Administration of Anesthetic Agents for Dental Procedures

The Dental Quality Assurance Commission (DQAC) updated the administration of anesthetic agents for dental procedures rules January 11, 2024.

The changes include:

Creating a pediatric sedation endorsement,
24 hour on-call availability,
Updates to basic life support education,
Requirements for emergency protocols and training,
Clarity of record keeping and emergency medications,
Updates of Continuing Education (CE) requirements,
Self-inspections for all dentists when anesthetic is administered,
Updates to on-site inspections for dentists with moderate sedation with parenteral agents and general anesthesia permits, and
Updates to vital sign monitoring requirements.

The rules are effective January 11, 2024. There is one exception: pediatric sedation endorsement is not in effect until January 1, 2025.

WAC 246-817-720 Basic Life Support Requirements

Can I take my Basic Life Support (BLS) training online?: No, initial and renewal certification must include both didactic and hands-on components. BLS instruction must include an in-person skills assessment.

WAC 246-817-722 Defibrillator

I provide local anesthesia. Do I need an AED?: When anesthetic agents of any kind are administered, the dentist and staff must have access to an AED or defibrillator.

WAC 246-817-724 Recordkeeping, Equipment, and Emergency Medication or Drugs

What emergency medications or drugs do I need on hand?

Bronchodilator including, but not limited to albuterol
Sugar or glucose
Aspirin
Antihistaminic including, but not limited to diphenhydramine
Coronary artery vasodilator including, but not limited to nitroglycerin
Anti-anaphylactic agent including, but not limited to epinephrine

WAC 246-817-730 Local Anesthesia

Are vital signs always required before administration of local anesthesia?: No, for children 13 years and younger taking vital signs is at the discretion of the provider. Vital signs are required for adults unless there are medical reasons to not take them that are recorded and documented in the patient's chart.

WAC 246-817-740 Minimal Sedation with Nitrous Oxide

What training do I need to provide minimal sedation with nitrous oxide?

14 hours of training is needed in one of the following:

Minimal sedation with nitrous oxide,
Moderate sedation with nitrous oxide, or
Advanced education program accredited by CODA.

I provide minimal sedation. Do I need a BLS certification?

Yes, you must hold a current and valid BLS certification.

WAC 246-817-745 Minimal Sedation

What training do I need to provide minimal sedation which is limited to a single dose of a single oral agent with or without nitrous oxide?

16 hours of training is needed in one of the following:

Minimal sedation with nitrous oxide,
Moderate sedation with nitrous oxide, or
Advanced education program accredited by CODA.

When administering minimal sedation can the 16-hour educational requirements be completed in pre-doctoral training?

Yes, as long as 16 full hours of education is documented in applicant’s dental school transcripts.

In the absence of a manufacturer’s recommended home dose, meaning that there is no manufacturer’s maximum, would the administration of a single oral agent be considered minimal sedation?

The 2016 ADA Guidelines state that minimum sedation should be limited to drugs that have an FDA-approved manufacturer’s maximum dose for unmonitored home use. If that is not found, then an individual would need a moderate sedation permit. Please be aware that in the absence of a manufacturer's maximum dose for unmonitored home use, you may be providing a moderate level of sedation.

WAC 246-817-755 Moderate Sedation with Enteral Agents

Are moderate sedation permits and moderate sedation with enteral agents permits the same permit?

Yes, the name of the moderate sedation permit has been changed to moderate sedation with enteral agents.

What training do I need to provide moderate sedation with enteral agents?

A minimum of 16 hours of education and training is needed in one of the following:

Minimal sedation; or
Moderate sedation; or
Advanced education program accredited by CODA that meets comprehensive and appropriate training necessary to administer and manage minimal sedation.

AND

A minimum of 21 hours of education and training in moderate sedation that:

Meets ADA "Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students" adopted by ADA House of Delegates October 2016 or prior adopted version in effect at the time training was completed; and
Includes medical emergency management, not limited to airway management, conducted in-person with hands-on skills.

I want to apply for a moderate sedation with enteral agents permit. Can parenteral sedation training be used to meet the educational requirements?

Yes, higher level anesthesia training can be used as part of moderate sedation with enteral agents permit education requirements. Training must meet ADA guidelines in content and course objectives.

WAC 246-817-760 Moderate Sedation with Parenteral Agents

What training do I need to provide moderate sedation with parenteral agents?

