PURPOSE: This rule provides for the regulation of the administration of conscious sedation in a dental office.

1. (1) No dentist shall administer enteral and/or parenteral conscious sedation unless the dentist possesses a conscious sedation permit issued by the Missouri Dental Board. (A dentist is not required to possess a permit for the prescription or administration of drugs prescribed for anxiolysis and/or pain control.) This permit shall be renewed by June 1 every five (5) years from the year of issuance.
2. (2) No dentist shall prescribe sedative agents for enteral sedation unless the dentist possesses an enteral or parenteral conscious sedation permit issued by the Missouri Dental Board. No dentist shall prescribe parenteral conscious sedation agents unless the dentist possesses a parenteral conscious sedation permit issued by the Missouri Dental Board.
3. (3) No dentist shall administer enteral and/or parenteral conscious sedation at a dental office unless the office has been issued a site certificate by the Missouri Dental Board. No dental office shall be the site for the administration of enteral and/or parenteral conscious sedation without being issued a site certificate by the Missouri Dental Board. This 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 (8) and (10) of this rule. FINANCIAL INSTITUTIONS AND PROFESSIONAL REGISTRATION
4. (4) If the primary administrator of enteral and/or parenteral conscious sedation in a dental office is an anesthesiologist or a nurse anesthetist, the 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 sedation team, and the maintenance of appropriate records. The dentist must evaluate the patient prior to the procedure, remain in the dental office, and evaluate the patient prior to discharge.

5. (5) To qualify for an enteral conscious sedation permit, a dentist shall:

   1. (A) Document satisfactory completion of:

      1. 1. Training consistent with Part I and

Part III of the American Dental Association (ADA) Guidelines for Teaching the Comprehensive Control of Pain and Anxiety in Dentistry; or

1. 2. An ADA accredited post-doctoral

training program that affords training necessary to administer enteral conscious sedation; or

1. 3. An enteral conscious sedation course

approved by the Missouri Dental Board; and

1. (B) Document completion during the past five (5) years of—

   1. 1. An Advanced Cardiac Life Support

(ACLS) course; or

1. 2. A minimum of fifteen (15) hours of

other board-approved continuing education pertaining to medical emergencies, anesthesia complications, or patient management while under sedation.

1. 3. Additional hours, not to exceed five

(5), acquired beyond the required number may be carried forward into the renewal cycle.

1. (6) To qualify for a permit to administer enteral and parenteral conscious sedation, a dentist shall:

   1. (A) Document satisfactory completion of a postgraduate program which is approved or accredited to teach postgraduate dental or medical education by the ADA, the Accreditation Council for Graduate Medical Education of the American Medical Association (AMA), or the Education Committee of the American Osteopathic Association (AOA). This program shall include:

      1. 1. Sixty (60) hours of didactic training

in pain and anxiety control and related subjects in accordance with the guidelines of the ADA;

1. 2. Successful management of parenteral

conscious sedation in twenty (20) patients;

1. 3. General anesthesia training in which

there is documented clinical experience in managing compromised airways;

1. 4. Certification of competency by the

course director in airway management; and

1. 5. Certification of competency by the

course director in parenteral conscious sedation;

1. (B) Document completion during the past five (5) years of—

   1. 1. An Advanced Cardiac Life Support

(ACLS) course; or,

1. 2. A minimum of fifteen (15) hours of

other board-approved continuing education pertaining to medical emergencies, anesthesia complications, or patient management while under sedation.

1. 3. Additional hours, not to exceed five

(5), acquired beyond the required number may be carried forward into the renewal cycle;

1. (C) Successfully complete an on-site evaluation by consultants appointed by the board. On-site evaluations shall be conducted in accordance with 4 CSR 110-4.030.

1. (7) To qualify for a conscious sedation site certificate:

   1. (A) The dentist-in-charge of the dental office shall document that:

      1. 1. The primary administrator of enteral

and/or parenteral conscious sedation is a qualified sedation provider as set forth in 4 CSR 110-4.010(1)(S);

1. 2. All conscious sedation team members

(two (2) minimum) and the dentist, possess and maintain current certification in cardiopulmonary resuscitation (CPR), basic life support (BLS), or ACLS;

1. 3. All conscious sedation team mem-

bers, including the dentist, possess certification from a board-approved course provider in monitoring conscious sedation. Such certification for non-dentists shall be that approved by their respective licensing authority;

1. 4. The dental office is properly main-

tained and equipped as set forth in 4 CSR 110-4.030; and

1. 5. The dental office has written proto-

cols for sedation of dental patients as set forth in 4 CSR 110-4.030 including but not limited to the following:

1. A. Preoperative patient evaluation and

selection prior to conscious sedation;

1. B. Informed consent procedures;
2. C. Sedation monitoring procedures;
3. D. Maintaining appropriate records

during sedation procedures;

1. E. Patient discharge assessment; and
2. F. Responding to emergencies inci-

dent to the administration of enteral and/or parenteral conscious sedation.

