NEW JERSEY REGISTER
VOLUME 34, NUMBER 19
MONDAY, OCTOBER 7, 2002
RULE PROPOSAL

LAW AND PUBLIC SAFETY
DIVISION OF CONSUMER AFFAIRS
NEW JERSEY STATE BOARD OF DENTISTRY
SCOPE OF PRACTICE OF LICENSED DENTAL HYGIENIST; SCOPE OF PRACTICE OF REGISTERED
DENTAL ASSISTANT; NITROUS OXIDE/OXYGEN INHALATION ANALGESIA; DUTIES OF A
LICENSED DENTIST; DELEGATION TO LICENSED DENTAL HYGIENIST AND REGISTERED DENTAL
ASSISTANT


Reproposed Amendments: N.J.A.C. 13:30-1A.2 and 2.4

Reproposed New Rule: N.J.A.C. 13:30-8.20

Authorized by: New Jersey State Board of Dentistry, Kevin B. Earle, Executive Director.

Calendar Reference: See Summary below for explanation of exception to the calendar requirements.
Authority: N.J.S.A. 45:1-15.1 and 45:6-50.
Proposal Number: PRN 2002-344.

Submit comments by: December 6, 2002 to:

Kevin B. Earle, Executive Director

New Jersey Board of Dentistry

124 Halsey Street

PO Box 45005

Newark, New Jersey 07101

The agency proposal follows:

Summary

The New Jersey State Board of Dentistry (the Board) proposes to amend N.J.A.C. 13:30-1A.2, concerning the scope of practice for licensed dental hygienists, and N.J.A.C. 13:30-2.4, concerning the scope of practice of registered dental assistants, to allow dental hygienists and dental assistants working under the direct supervision of licensed dentists to monitor patients who have been administered nitrous oxide/oxygen inhalation analgesia (analgesia) under certain circumstances. The Board is also proposing a new rule at N.J.A.C. 13:30-8.20 to establish standards of practice for the supervising dentists responsible for the administration of the analgesia. The proposed amendment to N.J.A.C. 13:30-1A.2 and the new rule were originally proposed in the New Jersey Register on November 3, 1997, at 29 N.J.R. 4639(a). As part of the original proposal, the Board was amending N.J.A.C. 13:30-2.3, which detailed the duties of licensed dental hygienists. N.J.A.C. 13:30-2.3, however, has since been recodified as N.J.A.C. 13:30-1A.2.

During the initial public comment period, the Board received several comments expressing concern about the proposed amendment and new rule. In light of the comments received, the Board undertook a thorough review of the commenters' concerns. As part of this review, the Board requested and obtained expert information in the field of analgesia administration. Upon further review of the comments and in light of the information the Board has received, the Board is once again proposing to amend the duties of licensed dental hygienists set forth at N.J.A.C. 13:30-1A.2 to allow hygienists to monitor analgesia patients, and is also reproposing new rule N.J.A.C. 13:30-8.20, to guide licensed dentists in the administration of analgesia and their supervision of support personnel who monitor analgesia patients. The Board is also proposing amendments to N.J.A.C. 13:30-2.4 at this time, to allow registered dental assistants to monitor analgesia patients, provided the dental assistant does not engage in any other activities or functions while monitoring the patient.

In response to the original proposal, the Board received comments from the following:

1. Arthur Meisel, Esq. on behalf of the New Jersey Dental Association and Joel C. Gelbman, D.D.S.;

2. Ira Cheifitz, D.M.D., President, New Jersey Society of Oral and Maxillofacial Surgeons, Inc.;

3. Deborah C. Myers, RDH, Chair, Council on Practice and Regulation, The New Jersey Dental Hygienists' Association;

4. Ervin Moss, M.D., New Jersey State Society of Anesthesiologists;

5. Richard D. Riva, D.D.S.; and

6. Richard Hirschlag, D.M.D.

The Boardhas summarized and responded to those comments here, as the responses highlight the review and analysis performed by the Board in the intervening period.

COMMENT: Mr. Meisel urged the Board to refrain from adopting the proposed amendment and new rule because he stated that a hygienist's ability to decrease the flow of analgesia or to increase the flow of oxygen, as contemplated in the Board's original proposal at paragraph (c)4 of N.J.A.C. 13:30-2.3, constitutes "administration" and not "monitoring" of the analgesia.

RESPONSE: The Board has reconsidered the language originally proposed in N.J.A.C. 13:30-2.3(c)4, and has determined that the contemplated downward adjustment to decrease the flow of nitrous oxide and the upward adjustment to increase the flow of oxygen may be interpreted as constituting administration which was not intended by the proposed amendment. To clarify any ambiguity that may have been created by the proposed language, the Board, as part of this reproposal, is deleting all references to a hygienist's ability to make any adjustments to the analgesia or oxygen flow that has been established by the supervising dentist. The proposed amendment to paragraph (c)4 of N.J.A.C. 13:30-1A.2 and the proposed amendment to N.J.A.C. 13:30-2.4(b)4, now provide that the licensed hygienist or registered dental assistant must maintain and monitor the therapeutic level of the analgesia established by the supervising dentist. The Board believes that this change is in keeping with the original proposal's intent to leave administration of analgesia to the supervising dentist. As an added safeguard, the Board is also proposing to amend the language that originally appeared in paragraph (c)5 of N.J.A.C. 13:30-2.3, which required the hygienist to notify the supervising dentist of any atypical reaction to the analgesia. N.J.A.C. 13:30-1A.2(c)5 and 2.4(b)5 now require the hygienist or dental assistant to immediately turn off the nitrous oxide and summon the dentist upon any untoward reaction in the patient.

COMMENT: Mr. Meisel urged the Board to refrain from adopting the proposed amendment and new rule because he stated that even when a dentist is "on the premises," as required by the proposal, the dentist may not be immediately available to deal with an emergency. The dentist could be at a sensitive point in the treatment of another patient and could, therefore, be unavailable to the patient who is being monitored by the hygienist. For these reasons, the commenter noted that the proposal should be amended to require that the dentist be in "close proximity" to the patient.

RESPONSE: The Board disagrees with the commenter's concern because the definition of "direct supervision" in proposed new rule N.J.A.C. 13:30-8.20, which requires the dentist to be physically present on the premises, ensures that the dentist will be in close proximity to the patient. As a result, the Board believes that the supervising dentist will be immediately available to the patient should any emergency situation arise. The Board also believes that no dental procedure is so critical as to require that procedure to be completed prior to the dentist being able to immediately leave the patient to manage a medical emergency that has arisen with another patient. In addition, the Board notes that it is common practice for a dentist to have two patients under treatment simultaneously. Such situations occur routinely without the consequences alluded to by the commenter.

