Statement on Sedation & Anesthesia Administration in Dental Office-Based Settings*
Developed By: Committee on Quality Management and Departmental Administration
Last Amended: October 25, 2017 (original approval: October 25, 2017)
The American Society of Anesthesiologists (ASA) is a recognized leader in advancing patient safety and in the safe provision of sedation and anesthesia care. Since its founding in 1905, ASA’s achievements have made it the leading voice and the foremost expert in American medicine on matters of patient safety in the perioperative environment and in pain medicine. ASA has a record of establishing guiding principles for the safe care of patients receiving sedation and/or anesthesia care in diverse clinical settings, including dental offices.
ASA has witnessed a growing awareness of adverse events in dental office-based settings associated with sedation and/or anesthesia care – these events have continued to occur with unacceptable frequency. ASA recognizes that dental organizations and accrediting organizations have addressed many facets of dental sedation and/or anesthesia care thorough guidelines, practice parameters and other related guidance materials. ASA also recognizes that most aspects of dentist, dental practice and dental office credentialing, licensing and permitting are and will continue to be governed by state statutes and regulations.
Patient care for a procedure or surgery requiring sedation and/or anesthesia should be based on nationally accepted standards, guidelines and other statements as well as levels of care established by states that are consistent in a dental office, hospital, Ambulatory Surgery Center (ASC) or clinic. No patient should be unduly endangered by lack of training and education, inadequate facilities, poor patient selection or lack of safety, resuscitative or related emergency protocols.
To promote the optimal sedation and/or anesthesia care, ASA offers the following recommendations for sedation and anesthesia services in dental office-based settings. These recommendations are intended for use by those state and national organizations with oversight responsibilities, and state entities offering guidance to individuals providing sedation or anesthesia care in dental office-based settings.
- Training & Education:
- The individual providing sedation and/or anesthesia care in the dental office-based setting should:
- Successfully complete approved formal education, whether incorporated in the core curriculum or as post-graduate education, consistent and equivalent with the level of sedation and anesthesia required for credentialing and privileging in non-office-based facilities where similar procedures are routinely performed.
- Successfully complete approved education and training in airway maintenance and management of complications from sedation and anesthesia care that include, but are not limited to airway compromise,
hemodynamic instability and rescue from deeper than the intended level of sedation.1
- National organizations, accrediting entities and others should work with state licensing bodies to develop consistent requirements and standards for dental office-based settings and individuals providing sedation and/or anesthesia care in such settings.
- The individual providing sedation and/or anesthesia care should successfully complete training in age-appropriate resuscitative and related emergency measures. In settings where pediatric patients are administered sedation and/or anesthesia, Pediatric Advanced Life Support (PALS) education and training should be maintained. Basic Life Support for Healthcare Providers (BLS) and Advanced Cardiac Life Support (ACLS) education and training should likewise be documented and maintained within the dental office-based setting where non-pediatric patients undergo treatment.
- Monitoring & Equipment:
- For dental office-based sedation and/or anesthesia care, ASA recommends the availability and use of appropriate monitors and safety equipment in a manner consistent with current ASA Standards, Statements and Guidelines.
- ASA recommends that age appropriate equipment and medications for use in resuscitation and related emergency care are immediately available. ASA recommends emergency care and transfer processes should be incorporated into the office’s emergency protocols.
- A designated individual, other than the individual performing the procedure, should be present to monitor the patient throughout procedures performed with sedation. During deep sedation and/or general anesthesia, this individual should have no other responsibilities.
- Care should be provided in facilities equipped with the monitors as described by ASA Standards, Guidelines and Statements in procedural areas where sedation and/or anesthesia care is performed and anticipated.
- States should specify requirements for office registration, licensing/permitting and office inspections to ensure compliance with all appropriate guidelines and regulations.
- Individuals providing sedation and/or anesthesia care working within such dental office-based settings should ensure compliance governing monitoring and equipment requirements for facilities.
- Patient Selection & Case Selection:
- Patients age six (6) and under are unlikely to be able to cooperate with procedures under moderate sedation and may require deep sedation and/general anesthesia. They are at particular risk for respiratory or other complications and have a greater risk of sustaining life-threatening events. Therefore, ASA recommends that all training and protocols should have specific measures for this patient population, including the same standard of care and monitoring for moderate sedation as for deep sedation and general anesthesia, i.e. a distinct and separate qualified anesthesia provider not otherwise involved in the procedure, as stated above.
- Pediatric patients and adults with major medical problems (ASA Physical Status III and above) are at higher risk of adverse events than other patients. For these high-risk patients and younger pediatric patients, ASA recommends evaluation by a primary care physician or physician anesthesiologist prior to scheduling a procedure.
- Prolonged and extensive procedures with longer periods of sedation and anesthesia care are of concern in the office-based setting and qualified anesthesia providers, in consultation with such patients, should consider more suitable facilities for the procedure.
- State regulators, with input from qualified anesthesia providers, should consider the development of state-based patient selection criteria (e.g. minimum age, co-morbidities).
- Resuscitative Measures & Protocols:
Training for resuscitation and emergency scenarios should adhere to ASA Guidelines For Office-Based Anesthesia.
- All dental-based office settings where sedation and/or anesthesia care is performed, should have available appropriate equipment and supplies, including monitors and medications to address/treat emergencies. Defibrillators, appropriate resuscitative drugs and emergency age appropriate airway equipment should be available and functional at all times. All resuscitative drugs should be checked and equipment tested at routine accepted intervals.
- Data Reporting & Transparency:
- State agencies and licensing boards should consider the separate permitting process of individuals administering anesthesia/sedation and the office-based facility. Additionally, both should be included in an ongoing process that monitors and evaluates clinical performance, patient outcomes and adverse events in an effort to support continuous performance improvement. Selection of reportable events and outcomes should be based on published guidelines, clinical registries or Patient Safety Organization guidance.
1Educational and training programs would include pre- and post-doctoral programs approved by nationally-recognized entities such as the Commission on Dental Accreditation or ACGME.
- ASA Guidelines for Sedation by Non-Anesthesiologists (ASA expects that an update to this Guideline will occur in October 2017)
- ASA Standards For Basic Anesthetic Monitoring, 2015
- ASA Guidelines For Office-Based Anesthesia, 2014
- American Academy of Pediatrics Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016
- American Dental Associations Guidelines for the Use of Sedation and General Anesthesia by Dentists, 2016
- American Academy of Pediatrics & American Academy of Pediatric Dentistry Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures, 2016
- Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia, 2014
- Procedural Sedation Outcome Metrics ASA 2016
* The target groups for this document include general dentists, pediatrics dentists, oral and maxillofacial surgeons and dentist anesthesiologists as well as those physician anesthesiologists and anesthesia care team members providing sedation and/or anesthesia care in dental office-based settings.