PURPOSE: This rule expands the functions a dental assistant may perform under the dentist’s direct supervision and outlines the procedure for issuing and renewing expanded function permits.

1. (1) Definitions.

   1. (A) Accredited dental assisting program—A dental assisting educational program accredited by the Commission on Dental Accreditation of the American Dental Association.
   2. (B) Certified dental assistant—A dental assistant who is currently certified by the Dental Assisting National Board, Inc.
   3. (C) Dental assistant—An employee of a duly registered and currently licensed dentist in Missouri, other than either a dental hygienist or a certified dental assistant.
   4. (D) Dental auxiliary—Either a dental assistant or certified dental assistant as defined in subsections (1)(B) and (C).

   5. (E) Direct supervision—The following conditions must be satisfied for direct supervision to apply:

      1. 1. The dentist is in the dental office or treatment facility;
      2. 2. The dentist has personally diagnosed the condition to

be treated;

1. 3. The dentist has personally authorized the procedures;
2. 4. The dentist remains in the dental office or treatment fa-

cility while the procedures are being performed by the dental auxiliary; and

1. 5. The dentist evaluates the performance of the dental aux-

iliary before the dismissal of the patient.

1. (F) Expanded functions approved course provider—A provider of expanded functions curriculum and competency testing approved by the Missouri Dental Board.
2. (G) Expanded functions permit—A permit issued by the Missouri Dental Board authorizing a dental assistant, certified dental assistant, or Missouri licensed dental hygienist to perform expanded functions duties upon delegation from a Missouri licensed dentist. Expanded functions permits will be issued in the following categories: restorative I, restorative II, removable prosthodontics, fixed prosthodontics, and orthodontics.
3. (H) Missouri Test of Basic Dental Assisting Skills—A test of basic knowledge of dental assisting approved by the board including terminology, principles of asepsis, disinfection and sterilization, and other concepts of dental assisting deemed necessary to master courses in more advanced assisting functions.
4. (I) Proof of competence—Documentation, such as a diploma, a certificate of mastery, or a letter from an approved course provider or competency testing agent stating that the dental auxiliary has successfully completed a board-approved course of training and competency testing of that training.

1. (2) Prohibited Acts.

   1. (A) A registered and currently licensed dentist may not delegate to a dental assistant or certified dental assistant, as defined in subsections (1)(B) and (C) respectively, the performance of the following procedures:

      1. 1. Diagnosis, including interpretation of dental radio-

graphs and treatment planning;

1. 2. Cutting of tooth structure;
2. 3. Surgical procedures on hard and soft tissues including,

but not limited to, the removal of teeth and the cutting and suturing of soft tissues;

1. 4. The prescription, injection, and parenteral administra-

tion of drugs;

1. 5. The final bending of archwire prior to ligation;
2. 6. The scaling of teeth; and
3. 7. Administration of nitrous oxide-oxygen analgesia except

that a dental assistant or certified dental assistant may assist in the administration of and monitor nitrous oxide-oxygen analgesia with specific training as provided in section (3) of this rule.

1. (3) Permitted Acts.

   1. (A) A dental assistant or certified dental assistant may assist in the administration of and monitor nitrous oxide analgesia under direct supervision if s/he—

      1. 1. Has successfully completed formal certified training in a

course approved by the Missouri Dental Board; and

1. 2. Has successfully passed an approved competency test

regarding the clinical and didactic training; or

1. 3. Has been certified in another state to assist in the ad-

ministration of and monitor nitrous oxide subsequent to equivalent training and testing. The dental assistant may qualify to perform these functions by presenting proof of competence of this equivalent training and testing to the Missouri Dental Board.

1. (4) Expanded Functions Permits.

