216-RICR-40-05-2. Dentists, Dental Hygienists, and Dental Assistants (version Amendment, 03/13/2006 to 10/18/2007)

RULES AND REGULATIONS PERTAINING TO DENTISTS - DENTAL HYGIENISTS - AND DENTAL ASSISTANTS (R5-31.1-DHA) STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS DEPARTMENT OF HEALTH BOARD OF EXAMINERS IN DENTISTRY July 1959 As Amended: January 1964 May 1977 January 1986 August 1988 October 1989 February 1991(E) June 1991(E) September 1991 (E) January 1992 (E) April 1992 February 1993 April 1996 July 1999 November 2001 January 2002 (re-filing in accordance with the provisions of section 42-35-4.1 of the Rhode Island General Laws, as amended) November 2004 February 2006 i INTRODUCTION These rules and regulations are promulgated pursuant to the authority conferred under Chapter 5-31.1 of the General Laws of Rhode Island, as amended, and are established for the purpose of adopting prevailing standards governing the licensure of dentists and dental hygienists; the practice of dentistry as it pertains to dentists, dental hygienists and dental assistants; continuing education for dentists and dental hygienists; the administration of general anesthesia/deep sedation, inhalation conscious sedation, combined conscious sedation, parenteral conscious sedation, and/or nitrous oxide analgesia; and to establish administrative procedures for the implementation of the statutory and regulatory provisions. Pursuant to the provisions of section 42-35-3(c) of the General Laws of Rhode Island, as amended, consideration was given in arriving at the regulations as to: (1) alternative approaches to the regulations; and (2) duplication or overlap with other state regulations. No known overlap, duplication, alternative approach or significant economic impact was identified. Consequently, these amended rules and regulations are adopted in the best interest of the public health, safety and welfare. These amended rules and regulations shall supersede all previous rules and regulations pertaining to dentists and dental hygienists promulgated by the Rhode Island Department of Health and the Board of Examiners in Dentistry and filed with the Secretary of State. ii TABLE OF CONTENTS Page PART I DEFINITIONS 1 1.0 Definitions 1 PART II DENTISTS/LICENSING REQUIREMENTS 4 2.0 License Requirements 4 3.0 Qualifications 4 4.0 Application/Fee 5 5.0 Examinations 5 5.2 Continuing Education 6 6.0 Issuance and Renewal of License 7 PART III DENTAL HYGIENISTS/LICENSING REQUIREMENTS 9 7.0 License Requirements 9 8.0 Qualifications 9 9.0 Application/Fee 9 10.0 Examinations 10 10.2 Continuing Education 11 11.0 Issuance and Renewal of License 12 PART IV DELEGABLE/NON-DELEGABLE PROCEDURES/ DUTIES - SUPERVISION 14 12.0 General Requirements 14 12.1 Dental Hygienists 14 12.2 Certified Dental Assistants & Dental Assistants 14 13.0 Delegable Procedures/Duties 15 14.0 Non-Delegable (Exclusionary) Procedures/Duties 16 PART V ADMINISTRATION OF ANESTHESIA IN DENTAL OFFICES 18 15.0 General Requirements 18 16.0 Qualifications for Permit 18 17.0 Application for Permit 20 18.0 Issuance and Renewal of Permit 21 19.0 Inspections 21 20.0 Inactive Status 22 21.0 General Anesthesia/Deep Sedation, Inhalation Conscious Sedation, Parenteral Conscious Sedation, Combined Conscious Sedation, or Nitrous Oxide Analgesia Services 22 22.0 Administration of Local Anesthesia by Dental Hygienists 25 23.0 Physical Facility, Equipment & Safety 26 24.0 Violations & Sanctions 28 PART VI RECORD KEEPING & DISCLOSURE 29 25.0 Dental Records 29 26.0 Controlled Substances - Records 30 PART VII VIOLATIONS, SANCTIONS, SEVERABILITY 31 27.0 Denial, Suspension or Revocation of License, Violations & Sanctions 31 28.0 Rules Governing Practices & Procedures 33 29.0 Severability 33 REFERENCES 34 1 PART I Definitions Section 1.0 Definitions Whenever used in these rules and regulations the following terms shall be construed as follows: 1.1 "Act" refers to Chapter 5-31.1 entitled "Dentists and Dental Hygienists" of the General Laws of Rhode Island. 1.2 "Advisory consultants" means those individuals appointed by the Board to serve as advisory consultants to the Board in determining compliance with the statutory and regulatory provisions herein, of applicants seeking a permit to administer or to permit the administration of general anesthesia/deep sedation, conscious sedation, or nitrous oxide analgesia. Such consultants may be Diplomates of the American Board of Oral and Maxillofacial Surgery, Members or Fellows of the American Association of Oral and Maxillofacial Surgeons, or Fellows of the American Dental Society of Anesthesiology, and may include a Board Certified Anesthesiologist and a licensed dentist with experience in the administration of general anesthesia/deep sedation, conscious sedation, or nitrous oxide analgesia. 1.3 "Board" refers to the Board of Examiners in Dentistry, or any committee or subcommittee thereof, established in the Rhode Island Department of Health pursuant to the provisions of the Act. 1.4 "Certified dental assistant" means a person currently certified by the Dental Assisting National Board, Inc., or its successor agency as a certified dental assistant in general dentistry or in one of the appropriate specialties, and employed for the purpose of assisting a dentist in the performance of procedures/duties related to dental care in accordance with the provisions herein. 1.5 “Combination inhalation-enteral conscious sedation (combined conscious sedation)” means conscious sedation using inhalation and enteral agents. 1.6 "Conscious sedation" means a minimally depressed level of consciousness that retains the patient's ability to independently and continuously maintain an airway and respond appropriately to physical stimulation or verbal command; conscious sedation may be produced by a pharmacological or non-pharmacological method, or by a combination thereof. The term “inhalation conscious sedation” is not intended to include nitrous oxide/oxygen, when used alone and/or with local anesthetics. 1.7 “Dental administrator” means the Administrator of the Rhode Island Board of Examiners in Dentistry. 1.8 “Deep sedation” means an induced state of depressed consciousness accompanied by partial loss of protective reflexes, including the inability to continually maintain an airway independently and/or to respond purposefully to physical stimulation or verbal command; deep sedation may be produced by a pharmacological or non-pharmacological method, or by a combination thereof. 1.9 "Dental assistant" means a person not currently certified by the Dental Assisting National 2 Board, Inc., or its successor agency as a certified dental assistant in general dentistry or in one of the appropriate specialties, and employed for the purpose of assisting a dentist in the performance of procedures/duties related to dental care in accordance with the provisions herein. 1.10 "Dental auxiliary personnel" refers to a dental hygienist, a certified dental assistant or a dental assistant. 1.11 "Dental hygienist" means an individual licensed under the provisions of Chapter 5-31.1 of the General Laws of Rhode Island, as amended to practice dental hygiene. 1.12 "Dental office" means a place, however named, where a dentist actively, regularly, and personally practices dentistry, pursuant to the provisions of 5-31.1-1 (g) of the General Laws. 1.13 "Dentist" means an individual licensed under the provisions of Chapter 5-31.1 of the General Laws of Rhode Island, as amended, to practice dentistry in this state. 