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SB-501 Dentistry: anesthesia and sedation: report.(2017-2018)

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Date Published: 04/20/2017 09:00 PM
SB501:v97#DOCUMENT

Amended  IN  Senate  April 20, 2017
Amended  IN  Senate  April 17, 2017

CALIFORNIA LEGISLATURE— 2017–2018 REGULAR SESSION

Senate Bill No. 501


Introduced by Senator Glazer

February 16, 2017


An act to amend Sections 1601.4, 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 of, to amend the heading of Article 2.7 (commencing with Section 1646) of Chapter 4 of Division 2 of, to add Sections 1601.7 and 1616.1 to, and 1601.7, 1616.1, 1646.6.5, and 1647.8.5 to, to add Article 2.87 (commencing with Section 1647.30) to Chapter 4 of Division 2 of, and to repeal Article 2.85 (commencing with Section 1647.10) and Article 2.86 (commencing with Section 1647.18) of Chapter 4 of Division 2 of, the Business and Professions Code, relating to dentistry.


LEGISLATIVE COUNSEL'S DIGEST


SB 501, as amended, Glazer. Dentistry: anesthesia and sedation: report.
The Dental Practice Act provides for the licensure and regulation of dentists by the Dental Board of California 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 repeal those provisions relating to the use of oral concious sedation for pediatric and adult patients. The 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 dentists, beginning January 1, 2019, 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 7 years of age. The bill also would require dentists dentists, beginning January 1, 2019, to have completed at least 20 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 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 at least 3 people to be present during procedures on children under 7 years of age and would require the dentist and other attendees to hold specified certifications and 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” with “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 authorize a dentist to administer or order the administration of moderate sedation on an outpatient basis to a dental patient unless if 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. specify that a pediatric endorsement requires a dentist to obtain specified training. The bill also would require for a child under 7 years of age that there be at least 2 support staff persons in addition to the practicing dentist at all times during the procedure, with one staff 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 conduct an interval update a review of pediatric morbidity and mortality data, as provided, for the purpose of obtaining high-quality pediatric sedation and anesthesia-related data.
This bill, on or before January 1, 2019, would require the board to provide to the Legislature a report and analysis, as specified, of the effects on access to care for pediatric dental patients specifically as it relates to requiring the addition of a 2nd general anesthesia permitholder to be present during the administration of general anesthesia on a patient 7 years of age or younger, if the provider is currently a general anesthesia permitholder.
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 1601.4 of the Business and Professions Code is amended to read:

(a)On or before January 1, 2017, the board shall provide to the Legislature a report on whether current statutes and regulations for the administration and monitoring of pediatric anesthesia in dentistry provide adequate protection for pediatric dental patients. The report shall be submitted in compliance with Section 9795 of the Government Code. The requirement for submitting a report imposed by this subdivision is inoperative on December 1, 2021, pursuant to Section 10231.5 of the Government Code. The board shall make the report publicly available on the board’s Internet Web site.

1601.4.
 (b)The board shall provide a report on pediatric deaths related to general anesthesia and deep sedation in dentistry at the time of its sunset review pursuant to subdivision (d) of Section 1601.1.

SECTION 1.SEC. 2.

 Section 1601.7 is added to the Business and Professions Code, to read:

1601.7.
 (a) On or before January 1, 2019, the board shall provide to the Legislature a report and analysis of the effects on access to care for pediatric dental patients specifically as it relates to requiring the addition of a second general anesthesia permitholder to be present during the administration of general anesthesia on a patient seven years of age or younger, if the provider is currently a general anesthesia permitholder. The analysis should include costs of sedation and anesthesia, resource constraints of the health care system, including Denti-Cal compared to private insurance, and feasibility issues that include, but are not limited to, time, skills, staff availability, and equipment availability for the provider to carry out necessary dental procedures. The board shall make the report publicly available on the board’s Internet Web site.
(b) (1) A report to be submitted pursuant to subdivision (a) shall be submitted in compliance with Section 9795 of the Government Code.
(2) Pursuant to Section 10231.5 of the Government Code, this section is repealed on January 1, 2023.