COMMENT: Mr. Meisel questioned the propriety of a dentist leaving a patient while a drug is being administered, and stated that if a patient suffers any untoward reaction, a malpractice suit would inevitably follow. He stated that if the Board were to adopt the rule, it should add a provision stating that there is no deviation from the standard of care owed by a dentist to a patient if a dentist leaves a patient and goes elsewhere on the premises after a therapeutic level of analgesia is achieved.

RESPONSE: The Board notes that dentists often leave patients unattended after a drug has been administered, such as when a dentist injects a local anesthetic and leaves the patient for a time while the anesthetic takes effect. The Board does not believe that the dentist is engaging in inappropriate conduct when he or she does so. In addition, as noted above, a dentist must be on the premises and immediately available to the patient and the hygienist or dental assistant who is monitoring the patient once nitrous oxide/oxygen inhalation analgesia has been administered, in order to deal with any untoward reaction in the patient. The Board believes that it is clearly understood that a dentist does not deviate from the standard of care owed a patient if the dentist complies with the provisions of N.J.A.C. 13:30-8.20. The Board, therefore, did not amend the new rule proposal as suggested by the commenter.

COMMENT: Mr. Meisel urged the Board to limit analgesia administration to one patient per dentist at any one time.

RESPONSE: The Board declines to accept the commenter's suggestion and believes that the number of patients to whom analgesia is administered at any one time in a dental office is a matter best left to the discretion of the treating dentist. In addition, as noted above, dentists often work on more than one patient at a time without any untoward effects. The Board believes that the proposed amendments and new rule provide dentists with sufficient guidance as to the appropriate administration of analgesia by a dentist and the monitoring of an analgesia patient by a dental hygienist or dental assistant and, therefore, declines to amend the proposal as suggested by the commenter.

COMMENT: Mr. Meisel stated that the Board-approved course required to be taken by dental hygienists should be at least 14 hours long, rather than seven as proposed. Dr. Cheifitz, on behalf of the New Jersey Society of Oral and Maxillofacial Surgeons, Inc. (the Society), also urged rejection of the seven- hour training requirement, believing seven hours to be inadequate to teach the necessary information required for patient safety. In addition, Ervin Moss, M.D., on behalf of the New Jersey State Society of Anesthesiologists (the NJSSA), stated that the required seven hours of training was insufficient to prepare a hygienist to monitor a nitrous oxide patient.

RESPONSE: The Board has concluded that the nitrous oxide/oxygen inhalation training courses taken by hygienists and dental assistants should be at least 14 hours in length. The Board believes, after further review of this issue, that a seven-hour course may be inadequate to prepare a dental hygienist or dental assistant to monitor a patient who has been administered nitrous oxide/oxygen analgesia. The Board notes that the American Dental Association's "Guidelines for Treating the Comprehensive Control of Anxiety and Pain in Dentistry" Part III, adopted by the ADA's House of Delegates in October, 2000, recommends 14 hours of didactic and clinical training for dentists in both the administration and monitoring of nitrous oxide/oxygen conscious sedation. Therefore, as part of the reproposal, N.J.A.C. 13:30-1A.2 and 2.4 now require dental hygienists and dental assistants to complete a 14-hour, Board- approved course, offered in a college or university clinical setting. The course must include seven hours of didactic training and seven hours of clinical training, including 10 monitored administrations of nitrous oxide/oxygen inhalation analgesia.

COMMENT: Dr. Cheifitz expressed concern that the proposed amendment to the duties of dental hygienists conflicts with the requirements of proposed new rule N.J.A.C. 13:30-8.20. The proposed new rule allows a dentist to administer nitrous oxide/oxygen inhalation analgesia while allowing monitoring by a hygienist. The commenter noted that administration and monitoring are functions which coexist and cannot be separated because the person who administers the drug alters the amount of gases based on the patient's mental, cardiovascular and respiratory states. Alteration of nitrous oxide or oxygen flow rates fall into the category of administration which is not within the purview of the amendment. The Society believes that the Board should leave the administration of nitrous oxide to licensed dental practitioners who have more appropriate experience.

RESPONSE: The Board disagrees with the commenter's suggestion that administration and monitoring cannot be separated and notes that the terms are specifically defined in the proposed new rule in order to demonstrate the distinction between the two for the benefit of the public and the regulated community. In addition, the Board reiterates the response provided to Mr. Meisel above, and notes that monitoring, as intended by the Board in the original proposal and as currently reproposed, would not permit a dental hygienist or registered dental assistant to alter the flow of nitrous oxide or oxygen to the patient unless there is an untoward reaction of the patient at which time the registered dental hygienist or registered dental assistant must turn off the nitrous oxide/oxygen inhalation analgesia and summon the dentist. The proposed amendments to paragraph (c)4 of N.J.A.C. 13:30-1A.2 and to paragraph (b)4 of N.J.A.C. 13:30-2.4, now provide that the licensed dental hygienist or registered dental assistant must maintain and monitor the therapeutic level of the analgesia established by the dentist. The Board believes that this change is in keeping with the original proposal's intent to leave administration of analgesia to the supervising dentist.

COMMENT: Dr. Cheifitz noted that the proposed new rule requires the dentist to exercise direct supervision of the hygienist and to have full responsibility for the patient. The Society, however, believes that supervision is not possible when the dentist is not in the operatory. In addition, the Society believes that it is unfair to the patient, the dentist, and the hygienist to require a dentist to be fully responsible for a patient under the influence of a mind-altering drug who is being monitored by the hygienist.

RESPONSE: The Board disagrees with the commenter's assertion that a dentist may not supervise a dental hygienist or dental assistant if the dentist is not present in the operatory. The definition of "direct supervision" provided in N.J.A.C. 13:30-8.20 requires the dentist to be physically present on the premises, which the Board believes, necessarily entails that the dentist be in close proximity to the patient, and that any functions performed by the hygienist are to be performed pursuant to the dentist's order, control and responsibility. As a result, the Board believes that a hygienist or dental assistant who is monitoring a patient pursuant to the parameters established in the proposal is acting under an appropriate level of supervision. The Board also believes that the training required of a dental hygienist or dental assistant will properly prepare the hygienist or dental assistant to safely monitor the patient.