1.14 "Dentistry" refers to the practice of dentistry as defined in section 5-31.1-1 of the Act. 1.15 “Enteral” means any technique of administration in which the agent is absorbed through the gastrointestinal (GI) tract or oral mucosa (i.e., oral, rectal, sublingual). 1.16 "General anesthesia" means an induced state of unconsciousness accompanied by partial or complete loss of protective reflexes, including the inability to continually maintain an airway independently and respond purposefully to physical stimulation or verbal command; general anesthesia may be produced by a pharmacological or non-pharmacological method, or by a combination thereof. 1.17 “Inhalation” means a technique of administration in which a gaseous or volatile agent is introduced into the pulmonary tree and whose primary effect is due to the absorption through the pulmonary bed. 1.18 "License", as used herein, is synonymous with "registration.” 1.19 "Local anesthesia" means the injection of a local anesthetic agent (e.g., Lidocaine) into and around the operative site to eliminate sensory perception in the area where a procedure(s) is to be performed. This type of anesthesia does not involve any systemic sedation. 1.20 "Nitrous oxide analgesia" means the administration of nitrous oxide to diminish or eliminate the sensibility to pain in the conscious patient, designating in particular the relief of pain without loss of consciousness. 1.21 "Parenteral" means a technique in which the drug bypasses the gastrointestinal (GI) tract [i.e., intramuscular (IM), intravenous (IV), intranasal (IN), submucosal (SM), subcutaneous (SC), intraocular (IO)]. 1.22 "Supervision" includes four (4) types of supervision as follows: a) "Direct supervision" means the dentist is in the dental office, personally diagnoses the 3 condition to be treated, personally authorizes the procedure(s)/duty(ies), remains in the dental office while the procedure(s)/duty(ies) are being performed and examines the patient before his/her dismissal. b) "General supervision" means the dentist has authorized the procedure/duty and such is being carried out in accordance with his/her diagnosis and treatment plan. The dentist does not have to be physically present in the dental office when such treatment is being performed under general supervision. c) "Indirect supervision" means the dentist is in the dental office, personally diagnoses the condition to be treated, personally authorizes the procedure(s)/duty(ies), and remains in the dental office while the procedure(s)/duty(ies) is being performed by the dental auxiliary. d) "Personal supervision" means the dentist is personally operating on a patient and authorizes the dental auxiliary to aid his/her treatment by concurrently performing a supportive procedure. 1.23 "Triennial" shall mean occurring every third (3) year. 1.24 "Unprofessional conduct" shall include, but not be limited to, the provisions of section 5-31.1- 10 of the General Laws, and is further defined as failure to conform to the current guidelines regarding Universal Precautions and Infection Control of the Centers for Disease Control of reference 3 herein. 4 PART II Dentists/Licensing Requirements Section 2.0 License Requirements 2.1 No person shall perform any act which constitutes the practice of dentistry in this state unless such person is duly licensed in accordance with the regulatory and statutory provisions of the Act as a dentist or a dental hygienist. Furthermore, dental hygienists, certified dental assistants and dental assistants shall perform only those auxiliary dental services, procedures and duties, and under the specified type of supervision, as set forth in section 13.0, Part IV of these Rules and Regulations. Exempt from these requirements are those persons listed in section 5-31.1-37 of the Act. Pain Assessment 2.2 All health care providers licensed by this state to provide health care services and all health care facilities licensed under Chapter 23-17 of the Rhode Island General Laws, as amended, shall assess patient pain in accordance with the requirements of the Rules and Regulations Related to Pain Assessment (R5-37.6-PAIN) promulgated by the Department. Latex 2.3 Any dentist who utilizes latex gloves shall do so in accordance with the provisions of the Rules and Regulations Pertaining to the Use of Latex Gloves by Health Care Workers, in Licensed Health Care Facilities, and by Other Persons, Firms, or Corporations Licensed or Registered by the Department promulgated by the Department of Health. Section 3.0 Qualifications for Licensure 3.1 An applicant seeking licensure to practice dentistry in the state of Rhode Island must: a) be of good moral character; b) be eighteen (18) years of age or over; c) be a graduate of a school of dentistry accredited by the American Dental Association Commission on Dental Accreditation or its designated agency and approved by the Board; d) have passed to the satisfaction of the Board the required examinations in accordance with section 5.0 herein or met the requirements for endorsement stipulated in section 5.1.1 (d) herein; and e) be in good standing in each state in which he/she holds a license. Section 4.0 Application for License and Fee 5 4.1 Application for license shall be made on forms provided by the Board, which shall be completed, notarized and submitted to the Board thirty (30) days prior to the scheduled date of the Board meeting at which the application is scheduled to be reviewed. Such application shall be accompanied by the following documents (non-returnable): a) one (1) unmounted recent photograph of the applicant, head and shoulder front view, approximately 2 x 3 inches in size. b) a certified copy of birth certificate; For foreign nationals: if a certified copy of birth certificate cannot be obtained, immigration papers or resident alien card or such other birth-verifying papers acceptable to the Director; c) supporting official transcript of grades and/or verification of graduation signed by the dean or registrar of the dental school; d) national board results in accordance with section 5.1.1(b) submitted either with application or submitted by the National Dental Examination Commission to the Board; e) the results of the Northeast Regional Board of Dental Examiners, Inc., (NERB) examination or other dental examination organizations (as required in section 5.1 herein) submitted directly by the Board of the Northeast Regional Board of Dental Examiners, Inc. or by the board of the other dental examination organizations; f) verification that the licensee is in good standing in state(s) where licensed [if licensed in another state(s)]; g) the application fee of four hundred thirty-seven dollars and fifty cents ($437.50) (non- refundable) made payable by check to the General Treasurer, state of Rhode Island, in accordance with section 5-31.1-6 of the Act. Section 5.0 Examination for Licensure 5.1 By Examination: Applicants shall be required to pass such examination(s) as the Board deems most practical and expeditious to test the applicant's knowledge and skills to practice dentistry in this state pursuant to section 5-31.1-6 of the Act; and: 5.1.1 The Board requires each applicant to: a) have graduated from a school of dentistry in accordance with section 3.1(c) herein; and b) have successfully passed the national examination of the Joint Commission on National Dental Examination (Parts I and II); and c) have successfully passed the Northeast Regional Board of Dental Examiners, Inc., Examination within five (5) years from the date of application for licensure in this state; 6 or i) have successfully passed an examination within five (5) years of the date of application for licensure offered by one of the following dental examination organizations: the Central