SEC. 2.SEC. 3.

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

1616.1.
 On or before January 1, 2019, the board shall conduct an interval update a review of pediatric morbidity and mortality data from the end of the review authorized by Section 1601.4 until January 1, 2019, beginning January 1, 2017, 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. 3.SEC. 4.

 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. 4.SEC. 5.

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

1646.
 As used in this article, the following definitions 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 pressureventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.

SEC. 5.SEC. 6.

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

1646.1.
 (a) A dentist shall not must possess either a general anesthesia permit issued by the board or a permit under Section 1638 or 1640 and a general anesthesia permit issued by the board in order to 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. patients.
(b) A dentist shall not must possess a pediatric endorsement for the general anesthesia permit to administer or order the administration of deep sedation or general anesthesia to patients under seven 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 six years of age or younger. age.

(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)Beginning January 1, 2019, 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 seven years of age. For patients under seven years of age, the applicant shall provide proof of completion of at least 20 cases to establish competency, both at the time of initial application and at renewal.

(c) A dentist must be physically within the dental office at the time of ordering, and during the administration of, general anesthesia or deep sedation.
(d) For patients seven to 13 years of age, inclusive, the dentist and at least two support staff shall be present for the procedure involving general anesthesia or deep sedation. The dentist shall be currently certified in Pediatric Advanced Life Support (PALS) and at least one support staff member shall be trained in pediatric life support 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.
(e) For children under seven years of age, there shall be at least three people present during the procedure involving general anesthesia or deep sedation, including the dentist. One person present shall be solely dedicated to monitoring the patient and shall be trained in pediatric life support and airway management, equivalent to the AAP-AAPD Guidelines or as determined by the board. The second person shall also be trained in pediatric life support and airway management, equivalent to the AAP-AAPD Guidelines or as determined by the board, and may assist in the procedure as needed. If a dedicated anesthesia provider is utilized, that person shall be a general anesthesia permitholder with a current pediatric endorsement and shall be certified in ACLS and PALS.
(f) This article does not apply to the administration of local anesthesia, minimal sedation, or moderate sedation.

SEC. 6.SEC. 7.

 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.
(c) Beginning January 1, 2019, a dentist may apply for a pediatric endorsement for the general anesthesia permit by:
(1) Providing proof of successful completion of a Commission on Dental Accreditation (CODA) accredited or equivalent residency training program that provides competency in the administration of deep sedation and general anesthesia on children under seven years of age.
(2) Providing proof of successful completion of at least 20 cases of pediatric sedation to patients under seven years of age to establish competency, both at the time of initial application and at renewal.
(3) Providing evidence of current and continuous certification in Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS) for the duration of holding the permit.
(d) Initial applicants for a pediatric endorsement who otherwise qualify for the pediatric endorsement but lack sufficient cases of pediatric sedation to patients under age seven years of age shall be allowed to provide deep sedation and general anesthesia on patients under seven years of age under the direct supervision of a general anesthesia permitholder with a pediatric endorsement. The applicant may count these cases toward the 20 necessary in order to qualify for the applicant’s pediatric endorsement.

SEC. 7.SEC. 8.

 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
(b) Any dentist holding a permit shall maintain medical history, physical evaluation, and deep sedation deep sedation, and general anesthesia records as required by board regulations.

(b)For patients seven to 13 years of age, inclusive, the dentist and at least two support staff shall be present. The dentist shall be currently certified in Pediatric Advanced Life Support (PALS) and at least one support staff member shall be trained in pediatric life support 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 at least three people present during the procedure, including the dentist and at least two support staff. The dentist shall be a general anaesthesia permitholder with a current pediatric endorsement and shall be currently certified in Advanced Cardiac Life Supports (ACLS) and Pediatric Advanced Life Support (PALS). One person present shall be an anesthesia support staff, dedicated to the anesthesia process, and shall be trained in pediatric life support and airway management, equivalent to the AAP-AAPD Guidelines or as determined by the board. One person present shall also be trained in pediatric life support and airway management, equivalent to the AAP-AAPD Guidelines or as determined by the board, and may assist in the procedure as needed. When a dedicated anesthesia provider is utilized, in addition to the operating dentist, both the dentist and at least one staff member shall be trained in pediatric life support and airway management, equivalent to the AAP-AAPD Guidelines or as determined by the board. The dedicated anesthesia provider shall be a general anesthesia permitholder with a current pediatric endorsement and shall be certified in ACLS and PALS.