60 clock hours of training which includes basic moderate sedation, physical evaluation, in-person venipuncture and intravenous drug administration, technical administration, in-person recognition and management of complications and emergencies, monitoring, and supervised experience in providing moderate sedation with parenteral agents to 20 or more patients.
Must hold and maintain a current certification in ACLS or PALS.

An interpretive statement has been adopted regarding the application requirements for moderate sedation with parenteral agents permits PDF.

I want to apply for a moderate sedation permit with parenteral agents. Can the education completed for a moderate sedation with enteral agents be submitted as part of the 60-hour training requirement?

Yes, if the training meets ADA Guidelines in content and course objectives

WAC 246-817-765 Pediatric Sedation Endorsement

Do I need a pediatric sedation endorsement?

Effective January 1, 2025, a pediatric sedation endorsement is required to administer moderate sedation with enteral agents or moderate sedation with parenteral agents to patients aged 12 and under. This only applies to moderate sedation permit holders. General anesthesia permit holders do not need a pediatric sedation endorsement.

What training do I need to obtain a pediatric sedation endorsement?

A current and valid moderate sedation with enteral agents or moderate sedation with parenteral agents permit;
A current and valid BLS and PALS certification, AND
Training in a CODA postgraduate instruction in either pediatric dentistry, oral and maxillofacial surgery, dental anesthesiology OR Predoctoral dental school, postgraduate instruction, or
Continuing education of at least 37 hours in minimal and moderate sedation and an additional 14 hours in pediatric sedation.

WAC 246-817-770 General Anesthesia and Deep Sedation

What training do I need to obtain a general anesthesia permit?

You must have a current ACLS and successfully complete two years of continuous full-time anesthesia training in at least one of the following:

A CODA accredited dental anesthesia program.
A dental anesthesiology program approved by the Dental Quality Assurance Commission (DQAC).
An anesthesia residency training at a medical program accredited by the Accreditation Council for Graduate Medical Education
An oral and maxillofacial surgery residency and obtain diplomate status of the American Board of Oral and Maxillofacial Surgery, or fellow status of the American Association of Oral and Maxillofacial Surgeons, or Diploma in a CODA accredited Oral and Maxillofacial Residency Program.

I provide general anesthesia. Can my team member who is providing patient monitoring perform other dental assistant tasks?

No, the team member designated for patient monitoring may not perform dental assistant tasks.

WAC 246-817-771 Dental Anesthesia Assistant

Can a dental anesthesia assistant be under the supervision of a periodontist?: No, dental anesthesia assistants must be under the supervision of an oral and maxillofacial surgeon or a dental anesthesiologist, per RCW 18.350.040. Periodontists are excluded from this statute.

WAC 246-817-773 Continuing Education for Dentists Administering Sedation

What CE do I need to maintain my permit?

Starting January 1, 2024, the CE reporting period for minimal sedation with nitrous oxide and minimal sedation is every five years.

Starting January 1, 2024, the CE reporting period for moderate sedation with enteral agents, moderate sedation with parenteral agents, pediatric sedation endorsement and general anesthesia permit is every 3 years.

	WAC 246-817-740: Minimal sedation with nitrous oxide – 7 hours	WAC 246-817-745: Minimal sedation – 7 hours	WAC 246-817-755 Moderate sedation with enteral agents – 7 hours	WAC 246-817-760 Moderate sedation with parenteral agents – 14 hours	WAC 246-817-765 Pediatric sedation endorsement – 14 hours	WAC 246-817-770 General anesthesia and deep sedation – 18 hours
Appropriate use of immobilization devices					X
ACLS	X	X	X
Behavioral management						X
General anesthesia						X
Inhalation analgesia						X
Medical emergencies	X	X	X	X	X	X
Nitrous oxide analgesia	X	X	X	X	X
Oral or intravenous sedation				X
Oral sedation	X	X	X
PALS	X	X	X	X		X
Patient evaluation	X	X	X	X	X	X
Patient monitoring	X	X	X	X	X	X
Pediatric behavioral management					X
Pediatric pharmacology					X
Pediatric physiological					X
Pediatric sedation					X
Pharmacology				X		X
Physiology	X	X	X	X		X

WAC 246-817-774 Permitting and Renewal Requirements

How do I give a written declaration of continuing compliance when I renew my anesthesia permit?

An attestation will be included in the anesthesia permit renewal application.