Regional Dental Testing Service, the Southern Regional Testing Agency, Inc., or the Western Regional Examining Board, Inc., with an earned score of seventy-five percent (75%) in each discipline, clinical skill, procedure or knowledge area that is tested on the NERB Examination using the internal weighting and scoring methods the NERB uses to score the NERB Examination in Dentistry; or have successfully passed an examination, approved by the Board, other than a regional board that is similar to the examination for which the applicant is seeking waiver, with an earned score of seventy-five percent (75%) in each discipline, clinical skill, procedure or knowledge area that is tested on the NERB Examination using the internal weighting and scoring methods the NERB uses to score the NERB Examination in Dentistry; and ii) have successfully passed a comprehensive examination in applied clinical diagnosis and treatment planning (NERB Dental Simulated Clinical Exercise {DSCE} written) with an earned score of seventy-five percent (75%); or d) hold a current license to practice dentistry in another state that required the successful completion of a clinical board examination not part of the applicant’s training program in order to be eligible for licensure; 5.1.2 Applicants must submit to the Board, the application accompanied with the appropriate documentation as set forth in section 4.0 herein. 5.1.3 Sites and schedules of examinations may be obtained directly from the examination service(s) referred to above or from the Board. 5.2 Continuing Education---Dentists 5.2.1 Pursuant to the provisions of section 5-31.1-7 of the Act, all dentists licensed to practice in this state under the provisions of the Act and the regulations herein, on or before the first day of May of each even-numbered year shall maintain evidence that in the preceding two (2) years he or she has satisfactorily completed at least forty (40) hours of continuing dental education courses, according to the criteria established by the Rhode Island Dental Association and approved by the Board. Continuing education requirements cited herein shall be prorated for a licensee whose license is in effect for a period of less than two (2) years (i.e., an average of twenty (20) hours of continuing education shall be required each year the license is in effect). a) It shall be the sole responsibility of the individual dentist to obtain documentation from the approved sponsoring or co-sponsoring organization, agency or other, of his or her participation in a learning experience, including 7 the date, and number of hours earned. b) At the time of license renewal, each licensee shall be required to attest to the fact that he/she has complied with the continuing education requirements stated herein. Course descriptions, proof of attendance, or other documentation of completion shall be retained by the licensee for a minimum of five (5) years and is subject to random audit by the Board. Failure to produce satisfactory documentation of completion of requirements upon request of the Board may constitute grounds for disciplinary action. 5.2.2 All dentists practicing in a dental setting shall receive a minimum of one (1) hour per year of training on and shall comply with the Occupational Safety and Health Administration’s (OSHA) Bloodborne Pathogen Standards (reference 1) in order to protect against occupational exposure to bloodborne pathogens. 5.2.3 If the applicant submits evidence satisfactory to the Board of completion of the prescribed course(s) of continuing dental education established by the Rhode Island Dental Association, as approved by the Board, and is in compliance with the provisions of section 5-31.1-7 of the Act, the Board shall issue the applicant a license registration for a one (1) year period in accordance with the requirements of section 6.0 herein. 5.2.4 Licensure renewal shall be denied to any applicant who fails to provide satisfactory evidence of continuing dental education as required herein. a) Notwithstanding the provisions of section 5.2.3 above, no license to practice dentistry in this state shall be refused, nor shall any license be suspended or revoked except as: (1) provided in the Act; and (2) for failure to provide satisfactory evidence of continuing dental education as required herein. 5.2.5 The Board may, however, extend for only one (1) six (6) month period such educational requirements, if the Board is satisfied that the applicant has suffered hardship which prevented him/her from meeting the requirements herein. Section 6.0 Issuance and Renewal of License 6.1 A license shall be issued by the Board to an applicant found to have satisfactorily met all requirements herein. Said license unless sooner suspended or revoked shall expire annually on the 30th of June. 6.2 Effective in the calendar year 2006, every person so licensed who desires to renew his or her license shall file with the Board before the first (1st) of May in each even-numbered year, a renewal application duly executed together with evidence of completion of continuing education requirement and the renewal fee as determined biennially by the Director of Health in consultation with the Board, made payable by check to the General Treasurer, state of Rhode Island. Upon receipt of such application and payment of such fee, a license renewal shall be granted effective for the biennial licensure period unless sooner suspended or revoked. i. for those licensees who shall have attained the age of not less than seventy (70) years 8 ("emeritus active") as of June 30th of the year of licensure, the renewal fee (non- refundable) shall be one hundred twenty-five dollars ($125.00) made payable by check to the General Treasurer, state of Rhode Island. 6.3 Pursuant to the provisions of section 5-31.1-21 of the Act, the registration certificate of all dentists whose renewals accompanied by the prescribed fee are not filed on or before the first day of June shall be automatically revoked. The Board may in its discretion and upon the payment by the dentist of the current licensure (registration) fee plus an additional fee of sixty- two dollars and fifty cents ($62.50) reinstate any license (certificate) revoked under the provisions of the Act and the regulations herein. Inactive Status 6.4 Dentists not intending to practice in this state may request on a biennial basis to be placed on inactive status. Such requests must be made in writing to the dental administrator and must be accompanied by a fee of one hundred twenty-five dollars ($125.00). Persons on inactive status may be reinstated by paying the current annual registration fee and must meet such requirements established by the Act and as prescribed herein, including demonstrating proof of completion of the required continuing dental education courses as specified in section 5.2.1 herein. 9 PART III Dental Hygienists Licensing Requirements Section 7.0 License Requirements 7.1 No person shall perform any act which constitutes the practice of dental hygiene in this state unless such person is duly licensed in accordance with the regulatory and statutory provisions of the Act as a dentist or dental hygienist. 