Current through Register Vol. 49, No. 18, September 16, 2024
PUBLISHER'S NOTE: The secretary of state has
determined that the publication of the entire text of the material which is
incorporated by reference as a portion of this rule would be unduly cumbersome
or expensive. This material as incorporated by reference in this rule shall be
maintained by the agency at its headquarters and shall be made available to the
public for inspection and copying at no more than the actual cost of
reproduction. This note applies only to the reference material. The entire text
of the rule is printed here.
PURPOSE: This rule provides for the regulation of the
administration of deep sedation/general anesthesia.
(1) Because sedation and general anesthesia
are a continuum, it is not always possible to predict how an individual patient
will respond. Hence, practitioners intending to produce a given level of
sedation should be able to diagnose and manage the physiologic consequences
(rescue) for patients whose level of sedation becomes deeper than initially
intended. For all levels of sedation, the practitioner must have the training,
skills, drugs, and equipment to identify and manage such an occurrence until
either assistance arrives (emergency medical service) or the patient returns to
the intended level of sedation without airway or cardiovascular
complication.
(2) No dentist shall
administer deep sedation/general anesthesia unless the dentist possesses a
permit issued by the Missouri Dental Board. This permit shall be renewed by
June 1 every five (5) years from the year of issuance.
(3) No dental office shall be the site for
the administration of deep sedation/general anesthesia without being issued a
site certificate issued by the Missouri Dental Board. The site certificate
shall be renewed by June 1 every five (5) years from the year of issuance. The
dentist-in-charge is responsible for submitting the application and maintaining
the documentation as required in sections (7) and (9) of this rule.
(4) No dentist shall prescribe deep
sedation/general anesthesia agents unless the dentist possesses a deep
sedation/general anesthesia permit.
(5) If the primary administrator of deep
sedation/general anesthesia in a dental office is a certified registered nurse
anesthetist, the operating dentist must possess a deep sedation/general
anesthesia permit.
(6) If the
primary administrator of deep sedation/general anesthesia in a dental office is
an anesthesiologist or a certified registered nurse anesthetist, the operating
dentist must order the anesthesia services, is responsible for the readiness of
the dental office, preoperative patient evaluation and appropriate medical
consultations, the coordination of and emergency preparedness of the anesthesia
team, and the maintenance of appropriate records. The operating dentist must
evaluate the patient prior to the procedure, remain in the dental office, and
evaluate the patient prior to discharge.
(7) To qualify for a permit to administer
deep sedation/general anesthesia, a dentist shall-
(A) Document satisfactory completion of-
1. An advanced educational program accredited
by the Americandental Association (ADA) Commission on Dental Accreditation that
affords comprehensive and appropriate training necessary to administer and
manage deep sedation or general anesthesia, commensurate with Part IV. C of
these guidelines. For all levels of sedation and anesthesia, dentists, who are
currently providing sedation and anesthesia in compliance with their state
rules and/or regulations prior to adoption of this document, are not subject to
these additional requirements; or
2. An ADA-accredited post-doctoral training
program in oral and maxillofacial surgery; or
3. An anesthesia training program that is
approved and accredited to teach postgraduate medical education by the
Accreditation Council for Graduate Medical Education of the American Medical
Association (AMA), or the Education Committee of the American Osteopathic
Association (AOA); or
4. A
Diplomate of the Americandental Board of Anesthesiology;
(B) Document completion of an Advanced
Cardiac Life Support (ACLS) course or board-approved equivalent during the past
five (5) years or a minimum of fifteen (15) hours of other board-approved
continuing education pertaining to medical emergencies, anesthetic
complications, or patient management while under deep sedation/general
anesthesia. Additional hours, not to exceed five (5), acquired beyond the
required number may be carried forward into the renewal cycle;
(C) Undergo and successfully complete an
on-site evaluation by consultants appointed by the board or other qualified
personnel approved by the board to confirm the adequacy of the facility and the
competency of the personnel. On-site evaluations shall be conducted in
accordance with the guidelines in the current American Association of Oral and
Maxillofacial Surgeons (AAOMS) Office Anesthesia Evaluation
Manual; and
(D) Document
that the facility to be used for deep sedation/general anesthesia has been
issued a deep sedation/general anesthesia site certificate.
(8) To qualify for a deep
sedation/general anesthesia site certificate the dental office must-
(A) Be properly equipped in accordance with
the AAOMS Office Anesthesia Evaluation Manual, 8th Edition,
2012, American Association of Oral and Maxillofacial Surgeons, 9700 West Bryn
Mawr Avenue, Rosemont, IL 60018-5701, which is incorporated by reference,
including but not limited to the capability of delivering positive pressure
oxygen, blood pressure and electrocardiographic (ECG) monitoring, and pulse
oximetry. This rule does not incorporate any subsequent amendments or
additions;
(B) Have and maintain
personnel capable of handling procedures and emergencies incident to the
administration of deep sedation/general anesthesia including but not limited
to:
1. All deep sedation/general anesthesia
sedation team members (two (2) minimum) and the operating dentist possess and
maintain current certification in the American Heart Association's Basic Life
Support for the Healthcare Provider (BLS), or an equivalent certification
approved by the Missouri Dental Board. Board-approved courses shall meet the
American Heart Association guidelines for cardiopulmonary resuscitation (CPR)
and emergency cardiovascular care (ECC) and provide written and manikin testing
on the course material by an instructor who is physically present with the
students. Online only courses will not be accepted to satisfy the BLS
requirement or ACLS; and
2. All
deep sedation/general anesthesia sedation team members, including the operating
dentist, have completed a board-approved course in monitoring sedated patients
during the past five (5) years. Certification of non-dentists shall be approved
by their respective licensing authorities;
(C) Undergo and successfully complete a
facility inspection by consultants appointed by the board or other qualified
personnel approved by the board to confirm the adequacy of the facility and the
qualifications of the deep sedation/general anesthesia sedation team;
and
(D) The dentist in charge of
the dental office shall document that-
1. The
administrator of deep sedation/general anesthesia is a qualified sedation
provider as defined in
20 CSR 2110-4.010;
and
2. All anesthesia team members,
including the operating dentist, possess and maintain current certification in
the American Heart Association's Basic Life Support for the Healthcare Provider
(BLS) or an equivalent certification approved by the Missouri Dental Board.