COMMENT: Dr. Cheifitz expressed concern regarding leaving a provider in a room alone with a patient under the influence of nitrous oxide. The commenter noted that patients have been known to hallucinate and have dreams, and the proposal fails to address this issue.

RESPONSE: Currently, there is neither a statutory nor a regulatory requirement which imposes an obligation upon a dentist to have a third person present in the room when a patient is receiving any dental services. The Board believes this issue, at this time, is better left to the discretion of licensed dentists in the management and administration of their dental practices.

COMMENT: Ms. Myers, on behalf of the New Jersey Dental Hygienists' Association (the Association), supports the proposal, and expressed support for the coursework, CPR, and recordkeeping requirements of the proposed amendment and new rule. The Association agreed with the Board's assessment that the proposal will positively impact the health, safety, and welfare of the public.

RESPONSE: The Board thanks the Association for its support of the original proposal and hopes that the Association will support the new proposal.

COMMENT: Dr. Moss noted that the New Jersey Society of Anesthesiologists (NJSSA) believes that the Board understands the dangers associated with the use of an inhalation anesthetic because of the CPR certification and fail safe system requirements of the proposal. The commenter noted, however, that the appropriate standard of care dictates use of an oxygen monitor to verify that the actual oxygen output is consistent with the flow meters. Moreover, factory trained and credentialed personnel should perform preventive maintenance of the machine.

RESPONSE: The Board disagrees with the commenter's assertion that an oxygen monitor should be required pursuant to the proposal and notes that the American Dental Association does not recommend the use of an oxygen monitor for nitrous oxide analgesia. The Board further notes that the American Society of Anesthesiologists' document on "Sedation and Analgesia by Non- Anesthesiologists" considers the use of nitrous oxide "minimal sedation" entailing "minimal risk" and specifically excludes nitrous oxide sedation from the various monitoring requirements imposed upon other, more significant sedation techniques. After further review of this issue, however, the Board believes it is prudent to require certain, basic equipment in all dental offices where nitrous oxide will be administered by a dentist and monitored by a dental hygienist or dental assistant, and has amended the proposal accordingly. N.J.A.C. 13:30-8.20(e) also now provides that the dental office must be equipped with a high speed vacuum source and suction equipment, as well as equipment to deliver positive pressure oxygen and to monitor a patient's blood pressure.

The Board declines to amend the proposed new rule to provide that only factory trained and credentialed personnel should perform preventive maintenance on the nitrous oxide machine, because the Board believes that the professional responsibility imposed upon each dentist to ensure that all their equipment is maintained in proper working order is clear.

COMMENT: Dr. Moss noted that the Board has addressed the potential dangers of allowing hygienists to monitor analgesia patients by proposing, as part of N.J.A.C. 13:30-2.3(c)4, that a hygienist can only turn the level of oxygen up or the level of nitrous oxide down. The NJSSA suggests that the Board rephrase the first paragraph of the Summary which states that the intent of the rule is "to allow a licensed dental hygienist practicing under the direct supervision of a licensed dentist to monitor a patient to whom the dentist has administered nitrous oxide/oxygen inhalation analgesia under certain circumstances." The Board should have stated that the intent of the rule is "to allow a licensed dental hygienist practicing under the supervision of a licensed dentist to scale teeth (or other activities) while monitoring the patient at the same time the nitrous oxide/oxygen mixture started by the dentist continues to flow with the dentist remaining in the suite performing other tasks." The NJSSA points out that, in the practice of surgical anesthesia, monitoring is the responsibility of a dedicated individual who is not performing another task at the same time.

RESPONSE: The Board notes that the Summary statement to which the commenter refers serves to explain the proposed amendments and new rule, but is not part of the rules, and that it does not believe it necessary to modify the statements as suggested by the commenter since the intent and content of the rules is clear as now proposed. The Board has reconsidered the language originally proposed in N.J.A.C. 13:30-2.3(c)4, and has determined that the contemplated downward adjustments to the flow of nitrous oxide and the upward adjustments to the flow of oxygen may be interpreted as constituting administration which was not intended by the proposed rule. To clarify any ambiguity that may have been created by the proposed language, the Board is deleting all references in the reproposal to a hygienist's or dental assistant's ability to make any adjustments to the nitrous or oxygen flow that has been established by the supervising dentist. The proposed amendments to paragraph (c)4 of N.J.A.C. 13:30-1A.2 and paragraph (b)4 of N.J.A.C. 13:30-2.4 now provide that the licensed hygienist or registered dental assistant must maintain and monitor the therapeutic level established by the dentist. In addition, although the commenter's assertion that surgical anesthesia monitoring is performed by a dedicated individual, the Board notes that the proposed regulation does not deal with anesthesia, but with nitrous which, as previously noted, entails minimal risk to a patient. As a result, the Board believes that it is safe for a dental hygienist to monitor a patient while performing functions delegated to him or her by the supervising dentist, and that it is safe for a dental assistant to monitor a patient provided he or she does not perform any other activities while performing this monitoring function.

COMMENT: Dr. Moss suggested that a patient's discharge pursuant to N.J.A.C. 13:30-8.20 should be to a responsible adult with advice to the patient not to drive a car that day because nitrous oxide presents an increased risk of accident due to depressed reflexes.

RESPONSE: The Board disagrees with the commenter's assertion that N.J.A.C. 13:30-8.20 should be amended to require patient discharge to an escort, and notes that the American Dental Association does not suggest or recommend that an escort be mandated for patients who will be receiving nitrous oxide analgesia. The Board notes further that the decision to require an escort for a patient who is being administered nitrous oxide, and the type of instructions provided to the patient for follow-up care, are matters that are best left to the discretion of the treating dentist who is required under subsection (h) of the reproposed new rule to personally discharge the patient.

COMMENT: Dr. Moss commented that "monitoring" as defined in N.J.A.C. 13:30- 8.20(a) does not address the need for an oximeter, blood pressure, pulse, or EKG monitor, and that the definition fails to define how a hygienist will "check" a patient's condition while he or she is working in the mouth. The NJSSA opines that, at a minimum, the Board should mandate an oximeter.

RESPONSE: The Board reiterates the response provided to the NJSSA above and notes that neither the American Dental Association nor any anesthesia-related dental organization with which the Board is familiar recommends the use of the monitors to which the commenter refers during the administration of nitrous oxide/oxygen inhalation analgesia. As noted above, the American Society of Anesthesiologists' publication on "Sedation and Analgesia by Non- Anesthesiologists" specifically excludes nitrous oxide from the various monitoring requirements imposed upon other, more significant sedation techniques. Therefore, the Board declines to amend the rule as suggested by the commenter, but notes that it has decided that certain, basic equipment should be required in all dental offices where nitrous oxide administration and monitoring will be carried out and has amended the reproposal accordingly.