SEC. 8.SEC. 9.

 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. 9.SEC. 10.

 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. 11.

 Section 1646.6.5 is added to the Business and Professions Code, to read:

1646.6.5.
 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.

SEC. 10.SEC. 12.

 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. 11.SEC. 13.

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

1646.9.
 (a) Notwithstanding any other provision of 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. 2079, and provides competency in the administration of deep sedation and general anesthesia on children under seven years of age. The applicant shall show proof of successful completion of at least 20 cases of pediatric sedation to patients under seven years of age to establish competency, both at the time of initial application and at renewal.
(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.
(E) Evidence of current and continuous certification in Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS) for the duration of holding the permit.
(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 five years. Refusal to submit to an inspection shall result in automatic denial or revocation of the permit.

SEC. 12.SEC. 14.

 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. 13.SEC. 15.

 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 patients or patients with intellectual disabilities individual, disabilities, incapable of the usually expected verbal response, a minimally depressed level of consciousness for that individual patient should be maintained.

SEC. 14.SEC. 16.

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

1647.2.
 (a) A dentist shall not may administer or order the administration of moderate sedation on an outpatient basis for a dental patient unless if 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.

(1) The dentist either holds a valid general anesthesia permit or obtains a moderate sedation permit.
(2) The dentist possesses a current permit under Section 1638 or 1640 and either holds a valid general anesthesia permit or obtains a moderate sedation permit.
(b) A dentist must obtain a pediatric endorsement on the moderate sedation permit prior to performing moderate sedation on a patient under 13 years of age.
(c) A dentist who orders the administration of moderate sedation shall be physically present in the treatment facility while the patient is sedated.
(d) For patients seven to 13 years of age, inclusive, there shall be at least one support staff in addition to the dentist present at all times during the procedure involving moderate sedation. That staff member shall be trained in pediatric life support and airway management, equivalent to the AAP-AAPD Guidelines or as determined by the board.
(e) For a patient under seven years of age, there shall be at least two support staff persons, in addition to the dentist, present at all times during the procedure involving moderate sedation. One staff member shall be solely dedicated to monitoring the patient, and shall be trained in pediatric life support and airway management, equivalent to the AAP-AAPD Guidelines or as determined by the board.

(d)

(f) This article shall not apply to the administration of local anesthesia, minimal sedation, deep sedation, or general anesthesia.

SEC. 15.SEC. 17.

 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:

(d) A pediatric endorsement requires the dentist to 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, and successful completion of 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 20 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 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.

SEC. 16.SEC. 18.

 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. 17.SEC. 19.

 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. 18.SEC. 20.

 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. 21.

 Section 1647.8.5 is added to the Business and Professions Code, to read:

1647.8.5.
 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.

SEC. 22.

 Article 2.85 (commencing with Section 1647.10) of Chapter 4 of Division 2 of the Business and Professions Code is repealed.

SEC. 23.

 Article 2.86 (commencing with Section 1647.18) of Chapter 4 of Division 2 of the Business and Professions Code is repealed.

SEC. 19.SEC. 24.

 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 may administer or order the administration of minimal sedation on an outpatient basis for pediatric dental patients, defined as patients under 13 years of age, unless if 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.

(1) The dentist holds a valid pediatric minimal sedation permit.
(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, 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 pediatric 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 pediatric 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 minimal sedation instruction in addition to one clinical case. The pediatric minimal 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. 20.SEC. 25.

 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.