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AB-224 Dentistry: anesthesia and sedation.(2017-2018)

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Date Published: 05/17/2017 09:00 PM
AB224:v95#DOCUMENT

Amended  IN  Assembly  May 17, 2017
Amended  IN  Assembly  May 02, 2017
Amended  IN  Assembly  April 20, 2017
Amended  IN  Assembly  March 27, 2017

CALIFORNIA LEGISLATURE— 2017–2018 REGULAR SESSION

Assembly Bill No. 224


Introduced by Assembly Member Thurmond

January 26, 2017


An act to amend Sections 1646, 1646.1, 1646.2, 1646.3, 1646.4, 1646.5, 1646.8, 1646.9, 1647, 1647.1, 1647.2, 1647.3, 1647.5, 1647.6, and 1647.7 1647.7, 1647.11, 1647.12, 1647.19, 1682, 1724, and 1750.5 of, to amend the heading of Article 2.7 (commencing with Section 1646) and Article 2.8 (commencing with Section 1647) of Chapter 4 of Division 2 of, to add Section 1616.1 to, and to add Article 2.87 (commencing with Section 1647.30) to Chapter 4 of Division 2 of, the Business and Professions Code, relating to dentistry.


LEGISLATIVE COUNSEL'S DIGEST


AB 224, as amended, Thurmond. Dentistry: anesthesia and sedation.
The Dental Practice Act provides for the licensure and regulation of dentists by the Dental Board of California, which is within the Department of Consumer Affairs. The act governs the use of general anesthesia, conscious sedation, and oral conscious sedation for pediatric and adult patients. The act makes it unprofessional conduct for a dentist to engage in certain conduct, including failing to obtain written consent prior to administering general anesthesia or conscious sedation. The act also makes a willful violation of its provisions, including practicing without a valid certificate or license, a crime, and defines various terms relating to anesthesia and sedation.
This bill would redefine general anesthesia for these purposes and additionally would define “deep sedation” to mean a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation, as specified.
The Dental Practice Act prohibits a dentist from administering or ordering the administration of general anesthesia on an outpatient basis for dental patients unless the dentist meets certain licensing criteria.
This bill would extend that licensing criteria to dentists administering deep sedation. The bill would require dentists to have a pediatric endorsement of their general anesthesia permit and have completed a Commission on Dental Accreditation accredited or equivalent residency training program providing competency in the administration of deep sedation or general anesthesia to be eligible to administer these drugs to patients under 13 years of age. The bill also would require dentists to have completed at least 52 cases to establish competency for patients under 7 years of age, and would require dentists to perform a physical evaluation and a medical history before administering deep sedation or general anesthesia. The bill would further require that, for any procedure involving deep sedation or general anesthesia for patients between 7 and 13 years of age, the dentist and at least 2 support staff be present, except as specified, and would require the dentist and at least one support staff to have certain advanced life support and airway management training, as specified. The bill also would require an operating dentist, a dental sedation assistant permitholder, an assistant, and a dedicated monitor, as defined, to be present during procedures on children under 7 years of age, and would require all of the persons present during the procedure to the dedicated monitor to have certain advanced life support and airway management training, as specified.
The Dental Practice Act prohibits a dentist from administering or ordering the administration of conscious sedation, as defined, on an outpatient basis unless the dentist meets certain licensing criteria.
This bill would replace the term conscious sedation “conscious sedation with moderate sedation, “moderate sedation, meaning a drug-induced depression of consciousness during which a patient responds purposefully to verbal commands and meets other criteria. The bill would prohibit a dentist from administering or ordering the administration of moderate sedation on an outpatient basis to a dental patient unless the dentist meets specified licensing criteria and has applied to the board, submitted an application fee, and shown successful completion of training in moderate sedation. The bill would require a dentist who orders the administration of moderate sedation to be physically present in the treatment facility while the patient is sedated. The bill would specify that training in the administration of moderate sedation for patients 13 years of age or older is acceptable if it consists of a certain number of instructional hours and completion of cases and complies with certain guidelines for teaching pain control and sedation. The bill would require a dentist, prior to performing any procedure involving moderate sedation of a patient under 13 years of age, to obtain a pediatric endorsement, requiring a specified number of didactic instruction and clinical cases as well as advanced life support and airway management training. The bill also would require an operating dentist, a dental sedation assistant permitholder, and a dedicated monitor, as defined, to be present during a procedure on children for a child under 7 years of age, and would require all of the persons present during the procedure to have certain advanced life support and airway management training, as specified. age that there be at least 2 support staff persons in addition to the practicing dentist present at all times during the procedure, with one staff person member serving as a dedicated patient monitor.
The bill also would establish new requirements for dentists administering or ordering the administration of minimal sedation, defined as a drug-induced state during which patients respond normally to verbal commands, as specified, for pediatric patients under 13 years of age. These new requirements would include that the dentist possess specified licensing credentials, and would require any dentist who desires to administer or order the administration of minimal sedation to apply to the board, as specified, and to submit an application fee. The bill would make a violation of these provisions governing minimal sedation unprofessional conduct, constituting grounds for the revocation or suspension of the dentist’s permit or other forms of reprimand. Additionally, by expanding the scope of an existing crime for violations of the Dental Practice Act, the bill would impose a state-mandated local program. This bill also would authorize the board to contract with a nonprofit research organization for the purpose of obtaining high-quality pediatric sedation and anesthesia-related data.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that no reimbursement is required by this act for a specified reason.
Vote: MAJORITY   Appropriation: NO   Fiscal Committee: YES   Local Program: YES  

