While academic interests and proclivities shape training in sedation to a large degree in the realm of science, state regulation governs sedation practice in dentistry. In about a dozen years, a threefold increase occurred in the number of state dental boards regulating oral sedation from 14 states (28 %) in 2001 requiring a permit to administer oral sedation to 41 states currently (82 %).

While sedation laws vary from state to state, the content is largely similar and based on contemporary sedation practice [1]. Variance across states can be attributed to a host of factors, not the least of which is political influence. In some states, permits are based on the route of administration, such as inhalational, enteral, and parenteral sedation. The permit requirements in other states are based on the level of consciousness and sedation defined in terms of minimal, moderate, and deep sedation. Most commonly, states require basic life support (BLS) training, in addition to licensure for administration of nitrous oxide/oxygen, for analgesia and minimal sedation, while continuing education and advanced training such as Pediatric Advanced Life Support (PALS) and Advanced Cardiac Life Support (ACLS) are required to obtain moderate and deep sedation permits. These requirements drive training in academic institutions to some degree.

At the time of this writing, some states do not require a separate permit for administration of nitrous oxide and oxygen and administration of antianxiety medications. Michigan and the District of Columbia do not require permits but require the provider to satisfy the board requirements to administer sedation and general anesthesia. Lapointe et al. stated that 41 states out of 50 require a permit to administer oral sedation [2]. Alaska, Connecticut, Indiana, Michigan, Nebraska, and South Dakota do not require a permit for administration of enteral or oral conscious sedation. On the other hand, Florida, Kentucky, Missouri, North Carolina, and Oklahoma mandate a separate permit for pediatric conscious sedation. The only state, at the time of writing this chapter, that requires a permit for anxiolysis was West Virginia. The permits for general anesthesia, parenteral sedation, and oral conscious sedation most often need to be renewed annually, biennially, or triennially, while in Idaho, there is a 5-year renewal period. The training requirements for renewal are also variable with some states requiring none.

In addition to the provider training and certification, some states mandate the need to inspect the office where sedation is performed. Consultants appointed by the board will inspect the office for operatory and equipment requirements, emergency equipment, required drugs, and written emergency protocol. In addition to evaluation of the above, the consultants will evaluate the applicant’s knowledge in the use of the required equipment and drugs in administering the sedation. Some states also have additional regulations with respect to medications used, maintenance of patient records, patient scheduling, discharge criteria, and use of other providers like physician anesthesiologists and nurse anesthetist. Clearly, while these checkpoints might be considered in the area of practitioner preparedness, they entail a training component.

Rules and regulations for every state, and thus provider education, are constantly evolving to improve the safety of patients treated with sedation and general anesthesia. The ADA, in addition to listing the sedation guidelines, also provides information with respect to requirements to obtain permits in different states. The other source for information on rules and regulations governing sedation and dental anesthesiology can be found in Dental Anesthesiology: A Guide to the Rules and Regulations [3]. As mentioned above, since regulations are constantly changing, readers are advised to contact their respective boards for more updated information with respect to sedation and general anesthesia in their state.

In summary, individual state dental boards use their state dental practice acts to protect patient’s safety and welfare and thus influence provider training. State law supersedes those sedation guidelines approved and propagated by national organizations such as the American Dental Association (ADA), American Academy of Pediatric Dentistry (AAPD), and the American Association of Oral and Maxillofacial Surgeons (AAOMS). This necessitates the need for all states to act in a unified manner and develop similar guidelines to decrease adverse events and reduce confusion. To do so would help educational institutions and organizations to develop standardized continuing education courses and training without much variation. This in turn will increase patient safety and provider compliance with sedation regulations. Sedation permit requirements are available online for most states.

Currently, no requirement exists for training dentists in sedative techniques, according to the most recent iteration of the accreditation standards for predoctoral dental education. The most recent standards are general in nature and do mandate that a graduate who is deemed competent to practice (1) have biomedical and behavioral science training, (2) be able to handle certain medical emergencies, and (3) be able to manage pain and anxiety in patients [4]. In implementation of these three areas relevant to sedation, depth and variation exist across the spectrum of dental education, with no exposure to and competence in sedation a guarantee. Some dental education programs offer exposure to nitrous oxide/oxygen analgesia to selected students but without a specific competency requirement; these experiences are variable. A few dental education programs offer elective experiences in various forms of sedation but limit student experiences. Some of these aim to provide adequate numbers of cases to enable participants to approach or meet state requirements for sedation certification upon graduation. In summary, predoctoral dental education does not uniformly graduate practitioners with sedation competency but does provide some prerequisites necessary for certification and practice. A small but unknown number of dentists do acquire basic skills in their predoctoral education program that would permit acquisition of permits in some states.

Table 12.1 portrays the disposition of sedation training in standards for the dental specialties [5]. Characteristics of these training standards are a wide range of experiences, ranging from pain and anxiety control in rather nonspecific language to specific reference to documents and guidelines, numbers and types of patient experiences, and adjunctive qualifications such as ACLS or PALS. To some degree, the waning concept of the operator-anesthetist drives the intensity of training in sedation across specialties. Oral and maxillofacial surgery and pediatric dentistry are two specialties that utilize this dual role in day-to-day practice. It also appears that when a specialty organization has a policy on sedation or its own guidelines, it tends to have more specific and rigorous training standards. Diagnostic specialties such as oral and maxillofacial pathology and radiology do not have strict training mentioned in their advanced standards which is understandable by the nature of their scope of practice and lack of need for these skills. Specialties and accredited training programs that have numbers of cases also tend to have required training encompassing all of the areas that are common to sedation guidelines such as basic biomedical science, assessment of patients, pharmacology, and management of emergencies (some requiring advanced skills). The numbers maximally are intended to provide the perceived broad experience to insure safety in practice upon graduation and minimally to meet the typical number of cases required by states for certification in some form of sedation. Specialty programs are also moving toward a long-standing medical practice of case logs for sedation patients treated in training as licensing authorities move to more intense scrutiny of training in light of publicized morbidity and mortality from sedation.

In summary, a wide range of training exists among advanced programs in dentistry, which is perhaps reflective of the perceived need for those skills in day-to-day practice of the respective specialty. Readers are encouraged to review training standards on the website of the Commission on Dental Accreditation as these are subject to change and are reviewed and revised on a periodic basis by the respective specialty or accredited interest area in dentistry.