   1. (A) Effective December 1, 2012, a currently licensed dentist may delegate, under direct supervision, functions listed in section (5) of this rule to a dental assistant possessing a board-issued permit authorizing the dental assistant to perform expanded functions duties. To qualify for a board-issued permit to perform expanded functions duties, the dental assistant must provide the board with the following:

      1. 1. Proof of certification as a certified dental assistant from

the Dental Assisting National Board and proof of competence as defined in subsection (1)(I) showing graduation from an accredited dental assisting program in which competency testing in the appropriate expanded functions category was completed; or

1. 2. Proof of certification as a certified dental assistant from

the Dental Assisting National Board and proof of competence as defined in subsection (1)(I) showing the dental assistant has completed a board-approved expanded functions training course; or

1. 3. Proof of competence as defined in subsection (1)(I) show-

ing that the dental assistant has passed the board’s Missouri Test of Basic Dental Assisting Skills and that the dental assistant has completed a board-approved expanded functions training course; and

1. 4. Evidence of 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.

1. (B) The board shall issue the appropriate expanded functions permit upon receipt of a completed application form, payment of the appropriate fee specified in 20 CSR 2110-2.170, and proof of competence as defined in subsection (1)(I) that the dental assistant has complied with the requirements of subsection (4)(A) of this rule. The requirements of this section must be completed within one (1) year of the date of submission of the application form. The board-issued expanded functions permit must be displayed in plain view in any facility where the dental assistant will be providing expanded functions prior to delegation of expanded functions to that dental assistant.
2. (C) Any dental assistant or certified dental assistant to whom a dentist could legally delegate expanded functions duties prior to December 1, 2012, or any dental assistant or certified dental assistant who meets the qualifications for a board-issued expanded functions permit prior to December 1, 2012, may submit their proof of competence to the Missouri Dental Board and be issued an expanded functions permit prior to December 1, 2012.

3. (D) Beginning March 1, 2013, every expanded functions permit issued by the board shall be renewed every five (5) years. In order to renew an expanded functions permit, the dental assistant shall submit to the board—

   1. 1. A completed renewal application form provided by the

board for each permit the permit holder wishes to renew;

1. 2. The renewal fee specified in 20 CSR 2110-2.170 payable

to the Missouri Dental Board for each permit the permit holder wishes to renew;

1. 3. Satisfactory evidence of completion of sixteen (16) hours

of continuing education from board-approved sponsors as specified in 20 CSR 2110-2.240(1)(C) during the five- (5-) year period immediately preceding the expiration date. All sixteen (16) hours of continuing education for renewal must be directly related to the updating and maintaining of knowledge and skills in the treatment, health, and safety of the individual dental patient. Permit holders shall only be required to complete sixteen (16) hours of continuing education regardless of the number of permits the permit holder wishes to renew. For any permits that are issued twelve (12) months or less from the expiration date of that permit, the permit holder shall only be required to obtain four (4) hours of board-approved continuing education to renew those permits. Each permit holder shall maintain documentation of completion of the required continuing education hours for five (5) years after the completion of the permit period in which the continuing education was earned; and

1. 4. Evidence of 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. (E) An expanded functions permit shall expire if not renewed on or before the permit expiration date. An expired permit can be renewed at any time within one (1) year of the permit expiration date. Any expired expanded functions permit that is not renewed within one (1) year of the expiration date shall be void.

1. (5) Categories.

   1. (A) Functions delegable to a dental assistant possessing a board-issued permit to perform expanded functions are divided into five (5) categories; restorative I, restorative II, removable prosthodontics, fixed prosthodontics, and orthodontics and are listed below by category.

      1. 1. Restorative I—

         1. A. Sizing and cementing of prefabricated crowns;
         2. B. Placing, condensing, carving, and finishing amalgam

for Class I, V, and VI restorations;

1. C. Placing and finishing composite for Class I, V, and VI

restorations; and

1. D. Minor palliative care of dental emergencies (place

sedative filling).

1. 2. Restorative II—

   1. A. Sizing and cementing of prefabricated crowns;
   2. B. Placing, condensing, carving, and finishing amalgam

for Class I, II, III, IV, V, and VI restorations;

1. C. Placing and finishing composite for Class I, II, III, IV, V,

and VI restorations; and

1. D. Minor palliative care of dental emergencies (place

sedative filling).

1. 3. Orthodontics—

   1. A. Preliminary bending of archwire;
   2. B. Removal of orthodontic bands and bonds;
   3. C. Final cementation of any permanent orthodontic

appliance or prosthesis;

1. D. Making impressions for the fabrication of any

orthodontic prosthesis/appliance; and

1. E. Placement and cementation of orthodontic brackets

and/or bands.

