TEXAS STATE BOARD OF DENTAL EXAMINERS

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					   TEXAS STATE BOARD OF DENTAL EXAMINERS                                                                      $28.75
   333 Guadalupe, Tower 3, Suite 800, Austin, Texas 78701                                                     APPLICATION
   Phone (512) 463-6400 Fax (512) 463-7452                                                                    FEE

                  SEDATION/ANESTHESIA PERMIT APPLICATION
  Name: ________________________________________________                                   Texas license #_____________________

  Mailing Address: ______________________________________________________________________________

  City, State, Zip      ______________________________________________________________________________

  Primary Office:       ______________________________________________________________________________

  City, State, Zip      ______________________________________________________________________________

  Daytime telephone         (____)_____________________ Alternate telephone (____)________________________

  Dental School ___________________________________ Degree ___________ Year of Graduation __________

  Post Graduate School _________________________ Program _______________ Year of Completion___________

                     I am applying for the following permits (check all that apply):
                         _____Enteral Conscious Sedation (proceed to page 2)

                         _____Nitrous Oxide/Oxygen Inhalation Conscious Sedation (proceed to page 4)

                         _____Parenteral Conscious Sedation (proceed to page 5)
                                  ___a) Intramuscular       ____ c) Subcutaneous
                                  ___b) Submucosal          ____ d) Intranasal
                                             ___e) Intravenous

                         _____Deep Sedation/General Anesthesia (proceed to page 7)


If you are applying for parenteral or deep sedation permits, would you like a provisional permit issued while awaiting the
next scheduled meeting of the SBDE?              _____yes                        _____no


                                                   Disciplinary Information
1. Have you ever had your DEA or DPS controlled substance registration certificate suspended or revoked? Yes No Initials _______
2. Have you ever had any dental license suspended, revoked, or disciplined by any authority responsible for the regulation of the
   dental profession?      Yes      No         Initials _______

3. Have you ever been denied liability insurance?        Yes       No           Initials _______

4. Have you ever had a civil or criminal legal action filed against you concerning the administration of conscious sedation or deep
   sedation/general anesthesia?          Yes       No        Initials _______

5. Have you ever been denied membership or a renewal thereof, or have been subject to disciplinary proceedings in any dental
   organization or hospital? Yes   No        Initials _______


*If you’ve answered ‘yes’ to any of the disciplinary information questions, attach an explanation.
                                                                                                                                      1
                                           Enteral Conscious Sedation

Yes     No       Have you completed training consistent with that described in the Part I or Part III of the American Dental
                 Association (ADA) Guidelines for Teaching the Comprehensive Control of Pain and Anxiety in Dentistry?
                                                                  or
Yes     No       Have you completed an ADA accredited post-doctoral training program which affords comprehensive and
                 appropriate training necessary to administer and manage enteral conscious sedation?
                                                                  or
Yes     No       Have you completed the two-day conscious sedation course in Pediatric Dentistry that is approved and
                 developed by the American Academy of Pediatric Dentistry?
                                                                  or
Yes     No       Have you completed a two-day enteral conscious sedation approved by the State Board of Dental
                 Examiners?


Proof of program completion must be attached. A program completion certificate and/or a letter from the Program
Director or Department Chairperson is acceptable.

Date current certification in Basic Life Support (BLS):        Issued _______________               Expires _______________

Note: In addition to BLS, dentists must document current, successful completion every three years appropriate continuing
education in enteral conscious sedation.

In addition to minimum standard of care requirements, every dentist holding a permit to administer enteral conscious
sedation must ensure the following clinical provisions are met:

       Thorough patient evaluation
       Informed consent from the patient and/or the guardian
       Evaluation of equipment to ensure proper operation
       Baseline vitals should be taken depending on the medical condition of the patient and the nature of the procedure
       At least one member of the assistant staff who is properly trained in cardiopulmonary resuscitation and familiar with
        procedures, problems, and emergencies incident to the use of enteral conscious sedation should be present during the
        administration of enteral conscious sedation
       Not allow an enteral conscious sedation procedure to be performed by a Certified Registered Nurse Anesthetist (CRNA)
        unless the dentist holds a permit issued by the SBDE for the procedure being performed
       Patients who have been administered enteral conscious sedation must be monitored during waiting periods prior to operative
        procedures. A responsible adult given appropriate written pre-procedural instruction may provide such monitoring. The
        patient should be monitored for alertness, responsiveness, breathing and skin coloration.
       Dentists administering enteral conscious sedation must maintain direct supervision of the patient during the operative
        procedure and for such a period of time necessary to establish pharmacologic and physiologic vital sign stability
       Continually evaluate oxygenation (by pulse oximetry except with sedation for brief procedures, on extremely young children,
        patients who cooperate poorly due to unwillingness or inability to follow instructions, or patients whose level of anxiety will be
        heightened by monitoring. If pulse oximetry is not used, the administering dentist must document the reasons preventing the
        recommended monitoring), ventilation, and circulation.
       Maintain an appropriate time oriented anesthetic record, which includes documentation of individual administering the drug(s),
        and show the name(s) of drug(s) and dosage(s) used.




                                                                                                                                        2
                                Enteral Conscious Sedation (Cont’d.)

      Positive pressure oxygen and suction equipment must be immediately available in the operatory and the recovery area
      Continual monitoring of vital signs when the sedation is no longer being administered
      The patient must have direct continuous supervision until oxygenation and circulation are stable and the patient is
       appropriately responsive for discharge form the facility
      The dentist must document that oxygenation, circulation, activity, skin color, and level of consciousness are appropriate and
       stable prior to discharge
      The dentist must provide written post-operative instructions to patient and/or a responsible adult at time of discharge
      Every patient must meet the following discharge criteria prior to leaving the office:
                 -Cardiovascular function satisfactory and stable
                 -airway patency uncompromised and satisfactory
                 -patient easily arousable and protective reflexes intact
                 -state of hydration adequate
                 -patient can talk, if applicable
                 -patient can sit unaided, if applicable
                 -patient can ambulate, if applicable, with minimum assistance
                 -for the child who is very young or disabled and incapable of the usually expected responses, the
                           pre-sedation level of responsiveness or the level as close as possible for that child should be
                           achieved
                 -responsible individual is available
        Patients who have unusual reactions to enteral conscious sedation must be assisted and monitored either in an operatory
           chair or recovery room until stable for discharge
        The dentist must determine that the patient is appropriately responsive prior to discharge
        The dentist, personnel, and facility must be prepared to treat emergencies that may arise from the administration of
           enteral conscious sedation and must have the ability to provide positive pressure ventilation with 100% oxygen with an
           age appropriate device




By signing below, you are attesting that all provided information is true and correct and that you
will adhere to the SBDE Rules and Regulations regarding the administration of enteral conscious
sedation. It is the dentist’s responsibility to remain apprised to amendments to the SBDE rules
regarding the administration of enteral conscious sedation.



Signature                                                                                                         Date


                                                                                                                                  3
                     Nitrous Oxide/Oxygen Inhalation Conscious Sedation

Yes      No       Have you completed training within the last five years consistent with that described in the Part I or Part
                  III of the American Dental Association (ADA) Guidelines for Teaching the Comprehensive Control of Pain
                  and Anxiety in Dentistry?
                                                                   or
Yes      No       Have you completed an ADA accredited post-doctoral training program which affords comprehensive and
                  appropriate training necessary to administer and manage nitrous oxide/oxygen inhalation conscious
                  sedation?

Date current Basic Life Support CPR certification:              Issued _______________              Expires _______________


Proof of course completion must be attached, unless you are a graduate of a Texas dental school within the last
five years. Lists of Texas dental school graduates who received appropriate training for the administration of
nitrous oxide have previously been submitted to the State Board of Dental Examiners.

In addition to minimum standard of care requirements, every dentist holding a permit to administer nitrous oxide/oxygen
inhalation conscious sedation must ensure the following clinical requirements are met:

   Thorough patient evaluation and informed consent
   Evaluation of inhalation equipment to ensure proper operation and delivery of inhalation agent
   Determination of adequate oxygen supply
   Baseline vitals should be taken depending on the medical condition of the patient
   At least one member of the assistant staff should be present during the administration of nitrous in non-emergency situations. The
     dentist must maintain personal supervision of the patient during the induction of the nitrous oxide/oxygen inhalation conscious
     sedation and during maintenance for such a period necessary to establish pharmacologic and physiologic vital sign stability. The
     dentist may delegate under direct supervision the monitoring of the sedation procedure to a dental auxiliary who has been certified
     by the State Board of Dental Examiners (SBDE) to monitor the administration. Certification is obtained by written examination
     offered by the SBDE on said subject.
   Individuals present during administration should be documented
   Maximum concentration administered should be documented
   The dentist must determine the patient is appropriately responsive prior to discharge
   The dentist , personnel, and facility must be prepared to treat emergencies that may arise from the administration of nitrous
     oxide/oxygen inhalation conscious sedation




By signing below, you are attesting that all provided information is true and correct and that you
will adhere to the SBDE Rules and Regulations regarding the administration of nitrous
oxide/oxygen inhalation conscious sedation. It is the dentist’s responsibility to remain apprised to
amendments to the SBDE rules regarding the administration of nitrous oxide/oxygen inhalation
conscious sedation.



Signature                                                                                                             Date


                                                                                                                                       4
                                        Parenteral Conscious Sedation

Yes      No       Have you completed a comprehensive training program in parenteral conscious sedation that satisfies the
                  requirement described in Part III of the American Dental Association (ADA) Guidelines for Teaching the
                  Comprehensive Control of Pain and Anxiety in Dentistry (60 didactic hours, 20 clinical cases)?
                                                                  or
Yes      No       Have you completed an ADA accredited post-doctoral training program which affords comprehensive and
                  appropriate training necessary to administer and manage parenteral conscious sedation?


Proof of program completion must be attached. A program completion certificate and/or a letter from the Program
Director or Department Chairperson is acceptable.


In addition to minimum standard of care requirements, every dentist holding a permit to administer parenteral conscious
sedation must ensure the following clinical requirements are met:

 maintain a written informed parenteral conscious sedation consent for each dental patient on whom each procedure is performed;
    consent shall specify that the risks related to the procedure include cardiac arrest, brain injury, and death
 maintain a time-oriented written anesthetic record and shall record dosages of anesthetic agents utilized , including physiologic vital
    sign monitoring during the course of the procedure
 maintain under continuous personal supervision auxiliary personnel who shall be capable of reasonably assisting in procedures,
    problems, and emergencies incident to the use of parenteral conscious sedation
 ensure all assistant staff have current certification in basic life support issued by the American Heart Association or the American
    Red Cross
 not allow a parenteral conscious sedation procedure to be performed in the office by a Certified Registered Nurse Anesthetist
    (CRNA) unless the dentist holds a permit issued by the SBDE for the procedure being performed
 suitably evaluate every patient for medical risk prior to the start of a procedure
 the patient and/or guardian must be advised of the procedure associated with the delivery of any sedative agent and the appropriate
    informed consent must be obtained
 baseline vital signs and pre-treatment physical evaluation must be performed as appropriate
 specific dietary restrictions must be delineated based on the technique used and patient’s physical status
 verbal or written instructions regarding the procedure must be given to the patient and/or guardian
 an intravenous line must be established and secured throughout a procedure utilizing an intravenous conscious sedation technique
    and should be maintained with other parenteral conscious sedation techniques when the patient’s physical or medical condition
    warrants
 during the administration of parenteral conscious sedation, the dentist and at least one other member of the assistant staff who is
    currently competent in basic life support must be present
 if nitrous oxide and oxygen delivery equipment capable of delivering less that 25% oxygen is used, an in-line oxygen analyzer must
    be utilized
 ability to deliver positive pressure must be maintained
 the inhalation equipment must have an appropriate nitrous oxide/oxygen scavenging system
 maintain personal supervision of the patient during the induction and maintenance phase of parenteral conscious sedation for a
    period necessary to establish pharmacologic and physiologic vital sign stability. When a Certified Registered Nurse Anesthetist
    (CRNA) provides conscious sedation care, he/she shall be under the direct supervision of the dentist in the dental office.
    Delegation of personal supervision may occur if a second dentist or physician anesthesiologist is delivering the anesthesia care
 Continually evaluate oxygenation, ventilation, and circulation
 Shall record and take blood pressure and pulse continually at least every 10 minutes