Do I need to perform emergency drills in my office?

Yes, if you have a permit for moderate sedation with enteral agents, moderate sedation with parenteral agents, or general anesthesia you must have written documentation. This documentation must show a minimum of 12 emergency drills scenarios were performed at least two times per year. You need to maintain this documentation for three years.

What is an emergency drill?

An emergency drill is an educational experience in which the anesthesia provider and staff discuss and demonstrate the steps taken in a possible patient emergency situation.

Use of on-site emergency equipment, expired drugs, and a simulated patient is strongly encouraged. Examples of possible emergency drills include but are not limited to syncope, angina, hypoglycemia, allergic reactions, postural hypotension, anaphylaxis, stroke, adrenal crisis, heart attack, choking, asthma attack, and epilepsy/seizure. The dentist has discretion to decide which medical emergencies they drill in their office.

How long should an emergency drill last and how often do I need to do them?

A minimum of 12 emergency drills must be performed at least two times per year. The provider can determine the frequency of the emergency drills. For example, during a 6-month period: one drill a week for 12 weeks or two drills every month. Each drill should take a minimum of 5-10 minutes to complete.

Do ACLS, PALS, or ACLS training count towards the drill requirement?

No. Examples of possible emergency drills include but are not limited to syncope, angina, hypoglycemia, allergic reactions, postural hypotension, anaphylaxis, stroke, adrenal crisis, heart attack, choking, asthma attack, and epilepsy/seizure.

How should I document emergency drills and how long do I need to keep the documentation?

The provider can decide what format they use to document emergency drills. Documentation needs to include the date of the drill, time spent on the drill, the specific drills practiced, and the staff present during the training. The training document must be signed and dated by the anesthesia provider/permit holder and be available for inspection for three years.

How do I conduct a self-assessment for office emergency preparedness?

It is at the discretion of each provider to review their individualized written plan. The plan needs to be reviewed annually, preferably with the staff during emergency drills. The on-site inspection forms Moderate Sedation with Parenteral Agents Self-Inspection Form (PDF) or General Anesthesia Self-Inspection Form (PDF) can be used as a guideline. Anesthesia providers can use the sections which relate to their sedation permit.

WAC 246-817-775 On-site Inspections

Do I need an on-site inspection to renew my sedation permit?

Dentists with a moderate sedation with parenteral agents or general anesthesia permit must have an on-site inspection every 5 years by a Dental Quality Assurance Commission (DQAC) approved organization as described in WAC 246-817-775. The on-site inspection documentation must be maintained for 5 years.

Where can I find the dental commission’s self-inspection form?

The self-inspection forms are on our website:

On-site documentation forms need to be maintained for 5 years.

How do I schedule an on-site inspection?

It is the decision of each applicant to choose an inspection by an approved organization or a self-arranged inspection by 2 independent anesthesia providers chosen by the applicant.

I’m arranging an inspection by 2 independent anesthesia providers. Do they both need to complete their inspection at the same time?

No, both independent anesthesia providers can complete their inspection at separate times. They will both need to sign and date the on-site inspection form certifying the provider has passed the inspection.

WAC 246-817-778 Nondentist Anesthesia Providers

I work with a nondentist anesthesia provider. Do I need a written contract?: Yes, you need a written contract which meets the requirements outlined in WAC 246-817-778.

Additional Questions

Do I need to consult with my patient’s primary care physician or consulting medical specialist prior to providing anesthesia?

You must consult with your patient’s primary care physician or consulting medical specialist if your patient meets the American Society of Anesthesiologists patient classification III or IV AND you are providing one of the following types of sedation:

Minimal sedation limited to a single dose of a single oral agents,
Moderate sedation with enteral agents,
Moderate sedation with parenteral agents, or
General anesthesia.

Do I need to assess a patient’s vital signs prior to administering anesthesia and sedation?

Yes, you need to assess a patient’s vital signs prior to treatment if you are providing any form of anesthesia or sedation, including local anesthesia or minimal sedation with nitrous oxide. However, this does not apply if the cooperation of the patient or circumstances of the case does not allow it. If pretreatment vitals cannot be taken, then you must record the reason(s).

Are registered dental assistants allowed to place topical anesthetic?

Yes, registered dental assistants may place topical anesthetic, per WAC 246-817-520. WAC 246-817-540(4) refers to injectable anesthetics.