The Board disagrees with the commenter's suggestion that proposed new rule N.J.A.C. 13:30-8.20 should define how a hygienist will "check" a patient's condition. The rule specifically requires that the hygienist or dental assistant monitor the patient's condition. Effective monitoring of a patient's condition is a necessary component of the training that must be completed by all licensed dental hygienists and dental assistants to whom the monitoring function will be delegated. This training will include both didactic and clinical experience which, the Board believes, will ensure that hygienists and dental assistants are able to effectively assess the safety and comfort of the patient receiving the nitrous oxide/oxygen inhalation analgesia.

COMMENT: Dr. Moss noted that recordkeeping is a vital component in the administration of anesthesia. The commenter noted that proposed N.J.A.C. 13:30-8.20(b) fails to mention the need to include the vital signs of the patient, including oxygen saturation, in the patient record. The commenter also believes that it would be impossible for an accurate patient record to be kept by a dentist who is not in the room or by a hygienist who is simultaneously working and monitoring the patient.

RESPONSE: The Board agrees that recordkeeping is vital to the proper administration of analgesia, as well as the administration of anesthesia, to which the commenter refers. The Board, however, disagrees with the commenter's assertion that an accurate patient record cannot be maintained by a supervising dentist or by a hygienist or dental assistant who is monitoring the patient. N.J.A.C. 13:30-8.20(g) specifically requires that the patient record reflect the nitrous oxide and oxygen flow rates, as well as the analgesia duration and clearing times. The Board believes that the recordation of such information is sufficient to provide a complete and accurate record of the nitrous oxide administration.

COMMENT: Dr. Moss questioned whether it is appropriate for a patient under the influence of nitrous oxide to remain alone in a room with only a hygienist. The NJSSA believes that both patient safety and potential sexual abuse charges are concerns the Board should address. Similarly, Dr. Riva stated that it is not prudent for a health care provider to administer nitrous oxide to any patient without a third party present.

RESPONSE: The Board notes that its intent in proposing the rules is to allow a dentist to perform other tasks while the hygienist or dental assistant monitors the patient. To require a dentist to be present in the room while the hygienist or dental assistant is monitoring the analgesia patient would negate the purpose of the rule. The Board notes that it has a reasonable expectation that practitioners will adhere to appropriate standards of care and respect for the patient-practitioner relationship. The Board reiterates that currently there is neither a statutory nor a regulatory requirement which imposes an obligation upon a dentist to have a third person present in the room when a patient is receiving any dental services. The Board, however, will continue to monitor this area closely, and modify its standards accordingly if it becomes appropriate at any time in the future.

COMMENT: Dr. Riva commented that the pharmacokinetics of nitrous oxide is dependent on the cardiovascular and respiratory function of the patient, and the mean alveolar concentration and clinical efficacy of the drug can change rapidly. He also stated that the proposed definition of the term "monitoring," which provides for the observation of the patient who is receiving nitrous oxide, conflicts with the proposed amendment to N.J.A.C. 13:30-2.3 because a licensed dental hygienist is not permitted to administer drugs. Dr Riva contends that the definition of "monitoring" as defined in N.J.A.C. 13:30- 8.20 contemplates the administration of the analgesia by the hygienist.

RESPONSE: The Board does not disagree with Dr. Riva's assessment of the pharmacokinetics of nitrous oxide, but notes that nitrous oxide analgesia is a highly safe and effective method of sedation. The proposed amendments and new rule ensure that the administration of nitrous oxide and the monitoring of patients receiving the analgesia is performed in a manner consistent with the proper standard of care. The Board, however, disagrees with Dr. Riva's assertion that the definition of "monitoring" includes the administration of nitrous oxide. The Board notes that there are distinct differences between the terms "administration" and "monitoring," and that it has chosen to specifically define them to demonstrate this distinction for the benefit of the public and the regulated community. It also notes that "monitoring" merely constitutes an observation by the hygienist or the dental assistant of the patient who is receiving the nitrous oxide from the supervising dentist to ensure the patient's safety and comfort; at no time does the Board intend the hygienist or dental assistant to engage in the introduction of nitrous oxide in the patient's system. The Board believes that the amendments it is proposing to N.J.A.C. 13:30-1A.2 and 2.4 at this time will further clarify any ambiguity or confusion that may exist regarding the scope of a dental hygienist's or dental assistant's practice in monitoring analgesia patients.

COMMENT: Dr. Hirschlag noted that the current policy which permits the use of nitrous oxide by a hygienist only if a licensed dentist is present is not only impractical and inconvenient for the hygienist and the dentist, but is also not in the best interest of the patient. The use of nitrous oxide helps some patients cope with the stress of a dental visit and patients may deny themselves needed hygiene care because nitrous oxide cannot be monitored by the hygienist alone. Dentists should initially administer the analgesia until the patient is stable and comfortable. As long as the dentist is in the office and able to check on the patient and hygienist, however, the commenter believes that it is unreasonable to deny the patient the benefits of analgesia by demanding the dentist's presence during the entire visit. Dr. Hirschlag noted further that nitrous oxide analgesia has a long and safe history in dental practice and, when used judiciously, has made needed dental care more palatable to the apprehensive patient. Dental hygienists are highly educated, carefully trained and more than competent to monitor patients using nitrous oxide. Moreover, the commenter noted that many states do not require the presence of the dentist in the hygiene room throughout the procedure if a patient has been administered analgesia by the dentist.

RESPONSE: The Board appreciates Dr. Hirschlag's comments and hopes that he will support the new proposal.

