Deep Sedation/General Anesthesia

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 American Dental 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 American Dental 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 nondentists 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. AUTHORITY: sections 332.031 and 332.361, RSMo 2000, and section 332.071, RSMo Supp. 2012.* 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. Amended: Filed July 26, 2012, effective Feb. 28, 2013. ** *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. **Pursuant to Executive Order 21-09, 20 CSR 2110-4.040, paragraph (8)(B)1. and subsection (13)(D) was suspended from April 10, 2020 through September 15, 2021.