7.1.1 Furthermore, dental hygienists, certified dental assistants and dental assistants, shall perform only those auxiliary dental services, procedures/duties, and under the specified type of supervision, as set forth in Part IV of these Rules and Regulations. Exempt from these requirements, are those persons listed in section 5-31.1-37 of the Act. Section 8.0 Qualifications for Licensure 8.1 An applicant seeking licensure to practice dental hygiene in this state must: a) be of good moral character; b) be eighteen (18) years of age or over; c) have graduated from a program for dental hygienists accredited by the Commission on Dental Accreditation or its designated agency and approved by the Board; d) have passed to the satisfaction of the Board the required examinations in accordance with section 10.0 herein or met the requirements for endorsement stipulated in section 10.1.1 d) herein; and e) be in good standing in each state in which he/she holds a license. Section 9.0 Application for Licensure and Fee 9.1 Application for licensure shall be made on forms provided by the Board which shall be completed, notarized and submitted to the Board thirty (30) days prior to the scheduled date of the Board meeting at which the application is scheduled to be reviewed. Such application shall be accompanied by the following documents (non-returnable): a) a certified copy of birth record; For foreign nationals: if a certified copy of birth certificate cannot be obtained, immigration papers or resident alien card or such other birth-verifying papers acceptable to the Director; b) one (1) unmounted photograph of the applicant, head and shoulder front view, approximately 2 x 3 inches in size; c) supporting official transcript of education credentials signed by the dean or registrar of the program of dental hygiene; d) national board results in accordance with section 10.1.1(a) herein, (submitted either with the application or submitted by the National Board Dental Hygiene Examination to the 10 Board); e) the results of the Northeast Regional Board of Dental Examiners, Inc., examination or other dental examination organizations (as required in section 10.1 herein) submitted directly by the Board of Northeast Regional Board of Dental Examiners, Inc. or by the board of the other dental examination organizations; f) verification that the licensee is in good standing in state(s) where licensed [if licensed in another state(s)]; and g) the application fee of ninety-three dollars and seventy-five cents ($93.75) (non- refundable) made payable by check to the General Treasurer, state of Rhode Island in accordance with section 5-31.1-6 of the Act. Section 10.0 Examination for Licensure 10.1 By Examination: Applicants shall be required to pass such examination(s) as the Board deems most practical and expeditious to test the applicant's knowledge and skills to practice dental hygiene in this state pursuant to section 5-31-12 of the Act, and: 10.1.1 The Board requires each applicant to: a) have graduated from a program for dental hygienists in accordance with section 8.1(c) herein; and b) have successfully passed the National Board Dental Hygiene Examination; and c) have successfully passed the Northeast Regional Board Examination in Dental Hygiene within five (5) years from the date of application for licensure in this state; or i. have successfully passed an examination within five (5) years of the date of application for licensure offered by any of the following dental examination organizations: the Central Regional Dental Testing Service, the Southern Regional Testing Agency, Inc., or the Western Regional Examining Board, Inc., with an earned score of seventy-five percent (75%) using the internal weighting and scoring methods the NERB uses to score the NERB Examination in Dental Hygiene; or have successfully passed an examination, approved by the Board, other than a regional board that is similar to the examination for which the applicant is seeking waiver, with an earned score of seventy-five percent (75%) using the internal weighting and scoring methods the NERB uses to score the NERB Examination in Dental Hygiene, and ii. have successfully passed a simulated patient clinical exercise (NERB 11 Computer Simulated Clinical Examination {CSCE} written) with an earned score of seventy-five percent (75%); or d) hold a current license to practice dental hygiene in another state that required the successful completion of a clinical board examination in order to be eligible for licensure; 10.1.2 Applicants must submit to the Board, the application accompanied with the appropriate documentation as set forth in section 9.0 herein. 10.1.3 Sites and schedules of examinations may be obtained directly from the examination service(s) referred to above or from the Board. 10.2 Continuing Education--Dental Hygienists 10.2.1 Pursuant to the provisions of section 5-31.1-7 of the Act, all dental hygienists licensed to practice in this state under the provisions of the Act and the regulations herein, shall, on or before the first day of May of each even-numbered year maintain evidence that in the preceding two (2) years he or she has satisfactorily completed at least twenty (20) hours of continuing education courses relevant to the practice of dental hygiene, according to the criteria established by the Rhode Island Dental Hygienists Association and approved by the Board. Continuing education requirements cited herein shall be prorated for a licensee whose license is in effect for a period of less than two (2) years (i.e., an average of ten (10) hours of continuing education shall be required each year the license is in effect). 10.2.2 All dental hygienists practicing in a dental setting shall receive a minimum of one (1) hour per year of training on and shall comply with the Occupational Safety and Health Administration’s (OSHA) Bloodborne Pathogen Standards (reference 1) in order to protect against occupational exposure to bloodborne pathogens. 10.2.3 If the applicant maintains evidence satisfactory to the Board of completion of prescribed course(s) of continuing education and is in compliance with the provisions of section 5- 31.1-6 of the Act, the Board shall issue the applicant a license registration for one (1) year period in accordance with the requirements of section 6.0 herein. 10.2.4 It shall be the sole responsibility of the individual dental hygienist to obtain documentation from the approved sponsoring or co-sponsoring organization, agency or other, of his or her participation in the learning experience, including the date and number of hours earned. a) These documents must be safeguarded by the dental hygienist for a minimum of five (5) years for random audit by the Board, if requested. At the time of license renewal, each licensee shall be required to attest that he/she has complied with the continuing education requirements stated herein. Failure to produce satisfactory documentation of completion of continuing education 12 requirements upon request by the Board may constitute grounds for disciplinary action. 10.2.5 Licensure renewal shall be denied to any applicant who fails to provide satisfactory evidence of continuing education courses relevant to the practice of dental hygiene as required herein. a) Notwithstanding the provisions of section 10.2.4 above, no license to practice dentistry or dental hygiene in this state shall be refused, nor shall any license be suspended or revoked, except as: (1) provided for in the Act; and (2) failure to provide satisfactory evidence of continuing education as provided herein. 