The following is a summary of the amendments and new rule which the Board is reproposing at this time. The proposed amendments to N.J.A.C. 13:30-1A.2 and 2.4 expand the scope of practice for licensed dental hygienists and registered dental assistants, respectively. N.J.A.C. 13:30-1A.2(c) and 2.4(b) provide that a licensed dental hygienist or a registered dental assistant, practicing under the direct supervision of a licensed dentist pursuant to the requirements of proposed new rule N.J.A.C. 13:30-8.20, may monitor a patient to whom the supervising dentist has administered nitrous oxide under limited circumstances. N.J.A.C. 13:30-2.4(b) specifies, however, that the registered dental assistant may not engage in any other permitted activity while monitoring the patient. The proposed amendments provide that a licensed dental hygienist or a registered dental assistant practicing under direct supervision may monitor a patient receiving analgesia provided that the hygienist or the dental assistant has completed a Board-approved course in nitrous oxide/oxygen inhalation analgesia offered in a college or university clinical or hospital setting. The course must be submitted to the Board for review and approval of course content, be at least 14 hours in length and must include seven hours of didactic training and seven hours of clinical training, with a minimum of 10 monitored administrations of the analgesia. The hygienist or the dental assistant must also maintain current certification in basic or advanced cardiac life support, and must complete a three hour didactic or clinical course in nitrous oxide/oxygen inhalation analgesia in each registration renewal period. Such re-certification course is required in addition to current continuing education requirements. In addition, the hygienist or the registered dental assistant is required to maintain and monitor the therapeutic level of the analgesia administered by the supervising dentist and he or she must immediately turn off the nitrous oxide and summon the supervising dentist if the patient has any untoward reaction. New subsection (d) in N.J.A.C. 13:30-1A.2 and new subsection (c) in N.J.A.C. 13:30-2.4 provide that the monitoring of nitrous oxide/oxygen inhalation analgesia by a dental hygienist or dental assistant who does not meet the training standards and procedures set forth in the respective rules will be considered a deviation from normal standards of practice. New subsection (d) in N.J.A.C. 13:30-2.4 provides that a registered dental assistant who engages in the activities delineated in (b) and (c) without direct supervision shall be deemed to be engaging in the unauthorized practice of dental assisting and will be penalized accordingly. Existing subsections (c) through (g) of N.J.A.C. 13:30-1A.2 are recodified as subsections (e) through (i); existing subsection (b) of N.J.A.C. 13:30-2.4 is recodified as subsection (e), without change.

The Board believes that the proposed standards mandate the competence of dental hygienists and registered dental hygienists engaged in the monitoring function to ensure that the patient's health and welfare are safeguarded, and carefully delineate the hygienist's or dental assistant's role in monitoring a patient to clarify that his or her duties will in no way constitute analgesia administration.

Proposed new rule N.J.A.C. 13:30-8.20 sets forth the parameters of a licensed dentist's duties in connection with nitrous oxide administration and his or her delegation of the monitoring of a patient who has been administered analgesia. Proposed N.J.A.C. 13:30-8.20(a) defines the terms "administration," "direct supervision," "monitoring," "nitrous-oxide/oxygen inhalation analgesia" and "supervising dentist" as they are used in the proposed new rule. Proposed N.J.A.C. 13:30-8.20(b) requires the supervising dentist to induce or administer the analgesia if any patient is going to receive it and requires the supervising dentist to exercise direct supervision and full responsibility for the patient. Subsection (c) of N.J.A.C. 13:30- 8.20 enables the supervising dentist to delegate analgesia monitoring to a hygienist provided that the patient is stabilized, and provided that the conditions of N.J.A.C. 13:30-1A.2 are satisfied. Subsection (d) enables the supervising dentist to delegate analgesia monitoring to a registered dental assistant who will perform no other functions while monitoring the patient, provided the patient is stabilized and the conditions of N.J.A.C. 13:30-2.4 are satisfied. Subsection (e) sets forth the parameters for the nitrous- oxide/oxygen delivery system in monitoring situations and delineates the minimum equipment that a dental office must maintain when delegation of analgesia is contemplated. Proposed N.J.A.C. 13:30-8.20(f) prohibits a dentist from delegating the monitoring of nitrous oxide to a licensed dental hygienist or to a registered dental assistant when a patient is taking any medications that could potentiate the effects of the analgesia or could change the patient's level of consciousness. Proposed subsection (g) requires the supervising dentist to ensure that the patient record is documented to reflect the nitrous oxide and oxygen flow rates and the analgesia duration and clearing times. Proposed N.J.A.C. 13:30-8.20(h) requires the supervising dentist to personally discharge the patient after he or she has been administered analgesia. Proposed subsection (i) provides that the delegation of the monitoring of nitrous oxide/oxygen inhalation analgesia by a dentist to a dental hygienist or dental assistant who does not meet the training standards and procedures of the rules will be considered a deviation from normal standards of practice.

The Board proposes the amendments and new rule in accordance with N.J.S.A. 45:6-50 which empowers it to adopt rules to prescribe expanded functions for dental hygienists and registered dental assistants and to impose restrictions and requirements for the functions including any educational prerequisites. In addition, N.J.S.A. 45:6-50 provides that expansion and assignment of such functions, training, and examination procedures shall be developed in consultation with the relevant advisory council. Prior to its decision to move forward with the original proposal, the Board, in furtherance of this statutory obligation to develop such additional standards, formed a subcommittee to conduct research into the health, welfare, and safety aspects of allowing dental hygienists to monitor analgesia-induced patients. The subcommittee consulted with professionals; reviewed other states' policies, rules, statutes, and data; and evaluated relevant publications including the Centers for Disease Control and Prevention literature.

The subcommittee determined that a licensed dental hygienist practicing under the direct supervision of a licensed dentist can safely and effectively monitor a patient who has been administered analgesia provided that the hygienist and supervising dentist adhere to the specifications set forth in the proposed standards. Thus, the Board believed at the time, and continues to believe now, that the proposed standards enable the general public to experience the relaxation and comfort benefits of receiving analgesia while the licensed hygienist performs such activities as scaling a patient's teeth during routine prophylaxis appointments. In addition, the Board notes that the subcommittee, which was reconvened to review the issues raised by the commenters in response to the original proposal, consulted an expert in the field of sedation and anesthesia recommended to it by the American Dental Association. Joel Weaver, D.D.S., Ph.D., who is Director of Anesthesiology and Associate Professor at the Ohio State University College of Dentistry, reviewed the original proposal, the comments submitted in opposition to the proposal, and the reproposal, and concluded that the rules as reproposed would ensure that nitrous oxide analgesia would be used in a safe and effective manner to treat patients. The Board also notes that in addition to the advice provided by Dr. Weaver, the subcommittee review comments in opposition to, and in support of, the reproposal presented at a recent Board meeting by members of the regulated community. Following this analysis, the subcommittee has now determined that registered dental assistants working under the direct supervision of a dentist may effectively monitor a patient to whom nitrous oxide has been administered provided that the dental assistant does not engage in any other activities and provided that all other safeguards delineated in N.J.A.C. 13:30-2.4 and 8.20 are satisfied.