The people of the State of California do enact as follows:


SECTION 1.

 Section 1616.1 is added to the Business and Professions Code, to read:

1616.1.
 On or before January 1, 2019, the board shall contract with a nonprofit research organization for the purpose of obtaining high-quality data about outcomes and complications related to pediatric dental sedation and anesthesia. It is the intent of this section that the collection of data shall lead to further quality improvement and safety.

SEC. 2.

 The heading of Article 2.7 (commencing with Section 1646) of Chapter 4 of Division 2 of the Business and Professions Code is amended to read:
Article  2.7. Use of Deep Sedation and General Anesthesia

SEC. 3.

 Section 1646 of the Business and Professions Code is amended to read:

1646.
 As used in this article, the following definitions shall apply:
(a) “Deep sedation” means 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.
(b) “General anesthesia” means 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.

SEC. 4.

 Section 1646.1 of the Business and Professions Code is amended to read:

1646.1.
 (a) A dentist shall not administer or order the administration of deep sedation or general anesthesia on an outpatient basis for dental patients unless the dentist either possesses a current license in good standing to practice dentistry in this state and holds a valid general anesthesia permit issued by the board or possesses a current permit under Section 1638 or 1640 and holds a valid general anesthesia permit issued by the board.
(b) A dentist shall not administer or order the administration of deep sedation or general anesthesia to patients under 13 years of age unless that dentist holds a pediatric endorsement for the general anesthesia permit, as required by the board, allowing the administration of deep sedation or general anesthesia for patients 12 years of age or younger.
(c) A dentist shall not order the administration of general anesthesia unless the dentist is physically within the dental office at the time of the administration.
(d) A general anesthesia permit shall expire on the date provided in Section 1715 that next occurs after its issuance, unless it is renewed as provided in this article.
(e) The dentist shall have completed a Commission on Dental Accreditation (CODA) accredited or equivalent residency training program that provides competency in the administration of deep sedation and general anesthesia in order to be eligible to perform deep sedation or general anesthesia on children under 13 years of age. For patients under seven years of age, the applicant shall provide proof of completion of at least 52 cases to establish competency, both at the time of initial application and at renewal.
(f) This article does not apply to the administration of local anesthesia, minimal sedation, or moderate sedation.

SEC. 5.

 Section 1646.2 of the Business and Professions Code is amended to read:

1646.2.
 (a) A dentist who desires to administer or order the administration of deep sedation or general anesthesia shall apply to the board on an application form prescribed by the board. The dentist must submit an application fee and produce evidence showing that he or she has successfully completed a minimum of one year of advanced training in anesthesiology and related academic subjects approved by the board, or equivalent training or experience approved by the board, beyond the undergraduate school level.
(b) The application for a permit shall include documentation that equipment and drugs required by the board are on the premises.

SEC. 6.

 Section 1646.3 of the Business and Professions Code is amended to read:

1646.3.
 (a) A physical evaluation and medical history shall be taken before the administration of deep sedation or general anesthesia. Any dentist holding a permit shall maintain medical history, physical evaluation, and deep sedation and general anesthesia records as required by board regulations.
(b) For patients 7 to 13 years of age, inclusive, the dentist and at least two support staff shall be present, unless there is a dedicated general anesthesia provider present. The dentist and at least one support staff member shall be trained in Pediatric Advanced Life Support (PALS) and airway management, equivalent to the American Academy of Pediatrics and American Academy of Pediatric Dentistry (AAP-AAPD) Guidelines or as determined by the board. That staff member shall be dedicated to monitoring the patient throughout the procedure.
(c) For children under seven years of age, there shall be present during the procedure all of the following:
(1) An operating dentist. Both the dentist and at least one staff member shall be trained in PALS and airway management, equivalent to the AAP-AAPD Guidelines or as determined by the board.

