another authorized licensed professional.
• Recovery: recovering patients must be closely monitored by licensed professionals experienced in resuscitation. If one professional covers more than one patient, all must be in the same room with continuous visual contact, at no more than 3 patients to 1 staff member.
• Pulse oximetry: patients must be continuously monitored with a pulse oximeter (or superior equipment) while undergoing and recovering from sedation.
• History, physical, and consent: an adequate history and physical and written informed consent are required before GA, deep sedation, or moderate sedation. For a minor, the parent or guardian consents.

Children under 13 — GA and deep sedation — Den 304.08(e)–(g); RSA 317-A:12, XII-a(h)

• Informed consent must state that the procedure may alternatively be performed in a hospital with additional anesthesia personnel. The statute adds "possibly at an increased expense."
• A separate dedicated anesthesia provider must be present to monitor the procedure and recovery, in addition to the dentist performing it. That provider is a GA-qualified dentist, a physician anesthesiologist, or a CRNA.
• Exemption: a dentist who is board eligible or board certified by the American Dental Board of Anesthesiology (ADBA) or the American Board of Oral and Maxillofacial Surgery (ABOMS) may apply. Requirements include an advanced airway course with hands-on training within the previous 6 years; a documented pre-operative airway exam consistent with the 2022 ASA difficult-airway guidelines; and a designated staff member with PALS, or 36 hours of didactic monitoring training, whose sole job is watching vital signs, airway, and ventilation.
• Patients 8 or younger without a separate provider: the exempt dentist must also document at least 20 patients 8 or younger personally sedated during CODA residency within the previous 2 years, or as a permit holder in the previous 2 years, or complete a supervised pathway of 20 such cases within 2 years. A true emergency case requires an Emergency Exemption form to OPLC within 15 working days that does not identify the patient.

Minimal sedation — Den 304.11; RSA 317-A:12, XII-c

• Follow ADA Guidelines Part IV A (2016) or the AAP guidelines, with a properly staffed and equipped facility and reversal agents for any enteral drugs used.
• Hold a pediatric minimal sedation permit to sedate patients under 13.
• Permitted routes: nitrous oxide inhalation; a single dose of one enteral drug with a margin of safety wide enough to make unintended loss of consciousness unlikely; or combined inhalation and enteral sedation only for patients 13 or older.
• For patients under 13, at least one staff member trained in pediatric monitoring and resuscitation must be present in addition to the dentist.