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. (1) 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 FINANCIAL INSTITUTIONS AND PROFESSIONAL REGISTRATION

1 every five (5) years from the date of issuance.

1. (2) 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 date of issuance. The dentist-in-charge is responsible for submitting the application and maintaining the documentation as required in sections (6) and
2. (8) of this rule.
3. (3) No dentist shall prescribe deep sedation/general anesthesia agents unless the dentist possesses a deep sedation/general anesthesia permit.
4. (4) If the primary administrator of deep sedation/general anesthesia 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 anesthesia 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 a permit to administer deep sedation/general anesthesia, a dentist shall:

   1. (A) Document satisfactory completion of:

      1. 1. A post-doctoral training program in

anesthesia and related subjects that satisfies the requirements described in Part II of the American Dental Association (ADA) Guidelines for Teaching the Comprehensive Control of Pain and Anxiety in Dentistry at the time the training was commenced; or

1. 2. An ADA accredited post-doctoral

training program in oral and maxillofacial surgery; or

1. 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); and

1. (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;
2. (C) Successfully complete an on-site evaluation as defined in subsection (6)(C) of this rule; and
3. (D) Document that the facility to be used for deep sedation/general anesthesia has been issued a deep sedation/general anesthesia site certificate.

1. (6) To qualify for a deep sedation/general anesthesia site certificate the dental office must—

   1. (A) Be properly equipped in accordance with the American Association of Oral and Maxillofacial Surgeons (AAOMS) Office Anesthesia Evaluation Manual, 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

2. (ECG) monitoring and pulse oximetry. This rule does not incorporate any subsequent amendments or additions;

   1. (B) Have and maintain personnel capable of handling procedures and emergencies incident to the administration of deep sedation/general anesthesia;
   2. (C) Undergo and successfully complete an on-site evaluation by consultants appointed by the board to confirm the adequacy of the facility and competency of the personnel. On-site evaluations shall be conducted in accordance with guidelines in the current AAOMS Office Anesthesia Evaluation Manual; and

   3. (D) The dentist in charge of the dental office shall document that:

      1. 1. The administrator of deep seda-

tion/general anesthesia is a qualified sedation provider as defined in 4 CSR 110-4.030; and

1. 2. All anesthesia team members, includ-

ing the operating dentist, possess and maintain current certification in cardiopulmonary resuscitation (CPR), basic life support (BLS), or ACLS.

1. (7) 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 (5) 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.
2. (8) 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 (6) 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.
3. (9) The board may authorize a dentist initially applying for a deep sedation/general anesthesia permit to administer deep sedation/general anesthesia pending an onsite evaluation according to subsection (6)(C) of this rule providing all other requirements outlined in sections (5) and (7) have been met. Such authorization shall be in writing and in effect for a period not to exceed ninety (90) days.
4. (10) When the primary administrator of anesthesia at a dental office is not a dentist with a valid deep sedation/general anesthesia permit, the board may authorize the dentist initially applying for a deep sedation/general anesthesia site certificate to allow the primary administrator to administer deep sedation/general anesthesia pending an on-site evaluation according to subsection (6)(C) of this rule providing all other requirements outlined in sections (6) and (8) have been met. Such authorization shall be in writing and in effect for a period not to exceed ninety (90) days.
5. (11) Subsequent to an on-site evaluation as outlined in subsection (6)(C) of this rule, the board, at its discretion, may issue a temporary authorization to administer deep sedation/general anesthesia to any dental office, providing all other provisions of this rule have been met. Such authorization shall be in writing and in effect for a period not to exceed ninety (90) days. A reevaluation may be undertaken prior to the issuance of a site certificate. The fee for the reevaluation shall be the same as the initial evaluation.
6. (12) To renew a deep sedation/general anesthesia permit a dentist shall, at least ninety

7. (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;

   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. (D) Successfully complete an on-site evaluation as defined in subsection (6)(C) of this rule.

1. (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:

   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 deep sedation/general anesthesia is a qualified sedation provider as set forth in 4 CSR 110-4.010(1)(S);
   4. (D) Document that anesthesia team members, including the operating dentist, possess and maintain current certification in CPR, BLS, or ACLS; and
   5. (E) Successfully complete an on-site evaluation as defined in subsection (6)(C) of this rule.
2. (14) A dentist holding a permit for authorization for the administration of deep sedation/general anesthesia under the provisions of this rule may administer enteral and/or parenteral conscious sedation without a permit for enteral and/or parenteral conscious sedation as required under 4 CSR 110-4.020.
3. (15) 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.
4. (16) 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.
5. (17) The provisions of this rule are declared severable. If any provision of this rule is held 20 CSR 2110-4

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 110-4.040. Original rule filed Sept. 15, 2004, effective April 30, 2005. Moved to 20 CSR 2110-4.040, 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.