The Board has decided to provide a 60-day comment period for the reproposal; therefore, pursuant to N.J.A.C. 13:30-3.3(a)5, this rulemaking is excepted from the rulemaking calendar requirement.

Social Impact

The Board believes that the proposed amendments to N.J.A.C. 13:30-1A.2 and proposed new rule N.J.A.C. 13:30-8.20 will positively impact the health, safety and welfare of the general public by enabling dental patients to derive the benefits of analgesia while dental hygienists perform such activities as scaling the patient's teeth during a routine dental cleaning. The Board also believes that the proposed amendments to N.J.A.C. 13:30-2.4 will positively impact the health, safety and welfare of the general public by ensuring that a registered dental assistant who is responsible for monitoring a patient to whom analgesia has been administered performs no other functions or activities while the patient is being so monitored. The Board has determined that a licensed dental hygienist and a registered dental assistant can monitor analgesia administration safely after a licensed dentist performs the administration, thus furthering patient comfort while continuing to ensure health and safety through the educational, technical, and supervisory components of the proposed amendments and new rule.

Economic Impact

The proposed amendments to N.J.A.C. 13:30-1A.2 and 2.4 may have a slight economic effect upon licensed dentists, licensed dental hygienists, registered dental assistants, and the general public. Licensed dental hygienists and registered dental assistants who choose to monitor patients to whom supervising dentists administer analgesia will incur the cost of completing a Board- approved course of at least 14 hours in length if the hygienist or dental assistant has not already done so. In some instances, the licensed dentist who employs such a dental hygienist or dental assistant may elect to incur the cost on behalf of the hygienist or dental assistant. In all cases, the economic impact is optional based on whether each individual licensed hygienist or registered dental assistant will complete the course so that he or she may monitor analgesia-induced patients. The Board believes that the cost to complete the course is not so significant as to cause dentists to increase their fees. Moreover, the cost which the licensed dental hygienists, registered dental assistants, or licensed dentists may incur is strongly outweighed by the greater accessibility of the public to analgesia during routine dental procedures.

The proposed amendments to N.J.A.C. 13:30-1A.2 and 2.4 may also have a slight economic impact upon the licensed dental hygienist and registered dental assistant who engage in analgesia monitoring by requiring maintenance of current certification in basic or advanced cardiac life support, as well as the completion of three hours of continuing education in nitrous oxide in every other registration renewal period. This cost which the hygienist, dental assistant, or his or her employing dentist incurs, the Board believes, is strongly outweighed by the health and safety considerations associated with the proposed amendments.

In addition, proposed new rule N.J.A.C. 13:30-8.20 may have an impact upon supervising dentists who must acquire the appropriate nitrous oxide unit and other minimum equipment to meet the specifications set forth in the rule. The Board proposes these requirements in order to safeguard patient safety and welfare, and, therefore, the Board believes that the cost to licensed dentists is strongly outweighed by the benefit of the rule to consumers.

The Board also believes that the proposed amendments to N.J.A.C. 13:30-1A.2 and 2.4, and proposed new rule N.J.A.C. 13:30-8.20, may have a positive impact upon the regulated community by allowing each licensed dentist to perform additional tasks while his or her licensed dental hygienist or registered dental assistant monitors a patient receiving analgesia.

Federal Standards Statement

A Federal standards analysis is not required because the proposed amendments to N.J.A.C. 13:30-1A.2 and 2.4, and proposed new rule N.J.A.C. 13:30- 8.20 are governed by N.J.S.A. 45:6-1 et seq., and are not subject to any Federal standards or requirements.

Jobs Impact

The proposed amendments and new rule may have some impact upon jobs in New Jersey. The amendments and new rule expand the scope of a dental hygienist's and dental assistant's responsibilities to facilitate the delivery of more comfortable dental services to the general public. Thus, the amendments and new rule may ultimately create more job opportunities for dental hygienists and dental assistants in dental offices, or may increase the amount of work available to dental hygienists and dental assistants who can now monitor a patient to whom the dentist administers the analgesia. The Board, however, cannot estimate at this time the number of jobs that may be created as a result of the proposed amendments and new rule because the number will vary depending on the number of dentists who elect to utilize the services of dental hygienists and dental assistants in the monitoring of patients who have been administered analgesia.

Agriculture Industry Impact

The Board does not believe that the proposed amendments and new rule will have any impact on the agriculture industry in the State.

Regulatory Flexibility Analysis

The Regulatory Flexibility Act (the Act), N.J.S.A. 52:14B-16 et seq., requires the Board to provide a description of the types and an estimate of the number of small businesses to which the proposed amendments andnew rule will apply. Currently, the Board licenses approximately 10,092 dentists, 4,780 dental hygienists and 317 dental assistants. If licensed dentists, licensed dental hygienists and registered dental assistants are considered "small businesses" within the meaning of the Act, then the following analysis applies.

The Act requires the Board to set forth the reporting, recordkeeping and other compliance requirements of the proposed amendments and new rule, including the kinds of professional services likely to be needed to comply with the requirements. The Act further requires the Board to estimate the initial and annual compliance costs of the proposed amendments and new rule, to outline the manner in which it has designed the proposed amendments and new rule to minimize any adverse economic impact upon small businesses, and to set forth whether the proposed amendments and new rule establish differing compliance requirements for small businesses.

The proposed amendments to N.J.A.C. 13:30-1A.2 and 2.4 do not impose any reporting or recordkeeping requirements upon licensed dental hygienists or registered dental assistants. Notations in patient charts regarding nitrous oxide and oxygen flow rates and duration and clearing times, as required by N.J.A.C. 13:30-8-20(f), are a customary component of the patient record. The proposed amendments, however, do impose various compliance requirements upon licensed dental hygienists and registered dental assistants who monitor patients who have been administered nitrous oxide/oxygen inhalation analgesia. To comply with the proposed amendments, licensed dental hygienists and registered dental assistants must complete a Board-approved course at least 14 hours in length which includes didactic and clinical experience. They must maintain current, basic or advanced cardiac life support certification, and they must also take an additional three hours of continuing education in nitrous oxide in every other registration renewal period. Moreover, licensed dental hygienists and registered dental assistants may only maintain and monitor the therapeutic level of the analgesia established by the supervising dentist. Dental hygienists and registered dental assistants are required to immediately turn off the nitrous oxide and summon the supervising dentist if the patient has any untoward reaction while he or she is being monitored by the hygienist.