1. (B) The dental office shall undergo a facility inspection as set forth in 4 CSR 110-4.030 to confirm the adequacy of the dental office and the competency of the sedation team.

1. (8) The board shall issue an enteral and/or parenteral conscious sedation permit upon receipt of a completed application form, payment of the appropriate fee specified in 4 CSR 110-2.170, proof of having met the requirements of sections (5) and/or (6) 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 must be completed within one (1) year of the date of submission of the application form.
2. (9) The board shall issue a conscious sedation site certificate upon receipt of a completed application form, payment of the appropriate fee specified in 4 CSR 110-2.170, and proof of having met the requirements of section (7) of this rule. The requirements of this section must be completed within one (1) year of the date of submission of the application form.

3. (10) To renew a permit to administer enteral and/or parenteral conscious sedation a dentist shall, at least ninety (90) days prior to the expiration of the current permit:

   1. (A) Submit a completed renewal application form provided by the board;
   2. (B) Submit the renewal fee specified in 4 CSR 110-2.170 payable to the Missouri Dental Board; and

   3. (C) Document completion during the past five (5) years of—

      1. 1. An Advanced Cardiac Life Support

(ACLS) course; or

1. 2. A minimum of fifteen (15) hours of

other board-approved continuing education pertaining to medical emergencies, anesthesia complications, or patient management while under sedation.

1. 3. Additional hours, not to exceed five

(5), acquired beyond the required number may be carried forward into the renewal cycle.

1. (11) To renew a site certificate for enteral and/or parenteral conscious sedation the dentist-in-charge shall, at least ninety (90) days prior to the expiration of the current site certificate:

   1. (A) Submit a completed renewal application form provided by the board;
   2. (B) Submit the renewal fee specified in 4 CSR 110-2.170 payable to the Missouri Dental Board;
   3. (C) Attest that the primary administrator of enteral and/or parenteral conscious sedation is a qualified sedation provider as set forth in 4 CSR 110-4.010(1)(S);
   4. (D) Document that the sedation team, as well as the permitted dentist, possess and maintain current certification in CPR, BLS, or ACLS;
   5. (E) Submit to the board a minimum of five

2. (5) unedited, complete patient records of the permitted dentist, anesthesiologist, or nurse anesthetist administering conscious sedation in the dental office that may be chosen by the board from the preceding five (5) years, documenting management of conscious sedation patients in accordance with the criteria set forth in 4 CSR 110-4.030; and

   1. (F) Undergo a facility inspection as set forth in 4 CSR 110-4.030 to confirm the adequacy of the dental office and the competency of the sedation team.
3. (12) A dentist holding a current intravenous conscious sedation (IVCS) permit or a parenteral conscious sedation permit on or before the effective date of this rule, shall be authorized to perform all means of parenteral conscious sedation set forth in 4 CSR 110- 4.010(1)(Q).
4. (13) A dentist holding a current IVCS permit or a parenteral conscious sedation permit on or before the effective date of this rule shall, upon renewal, receive a permit to administer enteral and parenteral conscious sedation upon compliance with the renewal requirements set forth in section (10) of this rule.
5. (14) A dentist holding a permit of authorization for the administration of deep sedation/general anesthesia under 4 CSR 110- 4.040 may use conscious sedation without a permit for conscious sedation.
6. (15) The dentist-in-charge of a dental office in receipt of a conscious sedation site certificate must insure that the conscious sedation team meet the clinical requirements and the dental office meets the standards for utilization as set forth in 4 CSR 110-4.030.
7. (16) At any time, the board may inspect a dental office where conscious sedation is administered in order to verify compliance with the minimum requirements of this rule.
8. (17) If at any time the board learns that a dentist who holds a permit to administer enteral and/or parenteral conscious sedation, or a site certificate where enteral and/or parenteral conscious sedation is administered, 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.
9. (18) Due to narrow therapeutic dose ranges for conscious sedation, use of thiopental, methohexital, and propofol for conscious sedation of dental patients will be restricted to qualified deep sedation/general anesthesia providers as defined in 4 CSR 110-4.040.
10. (19) 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.

AUTHORITY: sections 332.031 and 332.361 RSMo 2000 and 332.071 RSMo Supp. 2004.* This rule originally filed as 4 CSR 110-4.020. Original rule filed Sept. 15, 2004, effective April 30, 2005. Moved to 20 CSR 2110-4.020, effective Aug. 28, 2006. *Original authority: 332.031, RSMo 1969, amended 1981, 1993, 1995; 332.071, RSMo 1969, amended 1976, 1995, 2003, 2004; and 332.361, RSMo 1969, 1981.