This depends on the sedation administered.The American Dental Society and the American Society of Anesthesiologists, and the Florida Board of Dentistry define four levels of sedation and anesthesia:

• Minimal sedation (also called anxiolysis):
• Moderal sedation (also called conscious sedation):
• Deep sedation
• General anesthesia

These are not defined by the drugs used, nor the route of administration (ie, oral vs IV vs inhalation), but by the depth of sedation or anesthesia intended and achieved.

Any dentist in Florida can provide “minimal sedation” without advanced training, special permitting, or monitoring requirements. The Florida Board of Dentistry allows a dentist without advanced training in sedation to administer a single oral dose of a single drug, up to a maximum of the “PDR” maximum recommended dose of that drug. For example, a 170 adult may receive 0.50 mg of Halcion by mouth at one appointment. The dentist may supplement with nitrous oxide if needed.

To administer “moderate sedation” the dentist must have completed formal post-gradutate advanced training in sedation through an internship, residency, or an approved course that includes 60 hour hours of didactic andadministration of sedation to 20 patients. They then must apply to the Board of Dentistry for a permit, have an office inspection, which includes observation of sedation on a live patient and demonstration of competency in office sedation /medicalemergency drills.

To administer “deep sedation” and “general anesthesia” the dentist must have completed a two year residency in General Anesthesia, or completed a residency in Oral and Maxillofacial Surgery. Then apply to the Board of Dentistry for a permit, and again submit to an office inspection, including live patient anesthesia demonstration, and demonstration of emergency drills.

“Pediatric moderate sedation” is a separate permit, generally given to dentists who have completed a pediatric dentistry residency, during which they have received trainingto provideoral sedationto pediatric patients (generally defined as younger than 16).

Again, more details can be found on the Board of Dentistry website under the rules and regulations section, or by calling the Board of Dentistry.

The following are the definitions of sedation & general anesthesia from the American Society of Anesthesiology, also adopted by the American Dental Association, and the American Dental Society of Anesthesiology, and the Florida Board of Dentistry:

Minimal Sedation (Anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes, and ventilatory and cardiovascular functions are unaffected.

Moderate Sedation/Analgesia (“Conscious Sedation”) is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. Reflex withdrawal from a painful stimulus is NOT considered a purposeful response. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

Deep Sedation/Analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully** following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

General Anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.

No. Membership in the Florida Dental Society of Anesthesia is open to any Florida dentist who is interested in sedation and anesthesia in dentistry.

Yes, membership in FDSA and attendance at FDSA CE courses is open to any Florida licensed dentist, whether or not he possesses a sedation or anesthesia permit.

It depends what you mean by “sedation.” Please see the definitions of the different levels of sedation discussed elsewhere on this page.

A general dentist needs no special advanced training or permit to provide “minimal sedation,” formerly known as “anxiolysis.” “Minimal sedation” is a drug-induced state during which patients “respond normally” to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes, and ventilatory and cardiovascular functions are unaffected.

Specifically, the Florida Board of Dentistry allows a dentist without advanced training in sedation to administer a single oral dose of a single drug, up to a maximum of the “PDR” maximum recommended dose of that drug. For example, a 170 adult may receive 0.50 mg of Halcion by mouth at one appointment. The dentist may supplement with nitrous oxide if needed.

To administer “moderate sedation,” a dentist must have advanced post-graduate training and a permit from the Board of Dentistry. Moderate sedation requires specific patient monitoring, staff training, facility and equipment, office inspection, etc. Moderate sedation is not defined by the route of administration, but by the depth of sedation that results. Moderate sedation results in a patient who is sedated but can still “respond purposefully” to verbal commands.

Anxiolyisis, also called “minimal sedation” does not require the use of a pulse oximeter, because if the practitioner is truly just providing minimal sedation, the patients airway and respiratory status should never be compromised. Remember, the definintion of anxiolysis / minimal sedation is that the patient is continually responsive to normal verbal conversation. Should the patient inadvertently drift into moderate sedation, then the use of a pulse oximeter would be necessary (along with all the other requirements of administering moderate sedation). Also, the procedure should be discontinued and the patient returned to a lighter level of sedation or the practitioner will be practicing beyond the level of his training and license. Should the patients airway become compromised or respiratory status become depressed, then he should also be “rescued” from the unintended deeper sedation and appropriate airway recovery be performed.

For anxiolysis, routine vital signs such as heart rate, pulse, and respirations should be monitored and documented before and after the procedure.

No, propofol (and brevital, pentothal, ketamine, and volatile gases like sevoflurane, halothane, etc) are all general anesthetics and may not be used unless the practitioner has a deep sedation / general anesthesia permit. Although it is true that they can be used in small doses in experienced hands to provide moderate sedation, the therapeutic margin with these drugs between moderate sedation and general anesthesia is so small that it is difficult if not impossible for the patient not to drift into a deep level of anesthesia, and therefore their use requires training in general anesthesia.

The use of drugs classified as general anesthetics is restricted to practitioners holding a deep sedation / general anesthesia permit. This includes, but is not limited to, such agents as pentothal, etomidate, and halogenated volatile gases such as sevoflurane and halothane. These drugs have a very narrow therapeutic margin of safety and must only be used by practitioners with advanced training in general anesthesia, and in an office equipped, inspected, and permitted to provide general anesthesia.