No additional professional services are necessary to comply with the proposed amendments to N.J.A.C. 13:30-1A.2 and 2.4. Licensed dental hygienists and registered dental assistants who wish to monitor a patient to whom a supervising dentist has administered analgesia may incur an initial cost to complete a Board-approved course if they have not already done so. However, that cost is minimal and elective as only dental hygienists and registered dental assistants who wish to monitor such patients and who have not already completed such a course will incur it. In some instances, licensed dentists who supervise these licensed dental hygienists or registered dental assistants may choose to bear the program cost on the hygienist's or dental assistant's behalf. In addition, each hygienist or dental assistant will incur a cost to keep his or her cardiac life support training current and to complete the required number of continuing education hours. The Board has designed the proposed amendments to minimize economic impact by requiring only licensed dental hygienists and registered dental assistants who wish to monitor analgesia patients to incur the cost to complete a 14-hour Board-approved course to keep current cardiac life support certification and to complete the required amount of continuing education. Therefore, the proposed amendments offer differing compliance requirements by giving hygienists and dental assistants the option of monitoring analgesia if they choose to do so or if their employer wishes them to do so. The standards contained in the proposed amendments, however, will apply to every dental hygienist or registereddental assistant who engages in this process.

Proposed new rule N.J.A.C. 13:30-8.20 does not impose any reporting requirements upon licensed dentists. The proposed new rule, however, does impose one recordkeeping requirement upon licensed dentists who supervise the monitoring of patients by licensed dental hygienists or registered dental assistants. The supervising dentist must appropriately document the patient record to include the nitrous oxide and oxygen flow rates, as well as the analgesia duration and clearing time. Additional compliance requirements associated with proposed new rule N.J.A.C. 13:30-8.20 mandate that the supervising dentist must always induce or administer the analgesia and exercise direct supervision and full responsibility for the patient, and may only delegate the monitoring of the analgesia to a hygienist provided that the patient is stabilized and all of the conditions set forth in N.J.A.C. 13:30- 1A.2 are satisfied. The supervising dentist may only delegate the monitoring of the analgesia to a dental assistant provided the assistant does not engage in any other activities, and provided that the patient is stabilized and all of the conditions set forth in N.J.A.C. 13:30-2.4 are satisfied. Moreover, to comply with proposed new rule N.J.A.C. 13:30-8.20, the supervising dentist who delegates the monitoring function must ensure that the nitrous oxide unit is fail-safe and adheres to specific guidelines, and that certain, basic equipment is available for use in the dental office. The supervising dentist is precluded from delegating the monitoring of an analgesia patient to a dental hygienist or dental assistant if a patient is taking any medications that could potentiate the effects of the nitrous oxide or that could change the level of the patient's consciousness. The supervising dentist must personally discharge the patient after analgesia is administered.

No additional professional services will be necessary to comply with proposed new rule N.J.A.C. 13:30-8.20. The supervising dentist may incur costs to acquire a fail-safe unit and the additional equipment necessary to comply with the rule's specifications. In addition, he or she may incur ongoing costs to repair or maintain the unit or other equipment. The Board has designed proposed new rule N.J.A.C. 13:30-8.20 to minimize adverse economic impact upon the regulated community by offering dentists the option of delegating analgesia monitoring to a hygienist or to a dental assistant. Thus, only those supervising dentists who elect to do so will be required to comply with the rules. The proposed new standards, however, will apply to every licensed dentist who chooses to utilize the practice in his or her office.

Smart Growth Impact

The Board does not believe that the proposed amendments and new rule will have any impact upon the achievement of smart growth or upon the implementation of the State Development and Redevelopment Plan.

Full text of the proposal follows:

<< NJ ADC 13:30-1A.2 >>

13:30-1A.2 Scope of practice of licensed dental hygienist

(a)-(b) (No change.)

<<+(c) In addition to the activities set forth in (b) above, a licensed dental hygienist practicing under the direct supervision of a licensed dentist pursuant to N.J.A.C. 13:30-8.20 may monitor a patient to whom the supervising dentist has administered nitrous oxide/oxygen inhalation analgesia, provided that:+>>

<<+1. The licensed dental hygienist has successfully completed a Board- approved course offered in a CODA (Commission on Dental Accreditation of the American Dental Association) approved college or university clinical setting or hospital setting which emphasizes the administration of nitrous oxide simultaneous with the administration of oxygen and safe and effective patient monitoring;+>>

<<+i. The course shall be submitted to the Board for review and approval of course outline, content and objectives, curriculum vitae of instructors and whether the training is visual, hands-on or lecture;+>>

<<+ii. The nitrous oxide/oxygen administration course shall be at least 14 hours in length, which shall include at least seven hours of didactic training and seven hours of clinical training; and+>>

<<+iii. The clinical training shall include, at a minimum, 10 monitored administrations of nitrous oxide/oxygen inhalation analgesia;+>>

<<+2. The licensed dental hygienist holds a current certification in Basic or Advanced Cardiac Life Support by the American Heart Association, the American Red Cross or an equivalent association approved by the Board;+>>

<<+3. The licensed dental hygienist completes a three-hour didactic or clinical course in nitrous oxide/oxygen inhalation analgesia in every other registration renewal period. Completion of the recertification course shall be in addition to the continuing education requirements set forth at N.J.A.C. 13:30-5.2;+>>

<<+4. The licensed dental hygienist monitors the patient and maintains the therapeutic level of nitrous oxide/oxygen inhalation analgesia as established by the dentist; and+>>

<<+5. Upon any untoward reaction of the patient, the licensed dental hygienist immediately turns off the nitrous oxide/oxygen inhalation analgesia and summons the dentist.+>>

<<+(d) The monitoring of nitrous oxide/oxygen inhalation analgesia by a registered dental hygienist without first having met the minimum standards of training and procedures as contained in this section shall constitute a deviation from normal standards of practice required of a licensee.+>>

Recodify existing (c)-(d) as <<+(e)-(f)+>> (No change in text.)

<<-(e)->><<+(g)+>>-A licensed dental hygienist who engages in the activities outlined in (b) <<+and (c)+>> above without direct supervision shall be deemed to be engaging in the unauthorized practice of dental hygiene and shall be subject to the penalties set forth in N.J.S.A. 45:6-58 <<+and 45:1-25+>>.

<<-(f)->><<+(h)+>>-A licensed dentist who permits a licensed dental hygienist to engage in the activities outlined in (b) <<+and (c)+>> above without direct supervision shall be subject to the penalties set forth in N.J.S.A. 45:1-25.

<<-(g)->><<+(i)+>> (No change in text.)