Board-approved courses shall meet the American Heart Association guidelines for
cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) and
provide written and manikin testing on the course material by an instructor who
is physically present with the students. Online only courses will not be
accepted to satisfy the BLS requirement or ACLS.
(9) The board shall issue a deep
sedation/general anesthesia permit upon receipt of a completed application form
provided by the board, payment of the appropriate fee, proof of having met the
requirements of section (7) of this rule and determination that the applicant
is a licensee in good standing. To be in good standing the licensee's dental
license(s) must be current and not under restriction or discipline in any
state. The requirements of this section and the on-site evaluation must be
completed within one (1) year of the date of submission of the application
form.
(10) The board shall issue a
deep sedation/general anesthesia site certificate upon receipt of a completed
application form provided by the board, payment of the appropriate fee, and
proof of having met the requirements of section (8) of this rule. The
requirements of this section and the on-site evaluation for each site to be
authorized must be completed within one (1) year of the date of submission of
the application form.
(11) The
board may authorize a dentist initially applying for a deep sedation/general
anesthesia permit to administer deep sedation/general anesthesia in order to
complete an on-site evaluation according to subsection (8)(C) of this rule
providing all other requirements outlined in sections (7) and (9) have been
met. Such authorization shall be in writing and in effect for a period not to
exceed ninety (90) days.
(12) To
renew a deep sedation/general anesthesia permit a dentist shall, at least
ninety (90) days prior to the expiration of the current permit-
(A) Submit a completed renewal application
form provided by the board;
(B)
Submit the renewal fee specified in
20 CSR 2110-2.170 payable to
the Missouri Dental Board;
(C)
Document-
1. Current certification in
Advanced Cardiac Life Support (ACLS); and
2. Completion during the past five (5) years
of a minimum of fifteen (15) hours of other board-approved continuing education
pertaining to airway management in sedated patients.
3. Additional hours, not to exceed five (5),
acquired beyond the required number may be carried forward into the renewal
cycle;
(D) Successfully
complete an on-site evaluation as defined in subsection (6)(C) of this
rule.
(13) To renew a
site certificate for deep sedation/general anesthesia the dentist-in-charge
shall, at least ninety (90) days prior to the expiration of the current site
certificate-
(A) Submit a completed renewal
application form provided by the board;
(B) Submit the renewal fee specified in
20 CSR 2110-2.170 payable to
the Missouri Dental Board;
(C)
Attest that the primary administrator of deep sedation/general anesthesia is a
qualified sedation provider as set forth in
20 CSR
2110-4.010(1)(CC);
(D) Document that anesthesia team members,
including the operating dentist, possess and maintain current certification in
the American Heart Association's Basic Life Support for the Healthcare Provider
(BLS) or an equivalent certification approved by the Missouri Dental Board.
Board-approved courses shall meet the American Heart Association guidelines for
cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) and
provide written and manikin testing on the course material by an instructor who
is physically present with the students. Online only courses will not be
accepted to satisfy the BLS requirement or ACLS;
(E) Document that all deep sedation/general
anesthesia sedation team members, including the operating dentist, have
completed a board-approved course in monitoring sedated patients during the
past five (5) years; and
(F)
Undergo and successfully complete a facility inspection by consultants
appointed by the board or other qualified personnel approved by the board to
confirm the adequacy of the facility and the qualifications of the deep
sedation/general anesthesia sedation team.
(14) Each dentist possessing a permit to
administer deep sedation/general anesthesia shall maintain current
certification in Advanced Cardiac Life Support (ACLS) at all times the sedation
permit is active.
(15) A dentist
holding a permit for authorization for the administration of deep
sedation/general anesthesia under the provisions of this rule may administer
enteral, parenteral, or pediatric moderate sedation without a permit for
enteral and/or parenteral moderate sedation as required under
20 CSR
2110-4.020.
(16) At any time, the board may inspect sites
where deep sedation/general anesthesia is administered in order to verify
compliance with the minimum requirements of this rule.
(17) If at any time the board learns that a
dentist who holds a deep sedation/general anesthesia permit, or a deep
sedation/general anesthesia site certificate, has failed to meet the minimum
qualifications set out in this rule, the board may pursue disciplinary action
in accordance with section
332.321,
RSMo.
(18) The provisions of this
rule are declared severable. If any provision of this rule is held invalid by a
court of competent jurisdiction, the remaining provisions of this rule shall
remain in full force and effect unless otherwise determined by a court of
competent jurisdiction.
*Original authority: 332.031, RSMo 1969, amended 1981,
1993, 1995; 332.071, RSMo 1969, amended 1976, 1995, 2003, 2004, 2006; and
332.361, RSMo 1969, amended 1981.