“Deepening” the patient, even for just a few minutes, means that the patient is now out of moderate “conscious” sedation and into a deeper state of sedation. By definition, the patient will be in “deep sedation” and all the resultant training, licensure, monitoring, equipment requirements for deep sedation come into effect, and the practitioner is now practicing beyond the scope of his training and license.

In just a few minutes, a patient safely under moderate sedation, can become one with dangerous airway instability. It is therefore required, even if the patient inadvertently drifts into deep sedation, that the moderate sedation practictioner stop the procedure and immediately return the patient to moderate sedation.

If the practitioner has reached the limit sedation allowed by his training and licensure, and the patient’s anxiety still is unmanageable, the practitioner can abort the procedure / sedation and try a different sedative drug or technique at the next visit or he can refer the patient to someone trained to provide a deeper level of sedation. We all, generalists and specialists alike, have patients that are beyond the scope of our training or abilities, and just like in medical practice, these patients should be referred to a practitioner with more training.

Check the following web pages for information:

• http://www.doh.state.fl.us/mqa/dentistry/dn_statutes.html
• http://www.doh.state.fl.us/mqa/dentistry/info_julylaws10.pdf
• http://www.doh.state.fl.us/mqa/dentistry/rule_64B5-14Anes.pdf

Or contact the Board office directly at:

• Email: MQA_Dentistry@doh.state.fl.us
• Telephone – 850-245-4474
• Fax Number – 850-921-5389

The Florida Board of Dentistry requires sedation permit holders to complete 4 hours of CE in sedation every 2 years. Included in these 4 hours must be 2 hours of management of anesthesia emergencies. These 4 hours of sedation CE are part of the total 30 hours required, not in addition to them. Of course, it goes without saying that 4 hours are the bare minimum legal requirement, and administering a potentially dangerous therapy like anesthesia assumes the practitioner is responsible enough to seek far more continuing education than this.

Sedation, whether minimal, moderate, or deep, is not defined by the route of administration, such as IV vs. oral vs. inhalation, but by the depth of sedation that results. Obviously some routes and some drugs are more efficient and more effective for particular applications, but a similar depth of sedation or anesthesia can be achieved by any route of administration. Generally speaking, the complications that can occur under sedation are related to the depth of anesthesia, not the route of administration, therefore the management of patients under minimal, moderate or deep sedation is related to the level of anesthesia, not the route. Thus the permits and training that are required for administering different levels of anesthesia emphasize the depth of sedation, not the route.

The Rules section of the Board of Dentistry’s website contains detailed lists of required anesthesia equipment, monitors, emergency medications and resuscitation equipment, facility requirements, inspection and evaluation requirements, etc.

• http://www.doh.state.fl.us/mqa/dentistry/rule_64B5-14Anes.pdf

The initial office evaluation is an inspection the facility, equipment, and supplies. It is also required that the evaluator observe a typical sedative / anesthetic case on an actual patient. The doctor and his team must also show by demonstration competency to treat anesthesia emergencies.

Subsequent to the initial office evaluation, the office must be re-inspected every five years at a minimum. These subsequent office inspections do not require observation of sedation on an actual patient sedation.

No. For Oral & Maxillofacial Surgeons, the initial and subsequent office evaluations by the Board of Dentistry are now identical to the office anesthesia evaluations that are required for membership in the American Association of Oral and Maxillofacial Surgeons. Therefore a separate office evaluation by a representative of the FSOMS or AAOMS is no longer needed. The FSOMS reports the Board of Dentistry evaluations to the AAOMS in order for the OMS to fulfill his AAOMS membership requirement.

No, in Florida a dentist cannot advertise the administration of “sedation” if he does not have advanced training and a permit for moderate sedation. Similarly, a dentist cannot advertise the administration “sleep” dentistry unless he has advanced training and a permit to provide deep sedation and general anesthesia.

The dentist treating the patient must still have a sedation / anesthesia permit him(her)self in order to bring in a medical anesthesia provider. And the sedation permit must be at the same level as the anesthesia administered to the patient. In other words, a conscious sedation provider can bring in an MD anesthesiologist or nurse anesthetist, but they can only administer conscious sedation in that office, not general anesthesia. Only if the dentist has a deep sedation / general anesthesia permit, can the MD or CRNA can administer deep sedation or general anesthesia. The dentist is ultimately responsible for the anesthesia administered, and must therefore have an office that is appropriately equipped, with appropriately trained staff, inspected, and with the appropriate permits.

Yes, but the patient then also becomes a patient of record of the doctor administering the sedation, and all the requirements and responsibilities that that implies then ensue. For example, the doctor administering the sedation is responsible for reviewing the patients’ medical history, interviewing the patient, obtaining informed consent, ensuring the patient is an appropriate candidate for sedation, administering the sedation, continuously monitoring the patient, discharging the patient, etc. The sedation provider cannot leave the patient to be monitored by the dentist doing the dental procedure who is untrained in anesthesia.

(The Board of Dentistry “approved” “such and such” course, so it must be accurate.)

The Board of Dentistry only approves organizations to provide CE courses and does not investigate nor approve the content of any course. Basically, it is “buyer beware” when attending a CE course. Getting CE credit from an approved CE provider does not imply that the material that is taught is correct, appropriate, or approved by the Florida Board of Dentistry.