10.2.6 The Board may, however, extend for only one (1) six (6) month period such educational requirements, if the Board is satisfied that the applicant has suffered hardship which prevented the applicant from meeting the requirements herein. Dental Assistants 10.3 All dental assistants practicing in a dental setting shall receive a minimum of one (1) hour per year of training on and shall comply with the Occupational Safety and Health Administration’s (OSHA) Bloodborne Pathogen Standards (reference 1) in order to protect against occupational exposure to bloodborne pathogens. Section 11.0 Issuance and Renewal of License 11.1 A license shall be issued by the Board to an applicant found to have satisfactorily met all the requirements herein. Said license unless sooner suspended or revoked shall expire biennially on the 30th of June of each even-numbered year. 11.2 Effective in the calendar year 2006, every person so licensed who desires to renew his or her license shall file with the Board by the 1st of May in each even-numbered year, a renewal application duly executed together with evidence of completion of continuing education requirements and the renewal fee as determined biennially by the Director of Health in consultation with the Board, made payable by check to the General Treasurer, state of Rhode Island. Upon receipt of such application and payment of said fee, a license renewal shall be granted effective for the biennial licensure period unless sooner suspended or revoked. i. for those licensees who shall have attained the age of not less than seventy (70) years ("emeritus active") as of June 30th of the year of licensure, the renewal fee (non- refundable) shall be sixty-two dollars and fifty cents ($62.50), made payable by check to the General Treasurer, state of Rhode Island. 11.3 Pursuant to the provisions of section 5-31.1-21 of the Act, the registration certificate of all dental hygienists whose renewals accompanied by the prescribed fee are not filed on or before the first day of June, shall be automatically revoked. The Board may in its discretion and upon the payment by the dental hygienist of the current licensure (registration) fee plus an additional fee of sixty-two dollars and fifty cents ($62.50) reinstate any license (certificate) revoked under the provisions of the Act and the regulations herein. 13 Inactive Status 11.4 Dental hygienists not intending to practice in this state may request on a biennial basis to be placed on inactive status. Such requests must be made in writing to the dental administrator and must be accompanied by a fee of sixty-two dollars and fifty cents ($62.50). Persons on inactive status may be reinstated by paying the current annual registration fee and must meet such requirements established by the Act and as prescribed herein, including demonstrating proof of completion of the required continuing dental education courses relevant to the practice of dental hygiene as specified in section 10.2.1 herein. . 14 PART IV Delegable Procedures/Duties to Dental Hygienists, Certified Dental Assistants and Dental Assistants with Specific Type of Supervision Section 12.0 General Requirements 12.1 Dental Hygienists Pursuant to section 5-31.1-33 of the Act, any licensed dentist, public institution or school authority may employ any licensed dental hygienist whose activities shall be confined to those dental services, procedures/duties that licensed dental hygienist he/she has been educated to perform and which are authorized by the Board, and under the specific type of supervision as set forth in section 13.0 herein. Such dental procedures/duties may be delegated by the dentist and performed under the direction of the dentist, in accordance with the statutory and regulatory provisions herein. 12.1.1 Nothing in this section shall be construed to authorize a licensed dental hygienist to perform any of the non-delegable (exclusionary) procedures/ duties as set forth in section 14.0 herein. 12.2 Certified Dental Assistants and Dental Assistants A dentist may delegate to a certified dental assistant or a dental assistant, based on the individual's competency and/or training, reversible intraoral dental services, procedures or duties which are to be performed under the supervision of the dentist as approved by the Board and set forth in section 13.0 herein. Provided, however, oral prophylaxis shall be performed only by a licensed dentist or a licensed dental hygienist. 12.2.1 Nothing in this section shall authorize a certified dental assistant or a dental assistant to perform any of the non-delegable (exclusionary) procedures/duties as set forth in section 14.0 herein. 12.3 All procedures/duties performed by dental auxiliaries shall be performed under the direct supervision of a dentist, unless otherwise specified in section 13.0 herein. 12.4 Any reversible intraoral procedure not specifically enumerated as delegable or non-delegable (exclusionary) pursuant to sections 13.0 and 14.0 herein, may be delegated to any category of dental auxiliary, (dental hygienist, certified dental assistant, and dental assistant) based on the discretion of the delegating dentist, the education and training and competency of the dental auxiliary. 12.5 The supervising dentist shall be accountable and fully responsible for all dental services, procedures and duties performed by any dental auxiliary under his or her supervision. However, a dental auxiliary is responsible for his/her own professional behavior and shall be guided by existing professional standards. Section 13.0 Delegation of Duties 15 13.1 A dentist may delegate to auxiliary personnel those procedures which the dentist may deem advisable, except for those procedures excluded in Section 14. Any delegated procedures shall be both the responsibility of and under the specified supervision of the dentist. 13.1.1 Dental Hygienist A dental hygienist may remove calculus, accretions and stains from both supragingival and subgingival tooth surfaces by scaling and root planing, as well as any duties performed by a certified dental assistant or a dental assistant. These procedures may be accomplished under general supervision, in a dental office, and under general supervision of the dentist. 13.1.2 Certified Dental Assistant a) A certified dental assistant may perform reversible intraoral procedures under the direct supervision of the dentist. b) Such procedures may include the application of pit and fissure sealants and fluoride treatments, provided: i. such procedures were incorporated into the academic training from which the certified dental assistant graduated; OR ii. provided he/she has completed academic clinical training to clinical competence. c) The certified dental assistant may not perform any of the procedures specifically listed for a dental hygienist, nor any irreversible intraoral procedures. 13.1.3 Dental Assistant A dental assistant may perform reversible intraoral procedures under the personal supervision of the dentist. He/she may not perform any of the procedures listed specifically for a licensed dental hygienist nor any irreversible intraoral procedures. 13.2 Dentists licensed pursuant to section 5-31.1-6 of the Rhode Island General Laws, as amended, may delegate to any dental hygienists licensed pursuant to section 5-31.1-6 of the Rhode Island General Laws, as amended, who are employed on a regular basis by such dentists any procedures which he or she may deem advisable; including those procedures specified under section 13.0 herein pertaining to dentists and dental hygienists and any such dental hygienists may engage in the practice of dental hygiene outside of such dentists' office in order to render to residents of nursing facilities licensed pursuant to Chapter 23-17 of the Rhode Island General Laws, as amended, without the on-site direct supervision of a dentist licensed pursuant to section 5-31.1-6, those dental services, procedures and duties that he or she has been educated to perform and which are authorized by the Board. Section 14.0 Non-Delegable (Exclusionary) Procedures/Duties 14.1 Notwithstanding the provisions of sections 12.0 and 13.0 herein, nothing in these rules and 16 regulations shall authorize a dental hygienist, certified dental assistant or dental assistant, to perform any of the following procedures or duties: 1) Diagnosis and treatment planning; 2) Surgical procedures on hard or soft tissue; 3) Prescribing medications; 4) Administering parenteral conscious sedation, and/or general anesthesia/ deep sedation; 5) Administering inhalants or inhalation conscious sedation agents; 6) Taking impressions for models upon which full or partial dentures, or permanent crowns, bridges, inlays, onlays, posts and cores will be fabricated; 7) Adjusting occlusion of fixed and removable prosthodontic appliances; 8) Final cementation of permanent crowns, bridges, inlays, onlays and posts and cores; and insertion of final prosthesis. 