<< NJ ADC 13:30-2.4 >>

13:30-2.4 Scope of practice of registered dental assistant

(a) (No change.)

<<+(b) A registered dental assistant practicing under the direct supervision of a licensed dentist pursuant to N.J.A.C. 13:30-8.20 may monitor a patient to whom the supervising dentist has administered nitrous oxide/oxygen inhalation analgesia provided the registered dental assistant does not perform any other function while monitoring the patient, and provided that:+>>

<<+1. The registered dental assistant has successfully completed a Board- approved course offered in a CODA (Commission on Dental Accreditation of the American Dental Association) approved college or university clinical setting or hospital setting which emphasizes the administration of nitrous oxide simultaneous with the administration of oxygen and safe and effective patient monitor:+>>

<<+i. The course shall be submitted to the Board for review and approval of course outline, content and objectives, curriculum vitae of instructors and whether the training is visual, hands-on or lecture;+>>

<<+ii. The nitrous oxide/oxygen administration course shall be at least 14 hours in length, which shall include at least seven hours of didactic training and seven hours of clinical training; and+>>

<<+iii. The clinical training shall include, at a minimum, 10 monitored administrations of nitrous oxide/oxygen inhalation analgesia.+>>

<<+2. The registered dental assistant holds a current certification in Basic or Advanced Cardiac Life Support by the American Heart Association, the AmericanRed Cross or an equivalent association approved by the Board;+>>

<<+3. The registered dental assistant completes a three-hour didactic or clinical course in nitrous oxide/oxygen inhalation analgesia in every other registration renewal period. Completion of the recertification course shall be in addition to the continuing education requirements set forth at N.J.A.C. 13:30-5.3.+>>

<<+4. The registered dental assistant monitors the patient and maintains the therapeutic level of the nitrous oxide/oxygen inhalation analgesia as established by the dentist; and+>>

<<+5. Upon any untoward reaction of the patient, the registered dental assistant immediately turns off the nitrous oxide/oxygen inhalation analgesia and summons the dentist.+>>

<<+(c) The monitoring of nitrous oxide/oxygen inhalation analgesia by a registered dental assistant without first having met the minimum standards of training and procedures as contained in this section shall constitute a deviation from normal standards of practice required of a licensee.+>>

<<+(d) A registered dental assistant who engages in the activities outlined in (b) and (c) above without direct supervision shall be deemed to be engaging in the unauthorized practice of dental assisting and shall be subject to the penalties set forth in N.J.S.A. 45:1-25.+>>

<<-(b)->><<+(e)+>> (No change in text.)

<< NJ ADC 13:30-8.20 >>

13:30-8.20<<+ +>><<-(Reserved)->> <<+Nitrous oxide/oxygen inhalation analgesia; duties of a licensed dentist, delegation to licensed dental hygienist and registered dental assistant+>>

<<+(a) The following words and terms, as used in this section, shall have the following meanings, unless the context clearly indicates otherwise:+>>

<<+"Administration" means the determination and introduction of a therapeutic level of nitrous oxide/oxygen inhalation analgesia.+>>

<<+"Direct supervision" means acts performed in the office of a licensed dentist wherein the dentist is physically present on the premises at all times during the performance of such acts and such acts are performed pursuant to the dentist's order, control, and full professional responsibility.+>>

<<+"Monitoring" means observing or checking a patient's condition to assess the safety and comfort of the patient receiving nitrous oxide/oxygen inhalation analgesia.+>>

<<+"Nitrous oxide/oxygen inhalation analgesia" means the introduction by inhalation of a combination of nitrous oxide and oxygen gases to a conscious patient.+>>

<<+"Supervising dentist" means the dentist who induces or administers the nitrous oxide/oxygen inhalation analgesia to the patient.+>>

<<+(b) If a patient is to receive nitrous oxide/oxygen inhalation analgesia, a supervising dentist shall induce or administer the nitrous oxide/oxygen inhalation analgesia and shall exercise direct supervision and full responsibility for the patient.+>>

<<+(c) A supervising dentist may delegate the monitoring of the nitrous oxide/oxygen inhalation analgesia to a licensed dental hygienist during the performance of dental hygiene procedures provided that the patient is stabilized and that the licensed dental hygienist satisfies the requirements set forth in N.J.A.C. 13:30-1A.2.+>>

<<+(d) A supervising dentist may delegate the monitoring of the nitrous oxide/oxygen inhalation analgesia to a registered dental assistant who will perform no other function while monitoring the patient provided the patient is stabilized and the registered dental assistant satisfies the requirements set forth in N.J.A.C. 13:30-2.4.+>>

<<+(e) If a supervising dentist delegates the monitoring of the nitrous oxide/oxygen inhalation analgesia to a licensed dental hygienist pursuant to N.J.A.C. 13:30-1A.2, or to a registered dental assistant pursuant to N.J.A.C. 13:30-2.4, the supervising dentist shall ensure that:+>>

<<+1. The nitrous oxide/oxygen inhalation delivery system is a fail-safe unit which shall not deliver nitrous oxide unless oxygen is continuously flowing at a minimum of 30 percent and includes a scavenging system operating while the nitrous oxide is in use; and+>>

<<+2. The dental office is equipped, at a minimum, with the following:+>>

<<+i. A high speed vacuum source;+>>

<<+ii. Suction equipment;+>>

<<+iii. Equipment to deliver positive pressure oxygen; and+>>

<<+iv. Blood pressure monitoring equipment.+>>

<<+(f) A supervising dentist shall not delegate the monitoring of nitrous oxide/oxygen inhalation analgesia to a licensed dental hygienist or to a registered dental assistant if a patient is taking any medications, whether prescribed by the dentist or by another licensed practitioner, that in the professional judgment of the dentist may potentiate the effects of the nitrous oxide/oxygen inhalation analgesia, or may change the level of consciousness of the patient.+>>

<<+(g) The supervising dentist shall be responsible for ensuring that the patient records are documented to reflect the nitrous oxide and oxygen flow rates and the analgesia duration and clearing times.+>>

<<+(h) The supervising dentist shall personally discharge the patient following the administration of nitrous oxide/oxygen inhalation analgesia.+>>

<<+(i) The delegation of the monitoring of nitrous oxide/oxygen inhalation analgesia to a registered dental hygienist pursuant to N.J.A.C. 13:30-1A.2 or registered dental assistant pursuant to N.J.A.C. 13:30-2.4 without first having met the minimum standards of training and procedures as stated therein shall constitute a deviation from normal standards of practice required of a licensee.+>>



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