(2)A dental sedation assistant permitholder that is trained in PALS and airway management, equivalent to the AAP-AAPD Guidelines or as determined by the board.

(2) An assistant.
(3) A dedicated monitor. For purposes of this paragraph, “dedicated monitor” means a surgeon, dental sedation assistant permitholder, general anesthesia permitholder, or a nurse anesthetist directly supervised by a general anesthesia permitholder. The dedicated monitor shall be solely dedicated to administering anesthesia, monitoring the patient, and managing the airway through recovery. person licensed under Division 2 of this code whose license authorizes the person to monitor the patient’s airway through recovery. The dedicated monitor shall be trained in PALS and airway management, equivalent to the AAP-AAPD Guidelines or as determined by the board.

SEC. 7.

 Section 1646.4 of the Business and Professions Code is amended to read:

1646.4.
 (a) Prior to the issuance or renewal of a permit for the use of deep sedation or general anesthesia, the board may, at its discretion, require an onsite inspection and evaluation of the licentiate and the facility, equipment, personnel, and procedures utilized by the licentiate. The permit of any dentist who has failed an onsite inspection and evaluation shall be automatically suspended 30 days after the date on which the board notifies the dentist of the failure, unless within that time period the dentist has retaken and passed an onsite inspection and evaluation. Every dentist issued a permit under this article shall have an onsite inspection and evaluation at least once every five years. Refusal to submit to an inspection shall result in automatic denial or revocation of the permit.
(b) The board may contract with public or private organizations or individuals expert in dental outpatient general anesthesia to perform onsite inspections and evaluations. The board may not, however, delegate its authority to issue permits or to determine the persons or facilities to be inspected.

SEC. 8.

 Section 1646.5 of the Business and Professions Code is amended to read:

1646.5.
 A permittee shall be required to complete 24 hours of approved courses of study related to deep sedation or general anesthesia as a condition of renewal of a permit. Those courses of study shall be credited toward any continuing education required by the board pursuant to Section 1645.

SEC. 9.

 Section 1646.8 of the Business and Professions Code is amended to read:

1646.8.
 Nothing in this chapter shall be construed to authorize a dentist to administer or directly supervise the administration of general anesthesia or deep sedation for reasons other than dental treatment, as defined in Section 1625.

SEC. 10.

 Section 1646.9 of the Business and Professions Code is amended to read:

1646.9.
 (a) Notwithstanding any other law, including, but not limited to, Section 1646.1, a physician and surgeon licensed pursuant to Chapter 5 (commencing with Section 2000) may administer deep sedation or general anesthesia in the office of a licensed dentist for dental patients, without regard to whether the dentist possesses a permit issued pursuant to this article, if both of the following conditions are met:
(1) The physician and surgeon possesses a current license in good standing to practice medicine in this state.
(2) The physician and surgeon holds a valid general anesthesia permit issued by the Dental Board of California pursuant to subdivision (b).
(b) (1) A physician and surgeon who desires to administer deep sedation or general anesthesia as set forth in subdivision (a) shall apply to the Dental Board of California on an application form prescribed by the board and shall submit all of the following:
(A) The payment of an application fee prescribed by this article.
(B) Evidence satisfactory to the Medical Board of California showing that the applicant has successfully completed a postgraduate residency training program in anesthesiology that is recognized by the American Council on Graduate Medical Education, as set forth in Section 2079.
(C) Documentation demonstrating that all equipment and drugs required by the Dental Board of California are possessed by the applicant and shall be available for use in any dental office in which he or she administers deep sedation or general anesthesia.
(D) Information relative to the current membership of the applicant on hospital medical staffs.
(2) Prior to issuance or renewal of a permit pursuant to this section, the Dental Board of California may, at its discretion, require an onsite inspection and evaluation of the facility, equipment, personnel, including, but not limited to, the physician and surgeon, and procedures utilized. At least one of the persons evaluating the procedures utilized by the physician and surgeon shall be a licensed physician and surgeon expert in outpatient deep sedation or general anesthesia who has been authorized or retained under contract by the Dental Board of California for this purpose.
(3) The permit of a physician and surgeon who has failed an onsite inspection and evaluation shall be automatically suspended 30 days after the date on which the board notifies the physician and surgeon of the failure unless within that time period the physician and surgeon has retaken and passed an onsite inspection and evaluation. Every physician and surgeon issued a permit under this article shall have an onsite inspection and evaluation at least once every six years. Refusal to submit to an inspection shall result in automatic denial or revocation of the permit.

