I agree with the board's intentions to better clarify the rules and regulations for sedation and anesthesia in dental offices. The more consistency and clarity there is in the rules the less room there is for common error and mistakes. I think that the use of a three-person team in the operatory during administration of moderate sedation is a good idea because there are more people to monitor, catch errors and assist if necessary. 

While I believe that it is great that the Board made an effort to update the sedation regulations and I know a substantial effort has been put into this process over the past 2 years, I believe that the rapid addition of new substantial changes that were introduced in December of 2020 and placed in the final regulation published in the registrar was done hurriedly and without full opportunity to allow public input of the change.  This is especially true since the change made to 18VAC60-21-291 A.1 allows certified registered nurse anesthetists (CRNAs) to practice under non-permitted dentists may have broad implications.

As you will see the motion to make this addition was proposed on December 11^th 2020, as a virtual meeting and is yet to have its meeting’s minutes formally approved. Dr. Dawson put forward the recommendation that CRNAs be allowed to administer sedation under non-permitted dentists, and the motion was seconded and approved. Prior to this, the language to change the delegation to sedation and anesthesia administration was not discussed.  Instead, there was a public comment by the Virginia Association of Nurse Anesthetists putting forth the assertation the Board of Dentistry was showing favoritism to physician anesthesiologists over nurse anesthetists as they require dentists to have a sedation or anesthesia permit in order to delegate administration of such services to a CRNA, whereas a physician anesthesiologist may provide such services under their own medical license independently of the dentist. 

The Dental Board, at the December 11^th meeting, also reviewed the practices of the CRNA in an outpatient surgery center versus a dental office setting.  The concern here is that CRNAs practice under the anesthesia director / medical director in an outpatient surgery center, under which anesthesia protocols are developed and established by those with knowledge of sedation and anesthesia.  This is in addition to the fact that a CRNA under 18VAC90-30-121 may “render care under the supervision of a licensed doctor of medicine, osteopathy, podiatry, or dentistry.” The reason a direct comparison of the dental office setting, and the outpatient surgery center settings is not directly comparable, is that at the surgical center the medical director and / or anesthesiologists supervise the CRNA; however, with the new proposal a dentist, who may have little or no training in the delivery of sedation and anesthesia to that level, may be “supervising” the rendering of care in the dental office.

Furthermore, 18VAC60-21-291 B requires that the dentist ensure that all equipment for sedation and anesthesia be maintained in working order. However, a non-permitted sedation dentist may have little or no experience with said equipment, yet is regulated to ensure such and supervise the CRNA.

Additionally, in 2014, the Virginia Board of Dentistry announced that they would begin unannounced inspection of dental offices providing sedation and anesthesia “in keeping with the state’s interest in promoting a culture of compliance.” It has also been the Board’s position that such inspections are mandated to occur for all non OMFS offices (which self-inspect through VSOMS) by the employees of the Department of Health Professions under §54.1-2703. However, by allowing non-permitted dentists to provide such services, these dental offices are not identified and therefore are unlikely to have random, unannounced inspections “promoting a culture of compliance.” The Virginia Dental Board has stated that it does not have jurisdiction over physician anesthesiologists or CRNAs, as this would be under the watch of the Board of Medicine and the Board of Nursing, respectively. However, §54.1-2703 does not state that the dentist must be inspected, but that employees of the Department of Health Professions shall be authorized to inspect dental offices and dental laboratories. Therefore, it seems logical that the dental offices using the services of physician anesthesiologists and CRNAs should file for some sort of permit or advise the Board of the locations where sedation and anesthesia are rendered as is required by the dentist anesthesiologist.

Returning to the idea that the Virginia Association of Nurse Anesthetists forwarded – that the Board was unfairly restricting the ability of CRNAs to provide care as compared to the physician anesthesiologist, I would assert that the regulation similarly disadvantages dentists.  The regulation has, in effect, set up a system where CRNAs and physician anesthesiologists could practice in dental offices without the inspection requirements that are placed on dentists.

Lastly, there may be legal ramifications outside of the scope of dentistry for these regulatory changes.  CRNAs have long wanted to practice independently in dental offices as stated in their 2017 “Dental Office Sedation and Anesthesia Care: Position Statement” (available at https://www.aana.com/docs/default-source/practice-aana-com-web-documents-(all)/professional-practice-manual/dental-office-sedation-and-anesthesia-care.pdf?sfvrsn=ab0049b1_6). Across the country, CRNAs have been gaining the ability to practice independently without the supervision of the anesthesiologist. However, Virginia is not such a state.  While I neither agree nor disagree with this legal position and the independence of CRNAs, I do not believe that dental regulations should be a way of allowing such independence by saying a dentist without expertise in sedation and anesthesia should supervise the CRNA, in essence granting them largely independent practice – since one cannot truly supervise that which one is not educated in.

I understand that the amendments to 18VAC60-21-10, 18VAC60-21-260 through 18VAC60-21-301 are published in the registrar as final and will not change; I believe that the public record should note such concerns for future changes to the regulations.

Dr. Wong has provided excellent  points and I cannot agree more.  Taking one step forward and two steps back should not be the philosophy of the BOD.  To me liability is a key issue.  To have an anesthesia provider, whether it be a CRNA or an Anesthesiologist, be the only person trained in a Dental office is a set up for disaster.  Moderate sedation can progress to deep sedation very quickly and if an airway situation presents who is going to assist the anesthesia provider if the Dentist has no training.  No one can do this by themselves safely.  I am tired of reading about a bad outcome from anesthesia being provided in a Dental office by people who are not trained.  It reflects badly on the profession. 

I agree with and appreciate prior comments/concerns by Dr.'s Wong and Padgett. Truly concerning for patient care. There has most recently been a pediatric dental death in SW Virginia in which a child was treated by an anesthesiologist in a dental practice setting. Regardless of the situation, we never want a poor outcome, let alone a catastrophic event. Aside from the lack of training a dental office has with anesthesia training and continual need for CE to include BLS, ACLS and PALS (if applicable), the ancillary staff is not and will not be adequately trained to appropriately respond to situations which require immediate attention to mitigate a catastrophic event or to optimally treat an event that is catastrophic. We in the healthcare model are here to "do no harm"... Although I want to believe while the reasons behind why the CRNA wants to provide a deeper level of anesthesia to a phobic dental patient is to put their fears at ease in theory is a good omen, in practice this is not a "BEST PRACTICE" situation nor environment and I would not support this model. Appropriate training, i.e. OMFS model, or an appropriate out-patient or hospital setting would be best for a team approach.