9) Condensing and carving restorative materials in teeth, except temporary restoratives; 10) Placement or removal of bonded orthodontic attachments and/or cementation or removal of orthodontic bands; 11) Placement of sutures; 12) Exposure of radiographs without successful completion of a course in dental radiography which is offered by an education institution with a program accredited by the Commission on Dental Accreditation and which fulfills institutional requirements as set forth in section F.2.3 of the Rules and Regulations for the Control of Radiation (R23-1.3-RAD), Rhode Island Department of Health Office of Occupational and Radiological Health; 13) Perform direct pulp capping procedures; 14) Orthodontic arch wire activation with the exception of minor adjustments to eliminate pain or discomfort; 15) Flush root canal; 16) Temporary wire ligation; and 17) Use of a rotary instrument in the oral cavity unless licensed or certified under the provisions of the Act and the regulations herein. (See also section 13.1.2 (b) herein). 17 PART V Administration of Anesthesia in Dental Offices Section 15.0 General Requirements 15.1 Any dentist licensed in this state who is administering, permitting the administration of, or intending to administer general anesthesia/deep sedation, inhalation conscious sedation, combined conscious sedation, parenteral conscious sedation, or nitrous oxide analgesia in his or her dental office, must meet the statutory and regulatory requirements herein, and must hold a permit granted by the Board to administer or to permit the administration of general anesthesia/deep sedation, inhalation conscious sedation, combined conscious sedation, parenteral conscious sedation, or nitrous oxide analgesia in his or her dental office. 15.2 Any licensed dentist permitted to administer general anesthesia/deep sedation, inhalation conscious sedation, combined conscious sedation, parenteral conscious sedation, or nitrous oxide analgesia who intends to do so in a dental office in this state that does not have a facility permit allowing the administration of these anesthesia services on the premises, as required by section 23.3 below, shall be allowed to do so only with prior approval of the Board. 15.2.1 As a condition for this approval, the Board, or its designee, shall inspect all equipment utilized for the purpose of administering general anesthesia/deep sedation, inhalation conscious sedation, combined conscious sedation, parenteral conscious sedation, or nitrous oxide analgesia. Said equipment shall meet all applicable requirements of sections 23.1 and 23.2 herein. 15.2.2 The Board’s written approval shall be obtained by the licensed dentist prior to commencing the anesthesia services described in this section. 15.2.3 Those licensed dentists approved by the Board to engage in the practice of administering general anesthesia/deep sedation, inhalation conscious sedation, combined conscious sedation, parenteral conscious sedation, or nitrous oxide analgesia in those dental offices that do not possess a facility permit allowing the administration of these anesthesia services on the premises shall submit a written schedule at intervals required by the Board describing the frequency and location(s) of anesthesia services rendered. Section 16.0 Qualifications for Permit 16.1 An applicant seeking a permit to administer or to permit the administration of general anesthesia/deep sedation, inhalation conscious sedation, combined conscious sedation, parenteral conscious sedation, or nitrous oxide analgesia must: 16.1.1 For General Anesthesia/Deep Sedation: a) be licensed as a dentist in this state; and b) have completed an advanced training program in anesthesia and related subjects beyond the undergraduate dental curriculum that satisfies the requirements described in Part II of the American Dental Association Guidelines for Teaching 18 the Comprehensive Control of Pain and Anxiety in Dentistry at the time training was commenced; or c) have completed an American Dental Association accredited post-doctoral training program (e.g., oral and maxillofacial surgery) which affords comprehensive and appropriate training necessary to administer and manage deep sedation/general anesthesia, commensurate with the American Dental Association Guidelines for Teaching the Comprehensive Control of Pain and Anxiety in Dentistry; or d) be employed or practice in conjunction with a Board certified or Board eligible anesthesiologist. 16.1.2 For Combined Conscious Sedation: a) be licensed as a dentist in this state; and b) satisfy one of the following education and training requirements: i) completion of a comprehensive training program in enteral and/or combination inhalation-enteral conscious sedation (combined conscious sedation) consistent with that prescribed in Part III of the ADA Guidelines for Teaching the Comprehensive Control of Pain and Anxiety in Dentistry at the time training was commenced; or ii) completion of an ADA accredited post-doctoral training program which affords comprehensive and appropriate training necessary to administer and manage enteral and/or combination inhalation-enteral conscious sedation (combined conscious sedation); or, iii) meet one of the requirements as set forth in section 16.1.1 (b) through (d) above. 16.1.3 For Parenteral Conscious Sedation: a) be licensed as a dentist in this state; and b) satisfy one of the following education and training requirements: i) completion of a comprehensive training program in parenteral conscious sedation that satisfies the requirements described in Part III of the ADA Guidelines for Teaching the Comprehensive Control of Pain and Anxiety in Dentistry at the time training was commenced; 19 ii) Completion of an ADA accredited post-doctoral training program (e.g., general practice residency) which affords comprehensive and appropriate training necessary to administer and manage parenteral conscious sedation; or, iii) meet one of the requirements as set forth in section 16.1.1 (b) through (d) above. 16.1.4 For Inhalation Conscious Sedation: a) be licensed as a dentist in this state; and b) satisfy one of the following education and training requirements: i) completion of a training consistent with that described in Part I or Part III of the ADA Guidelines for Teaching the Comprehensive Control of Pain and Anxiety in Dentistry; ii) Completion of an ADA accredited post-doctoral training program which affords comprehensive and appropriate training necessary to administer and manage inhalation conscious sedation; or, iii) meet one of the requirements as set forth in section 16.1.1(b) through 16.1.1(d) or section 16.1.3 (b) above. 