1. 4. Prosthodontics—Fixed—

   1. A. Apply tissue retracting material prior to impression of

a fixed prosthesis;

1. B. Extra-oral adjustments of fixed prosthesis;
2. C. Final cementation of any permanent appliance or

prosthesis;

1. D. Making impressions for the fabrication of any

removable or fixed prosthesis/appliance; and

1. E. Sizing and cementing of prefabricated crowns.

2. 5. Prosthodontics—Removable—

   1. A. Placement of temporary soft liners in a removable

prosthesis;

1. B. Extra-oral adjustments of removable prosthesis during

and after insertion; and

1. C. Making impressions for the fabrication of any

removable or fixed prosthesis/appliance.

1. (6) Expanded Functions Course Providers.

   1. (A) The board may approve expanded functions course providers that satisfy the following minimum criteria:

      1. 1. Uses course curriculum approved by the board;
      2. 2. Demonstrates that faculty at each course include at least

one (1) dentist and that the student to faculty ratios do not exceed one (1) faculty member per ten (10) students;

1. 3. Demonstrates that adequate faculty calibration occurs

to insure that educational standards are maintained;

1. 4. Demonstrates that adequate testing, monitoring, and

evaluation is in place to assure that graduates can be certified as having attained mastery of the component skills and concepts in a laboratory setting; and

1. 5. Demonstrates that mechanisms are in place to provide

the board with data on the outcomes of expanded functions duty dental assisting training by reporting on follow-up blind surveys of certificated assistants, supervising dentists, and patients.

1. (7) Delegated Acts.

   1. (A) A currently licensed dentist may delegate under direct supervision to a dental assistant or certified dental assistant any functions not specifically referenced in section (5) of this rule and not considered either the practice of dentistry or the practice of dental hygiene as defined in sections 332.071 and 332.091, RSMo, and 20 CSR 2110-2.130.
   2. (B) The licensed dentist is responsible for determining the appropriateness of delegation of any specific functions based upon knowledge of the skills of the auxiliary, the needs of the patient, the requirements of the task, and whether proof of the competence is required.
   3. (C) Pursuant to section 332.031.2., RSMo, the licensed dentist is ultimately responsible for patient care. Nothing contained in the authority given the licensed dentist by this rule to delegate the performance of certain procedures shall in any way relieve the supervising licensed dentist from liability to the patient for negligent performance by a dental assistant or certified dental assistant. Expanded functions permits shall be subject to discipline as provided in section 332.321, RSMo.

AUTHORITY: sections 332.011, 332.031.2., and 332.098, RSMo 2016.* This rule originally filed as 4 CSR 110-2.120. Original rule filed Dec. 12, 1975, effective Jan. 12, 1976. Rescinded and readopted: Filed April 14, 1982, effective Oct. 11, 1982. Amended: Filed Feb. 10, 1983, effective June 11, 1983. Rescinded and readopted: Filed Oct. 13, 1983, effective Jan. 13, 1984. Amended: Filed May 2, 1988, effective July 28, 1988. Rescinded and readopted: Filed Feb. 16, 1994, effective Sept. 30, 1994. Emergency amendment filed Feb. 21, 1995, effective March 3, 1995, expired June 30, 1995. Amended: Filed March 14, 1995, effective Oct. 30, 1995. Moved to 20 CSR 2110-2.120, effective Aug. 28, 2006. Rescinded and readopted: Filed July 26, 2012, effective Feb. 28, 2013. Amended: Filed May 31, 2017, effective Nov. 30, 2017. ** Amended: Filed March 8, 2022, effective Sept. 30, 2022. *Original authority: 332.011, RSMo 1969, amended 1993, 1995, 2010; 332.031, RSMo 1969, amended 1981, 1993, 1995; and 332.098, RSMo 2010. **Pursuant to Executive Order 21-09, 20 CSR 2110-2.120, paragraph (4)(A)4. was suspended from April 10, 2020 through September 15, 2021.