SEC. 11.

 The heading of Article 2.8 (commencing with Section 1647) of Chapter 4 of Division 2 of the Business and Professions Code is amended to read:
Article  2.8. Use of Conscious Moderate Sedation

SEC. 11.SEC. 12.

 Section 1647 of the Business and Professions Code is amended to read:

1647.
 (a) The Legislature finds and declares that a commendable patient safety record has been maintained in the past by dentists and those other qualified providers of anesthesia services who, pursuant to a dentist’s authorization, administer patient sedation, and that the increasing number of pharmaceuticals and techniques used to administer them for patient sedation require additional regulation to maintain patient safety in the future.
(b) The Legislature further finds and declares all of the following:
(1) That previous laws enacted in 1980 contained separate and distinct definitions for general anesthesia and the state of consciousness.
(2) That in dental practice, there is a continuum of sedation used which cannot be adequately defined in terms of consciousness and general anesthesia.
(3) That the administration of sedation through this continuum results in different states of consciousness that may or may not be predictable in every instance.
(4) That in most instances, the level of sedation will result in a predictable level of consciousness during the entire time of sedation.
(c) The Legislature further finds and declares that the educational standards presently required for deep sedation and general anesthesia should be required when the degree of sedation in the continuum of sedation is such that there is a reasonable possibility that loss of consciousness may result, even if unintended. However, achieving the degree of moderate sedation, previously referred to as “conscious sedation,” where a margin of safety exists wide enough to render unintended loss of consciousness unlikely, requires educational standards appropriate to the administration of the resulting predictable level of consciousness.

SEC. 12.SEC. 13.

 Section 1647.1 of the Business and Professions Code is amended to read:

1647.1.
 (a) As used in this article, “moderate sedation” means a drug-induced depression of consciousness during which a patient responds purposefully to verbal commands, either alone or accompanied by light tactile stimulation, no interventions are required to maintain a patient’s airway, spontaneous ventilation is adequate, and cardiovascular function is usually maintained.
(b) The drugs and techniques used in moderate sedation shall have a margin of safety wide enough to render unintended loss of consciousness unlikely. Further, patients whose only response is reflex withdrawal from painful stimuli shall not be considered to be in a state of moderate sedation.
(c) For the very young or patients with intellectual disabilities, incapable of the usually expected verbal response, a minimally depressed level of consciousness for that individual should be maintained.

SEC. 13.SEC. 14.

 Section 1647.2 of the Business and Professions Code is amended to read:

1647.2.
 (a) A dentist shall not administer or order the administration of moderate sedation on an outpatient basis for a dental patient unless one of the following conditions is met:
(1) The dentist possesses a current license in good standing to practice dentistry in California and either holds a valid general anesthesia permit or obtains a permit issued by the board authorizing the dentist to administer moderate sedation.
(2) The dentist possesses a current permit under Section 1638 or 1640 and either holds a valid general anesthesia permit or obtains a permit issued by the board authorizing the dentist to administer moderate sedation.
(b) A moderate sedation permit shall expire on the date specified in Section 1715 that next occurs after its issuance, unless it is renewed as provided in this article.
(c) A dentist who orders the administration of moderate sedation shall be physically present in the treatment facility while the patient is sedated.
(d) This article shall not apply to the administration of local anesthesia, minimal sedation, deep sedation, or general anesthesia.

SEC. 14.SEC. 15.

 Section 1647.3 of the Business and Professions Code is amended to read:

1647.3.
 (a) A dentist who desires to administer or to order the administration of moderate sedation shall apply to the board on an application form prescribed by the board. The dentist shall submit an application fee and produce evidence showing that he or she has successfully completed training in moderate sedation that meets the requirements of subdivision (c).
(b) The application for a permit shall include documentation that equipment and drugs required by the board are on the premises.
(c) Training in the administration of moderate sedation for patients 13 years of age or older shall be acceptable if it meets all of the following as approved by the board:
(1) Consists of at least 60 hours of instruction.
(2) Requires satisfactory completion of at least 20 cases of administration of moderate sedation for a variety of dental procedures.
(3) Complies with the requirements of the Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students of the American Dental Association, including, but not limited to, certification of competence in rescuing patients from a deeper level of sedation than intended, and managing the airway, intravascular or intraosseous access, and reversal medications.
(d) Before performing any procedure involving moderate sedation of a patient under 13 years of age, the dentist shall obtain a pediatric endorsement of his or her moderate sedation permit. To be eligible for the pediatric moderate sedation permit, the dentist shall have completed any of the following:
(1) A moderate sedation course consisting of at least 60 hours of didactic instruction and at least 20 clinical cases, as described in subdivision (c), but that is directed at treating pediatric patients under 13 years of age.
(2) A moderate sedation course, as described in subdivision (c), that is directed at treating patients 13 years of age or older, in addition to at least 24 hours of didactic instruction in pediatric moderate sedation and at least 10 clinical cases in pediatric moderate sedation.
(3) A moderate sedation course that is directed at treating patients 13 years of age or older, as described in subdivision (c), in addition to completion of an accredited pediatric dental residency program. The pediatric moderate sedation permitholder shall provide proof of completion of at least 52 cases to establish competency, both at the time of the initial application and at renewal.
(e) The dentist and at least one member of the support staff shall be trained in Pediatric Advanced Life Support (PALS) and airway management, equivalent to the American Academy of Pediatrics and the American Academy of Pediatric Dentistry (AAP-AAPD) Guidelines, or as determined by the board.
(f) For a child under seven years of age, there shall be present during the procedure all of the following: at least two support staff persons, in addition to the practicing dentist, present at all times during the procedure. One staff member shall serve as a dedicated patient monitor.

(1)An operating dentist. Both the dentist and at least one staff member shall be trained in PALS and airway management, equivalent to the AAP-AAPD Guidelines or as determined by the board.

(2)A dental sedation assistant permitholder that is trained in PALS and airway management, equivalent to the AAP-AAPD Guidelines or as determined by the board.

(3)A dedicated monitor. For purposes of this paragraph, “dedicated monitor” means a surgeon, dental sedation assistant permitholder, general anesthesia permitholder, or a nurse anesthetist directly supervised by a general anesthesia permitholder. The dedicated monitor shall be solely dedicated to administering anesthesia, monitoring the patient, and managing the airway through recovery. The dedicated monitor shall be trained in PALS and airway management, equivalent to the AAP-AAPD Guidelines or as determined by the board.

SEC. 15.SEC. 16.

 Section 1647.5 of the Business and Professions Code is amended to read:

1647.5.
 A permittee shall be required to complete 15 hours of approved courses of study related to moderate sedation as a condition of renewal of a permit. Those courses of study shall be credited toward any continuing education required by the board pursuant to Section 1645.

SEC. 16.SEC. 17.

 Section 1647.6 of the Business and Professions Code is amended to read:

1647.6.
 A physical evaluation and medical history shall be taken before the administration of moderate sedation. Any dentist holding a permit shall maintain records of the physical evaluation, medical history, and moderate sedation procedures used as required by board regulations.

SEC. 17.SEC. 18.

 Section 1647.7 of the Business and Professions Code is amended to read:

1647.7.
 (a) Prior to the issuance or renewal of a permit to administer moderate sedation, the board may, at its discretion, require an onsite inspection and evaluation of the licentiate and the facility, equipment, personnel, and procedures utilized by the licentiate. The permit of any dentist who has failed an onsite inspection and evaluation shall be automatically suspended 30 days after the date on which the board notifies the dentist of the failure unless, within that time period, the dentist has retaken and passed an onsite inspection and evaluation. Every dentist issued a permit under this article shall have an onsite inspection and evaluation at least once in every six years. Refusal to submit to an inspection shall result in automatic denial or revocation of the permit.
(b) An applicant who has successfully completed the course required by Section 1647.3 may be granted a one-year temporary permit by the board prior to the onsite inspection and evaluation. Failure to pass the inspection and evaluation shall result in the immediate and automatic termination of the temporary permit.
(c) The board may contract with public or private organizations or individuals expert in dental outpatient moderate sedation to perform onsite inspections and evaluations. The board may not, however, delegate its authority to issue permits or to determine the persons or facilities to be inspected.

SEC. 19.

 Section 1647.11 of the Business and Professions Code is amended to read:

1647.11.
 (a) Notwithstanding subdivision (a) of Section 1647.2, a dentist may not administer oral conscious sedation on an outpatient basis to a minor patient unless one of the following conditions is met:
(1) The dentist possesses a current license in good standing to practice dentistry in California and either holds a valid general anesthesia permit, conscious moderate sedation permit, or has been certified by the board, pursuant to Section 1647.12, to administer oral sedation to minor patients.
(2) The dentist possesses a current permit issued under Section 1638 or 1640 and either holds a valid general anesthesia permit, or conscious moderate sedation permit, or possesses a certificate as a provider of oral conscious sedation to minor patients in compliance with, and pursuant to, this article.
(b) Certification as a provider of oral conscious sedation to minor patients expires at the same time the license or permit of the dentist expires unless renewed at the same time the dentist’s license or permit is renewed after its issuance, unless certification is renewed as provided in this article.
(c) This article shall not apply to the administration of local anesthesia or a mixture of nitrous oxide and oxygen or to the administration, dispensing, or prescription of postoperative medications.