16.1.5 For Nitrous Oxide Analgesia: a) be licensed as a dentist in this state; and b) meet one of the requirements as set forth in section 16.1.4 (b)(iii) above; or c) have satisfactorily completed a nitrous oxide analgesia training program from a school accredited by the American Dental Association, and whose training program is consistent with the provisions of the "GUIDELINES FOR TEACHING THE COMPREHENSIVE CONTROL OF PAIN AND ANXIETY IN DENTISTRY, PART ONE (1), or PART III", of the American Dental Association, Council on Dental Education and which includes clinical experience in the administration of nitrous oxide analgesia. Section 17.0 Application 17.1 Application for a permit shall be made on forms provided by the Board which shall be completed, notarized and submitted to the Board thirty (30) days prior to the scheduled date of the Board meeting. Such application shall be accompanied by the following documents (non- returnable and non-refundable): 20 a) supporting official transcripts of verification of the qualification requirements as set forth in section 16.1.1 or 16.1.2 or 16.1.3, 16.1.4 or 16.1.5 above; b) a statement attesting that he or she has or has not been involved in any morbidity or mortality secondary to the administration of general anesthesia/deep sedation, inhalation conscious sedation, combined conscious sedation, parenteral conscious sedation, or nitrous oxide analgesia; and c) the permit fee, where applicable, as determined annually by the Director of Health in consultation with the Board, made payable by check to the General Treasurer, state of Rhode Island; and d) such other information as may be deemed necessary and as may be requested by the Board. Section 18.0 Issuance and Renewal of Permit 18.1 Upon receipt of an application for a permit to administer or to permit the administration of general anesthesia/deep sedation, inhalation conscious sedation, combined conscious sedation, parenteral conscious sedation, or nitrous oxide analgesia, the Board with the advice of the advisory consultant(s), may issue a permit to an applicant found to meet all the prescribed requirements herein. Said permit unless sooner suspended or revoked shall expire every five (5) years from the date of issuance. 18.2 Every person issued a permit who desires to renew his or her permit shall file with the Board one month before the date of expiration of permit, a renewal application duly executed together with the renewal fee, where applicable, as determined annually by the Director of Health in consultation with the Board, made payable by check to the General Treasurer, state of Rhode Island. Upon receipt of such renewal application and payment of any fee, a renewal shall be issued effective for five (5) years from the date of renewal, unless sooner suspended or revoked. 18.3 Any person who allows his or her permit to lapse through accident, mistake or unforseen cause by failing to renew the permit on or before the expiration date, may be reinstated upon filing an application with payment of the current renewal fee, where applicable, in accordance with section 18.2 above. Section 19.0 Inspections 19.1 The Board may, through appointed advisory consultants, conduct such inspections and investigations as deemed necessary by the Board to ensure compliance with the requirements herein. 19.2 Refusal to permit inspection shall constitute a valid ground for permit denial, suspension or revocation. 19.3 Every applicant shall be given notice by the Board of all deficiencies reported as a result of an inspection or investigation. 21 Section 20.0 Inactive Status 20.1 A dentist who holds a permit for the administration of or to permit the administration of general anesthesia/deep sedation, inhalation conscious sedation, combined conscious sedation, parenteral conscious sedation, or nitrous oxide analgesia in his or her dental office and who desires to withdraw from the practice of dental anesthesia in his or her office, may request from the Board that his or her permit be withdrawn and placed on an inactive status. 20.2 A dentist whose permit has been inactive for more than one (1) year may be reactivated upon application to the Board and submission of any current application fee, made payable by check to the General Treasurer, state of Rhode Island. The Board shall determine, at its discretion, whether or not to reactivate the permit or require renewed proof of competency or need for additional educational requirements. Section 21.0 General Anesthesia/Deep Sedation, Inhalation Conscious Sedation, Combined Conscious Sedation, Parenteral Conscious Sedation, or Nitrous Oxide Analgesia Services 21.1 Personnel: 21.1.1 A dentist administering or permitting the administration of general anesthesia/deep sedation, inhalation conscious sedation, combined conscious sedation, parenteral conscious sedation, or nitrous oxide analgesia must ensure that there is a sufficient number of members on the "team of auxiliary personnel" to assist in handling procedures and emergencies. 21.1.2 a) The dentist administering or permitting the administration of general anesthesia/deep sedation shall hold a current certificate in Advanced Cardiac Life Support, as described in the most current version of the American Dental Association, “Guidelines for the Use of Conscious Sedation, Deep Sedation and General Anesthesia for Dentists.” b) The dentist administering or permitting the administration of inhalation conscious sedation shall hold a current certificate in Basic Life Support, as described in the most current version of the American Dental Association, “Guidelines for the Use of Conscious Sedation, Deep Sedation and General Anesthesia for Dentists.” c) The dentist administering or permitting the administration of combined conscious sedation shall hold a current certificate in Basic Life Support, as described in the most current version of the American Dental Association, “Guidelines for the Use of Conscious Sedation, Deep Sedation and General Anesthesia for Dentists.” d) The dentist administering or permitting the administration of parenteral conscious sedation shall hold a current certificate in Basic Life Support, as described in the most current version of the American Dental Association, “Guidelines for the Use of Conscious Sedation, Deep Sedation and General 22 Anesthesia for Dentists.” e) The dentist administering or permitting the administration of nitrous oxide analgesia shall hold a current certificate in Basic Life Support. f) Each member of the "team of auxiliary personnel" shall hold a current certificate in Basic Life Support. 21.2 Management of Services: 21.2.1 Written policies and procedures shall be established regarding: (1) the administration of general anesthesia/deep sedation, inhalation conscious sedation, combined conscious sedation, parenteral conscious sedation, or nitrous oxide analgesia; (2) maintenance of safety controls; (3) qualifications and supervision of the "team of auxiliary personnel" involved in the general anesthesia/deep sedation, inhalation conscious sedation, combined conscious sedation, parenteral conscious sedation, or nitrous oxide analgesia service. In addition, the policies shall include provisions for no less than the following: a) pre-anesthesia evaluation; b) safety of the patient during the anesthesia period; c) review of patient's condition prior to induction of general anesthesia/deep sedation, inhalation conscious sedation, combined conscious sedation, parenteral conscious sedation, or nitrous oxide analgesia, and post-anesthetic evaluation; d) signed informed consent obtained prior to the administration of general anesthesia/deep sedation, inhalation conscious sedation, combined conscious sedation, parenteral conscious sedation, or nitrous oxide analgesia. In the case of a minor, consent from a parent or legal