                                                                                                                                       5
                                Parenteral Conscious Sedation (Cont’d.)
 Shall perform continuous EKG monitoring of all patients with electrocardioscopy, except as provided in SBDE Rule 108.34(b)(3)(F)
 A written time-oriented anesthetic record mist be maintained. Individuals present during the administration of parenteral conscious
   sedation shall be documented
 Positive pressure and suction equipment must be immediately available in the recovery area and/or operatory
 continual monitoring of vital signs when the sedation/anesthesia is no longer being administered. The patient must have continuous
   supervision until oxygenation, ventilation and circulation are stable and the patient is appropriately responsive for discharge from
   the facility
 the dentist must determine and provide for documentation that the patient is appropriately responsive for discharge
 must provide explanation and documentation of postoperative instructions to patient and/or a responsible adult at the time of
   discharge
 the sedation/anesthesia permit holder/provider is responsible for the anesthetic management, the adequacy of the facility and
   treatment of emergencies associated with the administration of parenteral conscious sedation, including immediate access to
   pharmacologic antagonists and equipment for establishing a patent airway and providing positive pressure ventilation with oxygen.
   Advanced airway equipment, resuscitation medications must be available. A defibrillator must be immediately available when ASA
   III and ASA IV status patients are consciously sedated

By signing below, you are attesting that all provided information is true and correct and that you
will adhere to the SBDE Rules and Regulations regarding the administration of parenteral
conscious sedation. It is the dentist’s responsibility to remain apprised to amendments of the
SBDE rules regarding the administration of parenteral conscious sedation.


Signature                                                                                                            Date




Portability of Parenteral Conscious Sedation Privileges

If you desire the approval to offer parenteral conscious sedation services in locations other than your dental office or a
satellite office, you must indicate below and attach documentation of training.

I request portability of my sedation/anesthesia permit be granted at the time my sedation permit may be issued. I meet the
SBDE requirements for portability on the basis of completion of:

_____ a specialty program approved by the Commission on Dental Accreditation of the American Dental Association
_____ a general practice residency approved by the Commission on Dental Accreditation of the American Dental
      Association
_____ an advanced education in general dentistry program, approved by the Commission on Dental Accreditation of the
      American Dental Association
_____ a continuing education program specifically approved by the SBDE. Approval will be considered only if the applicant can
      demonstrate administration of IV parenteral conscious sedation in at least 30 documented cases showing provision of
      anesthesia services keeping with the standard of care. The program must consist of 60 hours of didactic courses and include
      administration of parenteral conscious sedation in at least 20 cases where the applicant was the anesthesia provider.



                                                                                                                                     6
                                     Deep Sedation/General Anesthesia

Yes      No       Have you completed an advanced training program in anesthesia and related subjects beyond the
                  undergraduate dental curriculum that satisfies the requirements described in Part II of the American Dental
                  Association (ADA) Guidelines for Teaching the Comprehensive Control of Pain and Anxiety (60 didactic
                  hours, 20 clinical cases)?
                                                                   or
Yes      No       Have you completed an ADA accredited post-doctoral training program which affords comprehensive and
                  appropriate training necessary to administer and manage deep sedation/general anesthesia?


Proof of program completion must be attached. A program completion certificate and/or a letter from the Program
Director or Program Chairperson is acceptable.

In addition to minimum standard of care requirements, every dentist holding a permit to administer deep sedation/general
anesthesia must ensure the following clinical requirements are met:

 maintain a written informed deep sedation and/or general anesthesia consent for each dental patient on whom each procedure is
    performed; consent shall specify that the risks related to the procedure include cardiac arrest, brain injury, and death
 maintain a time-oriented written anesthetic record which shall record dosages of anesthetic agents utilized and physiologic vital sign
    monitoring during the course of the procedure
 maintain under continuous direct supervision a minimum of two auxiliary personnel who shall be capable of reasonably assisting in
    procedures, problems, and emergencies incident to the use of deep sedation and/or general anesthesia
 ensure all assistant staff have current certification in basic life support issued by the American Heart Association or the American
    Red Cross
 not allow a deep sedation and/or general anesthesia procedure to be performed in the office by a Certified Registered Nurse
    Anesthetist (CRNA) unless the dentist holds a permit issued by the SBDE for the procedure being performed
 suitably evaluate every patient for medical risk prior to the start of a procedure
 the patient and/or guardian must be advised of the procedure associated with the delivery of any sedative agent and the appropriate
    informed consent must be obtained
 baseline vital signs and pre-treatment physical evaluation must be performed as appropriate
 specific dietary restrictions must be delineated based on the technique used and patient’s physical status
 verbal or written instructions regarding the procedure must be given to the patient and/or guardian
 an intravenous line must be established and secured throughout the procedure, except as provided in SBDE rule 108.34(c)(F)(i)
 during the administration of deep sedation and/or general anesthesia, the dentist and two additional individuals who are currently
    certified in basic cardiopulmonary resuscitation or its equivalent; one of whom is trained in patient monitoring shall be present for
    the delivery of anesthesia care
 when the same individual administering the deep sedation and/or general anesthesia is performing the dental/oral and maxillofacial
    procedure, one of the additional two individuals present for the delivery of anesthesia care must monitor the patient and record
    required information on the anesthesia record\
 equipment suitable to provide advanced airway management and advanced life support must be on premises and available for use
 any inhalation equipment utilized in conjunction with deep sedation and/or general anesthesia must have a fail safe system that is
    appropriately checked and calibrated
 the inhalation equipment must have an appropriate nitrous oxide/oxygen scavenging system
 if nitrous oxide and oxygen delivery equipment capable of delivering less that 25% oxygen is used, an in-line oxygen analyzer must
    be utilized
 ability to deliver positive pressure must be maintained
 maintain personal supervision of the patient during the induction and maintenance of deep sedation and/or general anesthesia for a
    period necessary to establish pharmacologic and physiologic vital sign stability. When a Certified Registered Nurse Anesthetist
    (CRNA) provides the anesthesia care, he/she shall be under the direct supervision of the dentist in the dental office. Delegation of
    personal supervision may occur if a second dentist or physician anesthesiologist is delivering the anesthesia care

                                                                                                                                       7
                            Deep Sedation/General Anesthesia (Cont’d.)
 Continually evaluate: oxygenation (by pulse oximetry), ventilation (intubated – must ascultate breath sounds and monitor of end-
   tidal CO2; non-intubated – auscultation of breath sounds, observation of chest excursions and/or monitoring of end-tidal CO2),
   circulation (continuous EKG monitoring of all patients throughout the procedure with electrocardioscopy shall occur) and
   temperature (a device capable of measuring body temperature should be readily available. When agents implicated in
   precipitating malignant hyperthermia are utilized, continual monitoring of body temperature should be performed). Shall record
   blood pressure and pulse continually at least every five minutes.
 A written time-oriented anesthetic record must be maintained. Individuals present during the administration of deep sedation and/or
   general anesthesia shall be documented
 Oxygen and suction equipment must be immediately available in the recovery area and/or operatory
 continual monitoring of vital signs when the sedation/anesthesia is no longer being administered. The patient must have continuous
   supervision until oxygenation, ventilation, circulation and temperature are stable and the patient is appropriately responsive for
   discharge from the facility
 the dentist must determine and provide for documentation that the patient is appropriately responsive for discharge
 must provide explanation and documentation of postoperative instructions to patient and/or a responsible adult at the time of
   discharge
 the sedation/anesthesia permit holder/provider is responsible for the anesthetic management, the adequacy of the facility and
   treatment of emergencies associated with the administration of deep sedation and/or general anesthesia, including immediate
   access to pharmacologic antagonists and equipment for establishing a patent airway and providing positive pressure ventilation
   with oxygen. Advanced airway equipment, resuscitation medications, and a defibrillator must be immediately available
 appropriate pharmacologic agents must be immediately available if known triggering agents of malignant hyperthermia are part of
   the anesthesia plan


By signing below, you are attesting that all provided information is true and correct and that you
will adhere to the SBDE Rules and Regulations regarding the administration of deep sedation
and/or general anesthesia. It is the dentist’s responsibility to remain apprised to amendments of
the SBDE rules regarding the administration of deep sedation and/or general anesthesia.


Signature                                                                                                          Date




Portability of Deep Sedation and/or General Anesthesia
                       Privileges
If you desire the approval to offer deep sedation and/or general anesthesia services in locations other than your dental
office or a satellite office, please initial below.

_____I request portability of my sedation/anesthesia permit be granted at the time my sedation permit may be issued,
        based on my education and training as required in the SBDE rules and regulations.

09/06




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