SEC. 20.

 Section 1647.12 of the Business and Professions Code is amended to read:

1647.12.
 A dentist who desires to administer, or order the administration of, oral conscious sedation for minor patients, who does not hold a general anesthesia permit, as provided in Sections 1646.1 and 1646.2, or a conscious moderate sedation permit, as provided in Sections 1647.2 and 1647.3, shall register his or her name with the board on a board-prescribed registration form. The dentist shall submit the registration fee and evidence showing that he or she satisfies any of the following requirements:
(a) Satisfactory completion of a postgraduate program in oral and maxillofacial surgery or pediatric dentistry approved by either the Commission on Dental Accreditation or a comparable organization approved by the board.
(b) Satisfactory completion of a periodontics or general practice residency or other advanced education in a general dentistry program approved by the board.
(c) Satisfactory completion of a board-approved educational program on oral medications and sedation.

SEC. 21.

 Section 1647.19 of the Business and Professions Code is amended to read:

1647.19.
 (a) Notwithstanding subdivision (a) of Section 1647.2, a dentist may not administer oral conscious sedation on an outpatient basis to an adult patient unless the dentist possesses a current license in good standing to practice dentistry in California, and one of the following conditions is met:
(1) The dentist holds a valid general anesthesia permit, holds a conscious moderate sedation permit, has been certified by the board, pursuant to Section 1647.20, to administer oral sedation to adult patients, or has been certified by the board, pursuant to Section 1647.12, to administer oral conscious sedation to minor patients.
(2) The dentist possesses a current permit issued under Section 1638 or 1640 and either holds a valid general anesthesia permit, or conscious moderate sedation permit, or possesses a certificate as a provider of oral conscious sedation to adult patients in compliance with, and pursuant to, this article.
(b) Certification as a provider of oral conscious sedation to adult patients expires at the same time the license or permit of the dentist expires unless renewed at the same time the dentist’s license or permit is renewed after its issuance, unless certification is renewed as provided in this article.
(c) This article shall not apply to the administration of local anesthesia or a mixture of nitrous oxide and oxygen, or to the administration, dispensing, or prescription of postoperative medications.

SEC. 18.SEC. 22.

 Article 2.87 (commencing with Section 1647.30) is added to Chapter 4 of Division 2 of the Business and Professions Code, to read:
Article  2.87. Use of Pediatric Minimal Sedation

1647.30.
 (a) As used in this article, “minimal sedation” means a drug-induced state during which patients respond normally to verbal commands. Cognitive function and physical coordination may be impaired, but airway reflexes, ventilatory functions, and cardiovascular functions are unaffected.
(b) The drugs and techniques used in minimal sedation shall have a margin of safety wide enough to render unintended loss of consciousness unlikely. Further, patients whose only response is reflex withdrawal from painful stimuli shall not be considered to be in a state of minimal sedation.
(c) For the very young or developmentally delayed individual, incapable of the usually expected verbal response, a minimally depressed level of consciousness should be maintained.

1647.31.
 (a) A dentist shall not administer or order the administration of minimal sedation on an outpatient basis for pediatric dental patients, defined as under 13 years of age, unless one of the following conditions is met:
(1) The dentist possesses a current license in good standing to practice dentistry in California and either holds a valid pediatric minimal sedation permit or obtains a permit issued by the board authorizing the dentist to administer minimal sedation.
(2) The dentist possesses a current permit under Section 1638 or 1640 and either holds a valid anesthesia permit or obtains a permit issued by the board authorizing the dentist to administer moderate sedation, deep sedation, or general anesthesia.
(b) A dentist who orders the administration of minimal sedation shall be physically present in the treatment facility while the patient is sedated.
(c) This article does not apply to the administration of local anesthesia, moderate sedation, deep sedation, or general anesthesia.

1647.32.
 (a) A dentist who desires to administer or order the administration of pediatric minimal sedation shall apply to the board on an application form prescribed by the board. The dentist shall submit an application fee and produce evidence showing that he or she has successfully completed training in minimal sedation that meets the requirements of subdivision (c).
(b) The application for a permit shall include documentation that equipment and drugs required by the board are on the premises.
(c) Training in the administration of minimal sedation shall be acceptable if it meets both of the following as approved by the board:
(1) Consists of at least 24 hours of pediatric sedation instruction in addition to one clinical case. The pediatric sedation instruction shall include training in airway management and patient rescue from moderate sedation.
(2) Includes completion of an accredited residency in pediatric dentistry.
(d) A dentist is limited to administering a single dose of a single drug via the oral route, plus a mix of nitrous oxide and oxygen that is unlikely to produce a state of unintended moderate sedation.
(e) A minimum of one staff member, in addition to the dentist, trained in the monitoring and resuscitation of pediatric patients shall be present.

1647.33.
 (a) The application fee for a pediatric minimal sedation permit or renewal under this article shall not exceed the amount prescribed in Section 1724.
(b) It is the intent of the Legislature that the board hire sufficient staff to administer the program and that the fees established pursuant to this section be equivalent to administration and enforcement costs incurred by the board in carrying out this article.

1647.34.
 A violation of any provision of this article constitutes unprofessional conduct and is grounds for the revocation or suspension of the dentist’s permit or license, or both, or the dentist may be reprimanded or placed on probation. The proceedings under this section shall be conducted in accordance with Chapter 5 (commencing with Section 11500) of Part 1 of Division 3 of Title 2 of the Government Code, and the board shall have all the powers granted therein.

SEC. 23.

 Section 1682 of the Business and Professions Code is amended to read:

1682.
 In addition to other acts constituting unprofessional conduct under this chapter, it is unprofessional conduct for:
(a) Any dentist performing dental procedures to have more than one patient undergoing conscious moderate sedation or general anesthesia on an outpatient basis at any given time unless each patient is being continuously monitored on a one-to-one ratio while sedated by either the dentist or another licensed health professional authorized by law to administer conscious moderate sedation or general anesthesia.
(b) Any dentist with patients recovering from conscious moderate sedation or general anesthesia to fail to have the patients closely monitored by licensed health professionals experienced in the care and resuscitation of patients recovering from conscious moderate sedation or general anesthesia. If one licensed professional is responsible for the recovery care of more than one patient at a time, all of the patients shall be physically in the same room to allow continuous visual contact with all patients and the patient to recovery staff ratio should not exceed three to one.
(c) Any dentist with patients who are undergoing conscious moderate sedation to fail to have these patients continuously monitored during the dental procedure with a pulse oximeter or similar or superior monitoring equipment required by the board.
(d) Any dentist with patients who are undergoing conscious moderate sedation to have dental office personnel directly involved with the care of those patients who are not certified in basic cardiac life support (CPR) and recertified biennially.
(e) (1) Any dentist to fail to obtain the written informed consent of a patient prior to administering general anesthesia or conscious moderate sedation. In the case of a minor, the consent shall be obtained from the child’s parent or guardian.
(2) The written informed consent, in the case of a minor, shall include, but not be limited to, the following information:
“The administration and monitoring of general anesthesia may vary depending on the type of procedure, the type of practitioner, the age and health of the patient, and the setting in which anesthesia is provided. Risks may vary with each specific situation. You are encouraged to explore all the options available for your child’s anesthesia for his or her dental treatment, and consult with your dentist or pediatrician as needed.”
(3) Nothing in this subdivision shall be construed to establish the reasonable standard of care for administering or monitoring oral conscious sedation, conscious moderate sedation, or general anesthesia.

SEC. 24.

 Section 1724 of the Business and Professions Code is amended to read:

1724.
 The amount of charges and fees for dentists licensed pursuant to this chapter shall be established by the board as is necessary for the purpose of carrying out the responsibilities required by this chapter as it relates to dentists, subject to the following limitations:
(a) The fee for an application for licensure qualifying pursuant to paragraph (1) of subdivision (c) of Section 1632 shall not exceed one thousand five hundred dollars ($1,500). The fee for an application for licensure qualifying pursuant to paragraph (2) of subdivision (c) of Section 1632 shall not exceed one thousand dollars ($1,000).
(b) The fee for an application for licensure qualifying pursuant to Section 1634.1 shall not exceed one thousand dollars ($1,000).
(c) The fee for an application for licensure qualifying pursuant to Section 1635.5 shall not exceed one thousand dollars ($1,000).
(d) The fee for an initial license and for the renewal of a license is five hundred twenty-five dollars ($525). On and after January 1, 2016, the fee for an initial license shall not exceed six hundred fifty dollars ($650), and the fee for the renewal of a license shall not exceed six hundred fifty dollars ($650). On and after January 1, 2018, the fee for an initial license shall not exceed eight hundred dollars ($800), and the fee for the renewal of a license shall not exceed eight hundred dollars ($800).
(e) The fee for an application for a special permit shall not exceed one thousand dollars ($1,000), and the renewal fee for a special permit shall not exceed six hundred dollars ($600).
(f) The delinquency fee shall be 50 percent of the renewal fee for such a license or permit in effect on the date of the renewal of the license or permit.
(g) The penalty for late registration of change of place of practice shall not exceed seventy-five dollars ($75).
(h) The fee for an application for an additional office permit shall not exceed seven hundred fifty dollars ($750), and the fee for the renewal of an additional office permit shall not exceed three hundred seventy-five dollars ($375).
(i) The fee for issuance of a replacement pocket license, replacement wall certificate, or replacement engraved certificate shall not exceed one hundred twenty-five dollars ($125).
(j) The fee for a provider of continuing education shall not exceed five hundred dollars ($500) per year.
(k) The fee for application for a referral service permit and for renewal of that permit shall not exceed twenty-five dollars ($25).
(l) The fee for application for an extramural facility permit and for the renewal of a permit shall not exceed twenty-five dollars ($25).
(m) The fee for an application for an elective facial cosmetic surgery permit shall not exceed four thousand dollars ($4,000), and the fee for the renewal of an elective facial cosmetic surgery permit shall not exceed eight hundred dollars ($800).
(n) The fee for an application for an oral and maxillofacial surgery permit shall not exceed one thousand dollars ($1,000), and the fee for the renewal of an oral and maxillofacial surgery permit shall not exceed one thousand two hundred dollars ($1,200).
(o) The fee for an application for a general anesthesia permit shall not exceed one thousand dollars ($1,000), and the fee for the renewal of a general anesthesia permit shall not exceed six hundred dollars ($600).
(p) The fee for an onsite inspection and evaluation related to a general anesthesia or conscious sedation permit shall not exceed four thousand five hundred dollars ($4,500).
(q) The fee for an application for a conscious moderate sedation permit shall not exceed one thousand dollars ($1,000), and the fee for the renewal of a conscious moderate sedation permit shall not exceed six hundred dollars ($600).
(r) The fee for an application for an oral conscious sedation permit shall not exceed one thousand dollars ($1,000), and the fee for the renewal of an oral conscious sedation permit shall not exceed six hundred dollars ($600).
(s) The fee for a certification of licensure shall not exceed one hundred twenty-five dollars ($125).
(t) The fee for an application for the law and ethics examination shall not exceed two hundred fifty dollars ($250).
The board shall report to the appropriate fiscal committees of each house of the Legislature whenever the board increases any fee pursuant to this section and shall specify the rationale and justification for that increase.

SEC. 25.

 Section 1750.5 of the Business and Professions Code is amended to read:

1750.5.
 A person holding a dental sedation assistant permit pursuant to Section 1750.4 may perform the following duties under the direct supervision of a licensed dentist or other licensed health care professional authorized to administer conscious sedation or general anesthesia in the dental office:
(a) All duties that a dental assistant is allowed to perform.
(b) Monitor patients undergoing conscious moderate sedation or general anesthesia utilizing data from noninvasive instrumentation such as pulse oximeters, electrocardiograms, capnography, blood pressure, pulse, and respiration rate monitoring devices. Evaluation of the condition of a sedated patient shall remain the responsibility of the dentist or other licensed health care professional authorized to administer conscious sedation or general anesthesia, who shall be at the patient’s chairside while conscious sedation or general anesthesia is being administered.
(c) Drug identification and draw, limited to identification of appropriate medications, ampule and vial preparation, and withdrawing drugs of correct amount as verified by the supervising licensed dentist.
(d) Add drugs, medications, and fluids to intravenous lines using a syringe, provided that a supervising licensed dentist is present at the patient’s chairside, limited to determining patency of intravenous line, selection of injection port, syringe insertion into injection port, occlusion of intravenous line and blood aspiration, line release and injection of drugs for appropriate time interval. The exception to this duty is that the initial dose of a drug or medication shall be administered by the supervising licensed dentist.
(e) Removal of intravenous lines.
(f) Any additional duties that the board may prescribe by regulation.
(g) The duties listed in subdivisions (b) to (e), inclusive, may not be performed in any setting other than a dental office or dental clinic.

SEC. 19.SEC. 26.

 No reimbursement is required by this act pursuant to Section 6 of Article XIII B of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIII B of the California Constitution.