guardian must be obtained; in case of emergency, an oral permit will be acceptable; e) recording of all events related to the administration of general anesthesia/deep sedation, inhalation conscious sedation, combined conscious sedation, parenteral conscious sedation, or nitrous oxide analgesia; f) written report(s) of any morbidity requiring hospitalization or mortality occurring in the dental office as a result of general anesthesia/deep sedation, inhalation conscious sedation, combined conscious sedation, parenteral conscious sedation, or nitrous oxide analgesia. Report of such mortality must be made within twenty-four (24) hours to the Board, and report of such morbidity must be made to the Board within thirty (30) days from the date of occurrence; g) dentists holding permits to administer general anesthesia/deep sedation, inhalation conscious sedation, combined conscious sedation, parenteral conscious sedation, or nitrous oxide analgesia, and/or Board certified or Board eligible anesthesiologists, employed by or practicing in conjunction with a dentist must remain on the premises of the dental office until the patient has 23 been discharged from the dentist’s (or anesthesiologist’s) care. Monitoring and Documentation 21.2.2 A dentist administering or permitting the administration of general anesthesia/deep sedation, inhalation conscious sedation, combined conscious sedation, or parenteral conscious sedation shall ensure that the following monitoring and documentation requirements are met: a) Monitoring: direct clinical observation of the patient during administration must occur. b) Oxygenation: the color of mucosa, skin or blood should be continually evaluated. Oxygen saturation shall be evaluated continuously by pulse oximetry. c) Ventilation: chest excursion must be observed. The dentist shall auscultate breath sounds or monitor end-tidal CO2. d) Circulation: The dentist shall continually evaluate blood pressure and heart rate (unless the patient is unable to tolerate such monitoring). e) Documentation: An appropriate time-oriented anesthetic record shall be maintained. The dentist shall document individuals present during the administration of anesthesia. f) Recovery and Discharge: Oxygen and suction equipment shall be immediately available in the recovery area and/or operatory. There shall be continual monitoring of oxygenation, ventilation, and circulation when the anesthetic is no longer being administered. The patient shall have continuous supervision until oxygenation, ventilation, and circulation are stable and the patient is appropriately responsive for discharge from the facility. The dentist shall determine and document that oxygenation, ventilation, and circulation are stable prior to discharge. The dentist shall provide explanation and documentation of postoperative instructions to the patient and/or a responsible adult at the time of discharge. The dentist shall determine that the patient has met discharge criteria prior to leaving the office. 21.2.3 The anesthesia permit holder shall be responsible for the anesthetic management, adequacy of the facility/office, and treatment of emergencies associated with the administration of anesthesia, including immediate access to pharmacologic antagonists, if any, and appropriately sized equipment for establishing a patent airway and providing positive pressure ventilation with oxygen. Section 22.0 Administration of Local Anesthesia by Dental Hygienists 22.1 A dental hygienist shall be qualified to administer local anesthesia only after successfully completing a course in local anesthesia that: a) is offered by an institution accredited by the Commission on Dental Accreditation of the 24 American Dental Association; b) is a minimum of twenty (20) didactic hours and twelve (12) clinical hours; c) includes no less than the following topics: i) neurophysiology of pain and pain control; ii) pharmacology of local anesthetic solutions and drug interactions; iii) potential local and systemic complications; iv) medical and dental indications and contraindications and emergency management; v) medical and dental history and assessment; vi) safe assembly and handling of a syringe; vii) location of anatomical landmarks associated with local anesthesia; viii) injection techniques; ix) clinical experience with maxillary and mandibular injections by administering infiltration and block injections; x) legal issues associated with local anesthesia administration by a dental hygienist; xi) record keeping. d) provides written evidence of successful course completion provided by the sponsoring organization; and e) current certification in basic life and cardiopulmonary resuscitation at the “health care provider” level by a nationally recognized organization. 22.2 A dental hygienist qualified to administer local anesthesia shall have successfully completed a local anesthesia examination administered by the North East Regional Board (NERB). 22.3 A dental hygienist qualified to administer local anesthesia shall do so only under the indirect supervision of a dentist. 22.4 If a dental hygienist graduated from an American Dental Association accredited school of dental hygiene that did not include a course in local anesthesia that meets the requirements of section 22.1 (above), a course that meets such requirements shall be successfully completed before local anesthesia may be administered by the dental hygienist. 22.5 A dental hygienist who has qualified to administer local anesthesia in another jurisdiction may qualify for endorsement by the Board to perform that function by presenting written documentation of training equivalent to section 22.1 (above), including successful completion of the local anesthesia portion of the NERB examination or successful completion of a substantially similar examination in the alternate jurisdiction. Application for Permit 22.6 Application for a two-year permit shall be made on forms provided by the Board which shall be completed, notarized and submitted to the Board thirty (30) days prior to the scheduled date of 25 the Board meeting. Such application shall be accompanied by the following documents (non- returnable and non-refundable): a) supporting official transcripts of verification of the qualification requirements as set forth in section 22.0 above; b) a statement attesting that he or she has or has not been involved in any morbidity or mortality secondary to the administration of local anesthesia; c) a payment of fifty dollars ($50.00) by check or money order made payable to General Treasurer, State of Rhode Island, for a two (2) year permit; and d) such other information as may be deemed necessary and as may be requested by the Board. Section 23.0 Physical Facility, Equipment and Safety 23.1 In order to ensure the protection and safety of patients receiving general anesthesia/deep sedation, inhalation conscious sedation, combined conscious sedation, or parenteral conscious sedation in a dental office, the following standards shall be applied in determining the adequacy and safety of the physical facility and equipment. a) the current standards of the American Dental Association, “Guidelines for the Use of Conscious Sedation, Deep Sedation and General Anesthesia for Dentists,” including but not limited to the following equipment requirements: i) equipment must have a fail-safe system that is appropriately checked and calibrated; ii) equipment must have an appropriate scavenging system; and, iii) if nitrous oxide and oxygen delivery equipment capable of delivering less than 25% oxygen is used, an in-line oxygen analyzer must be used; b) the standards for "Occupational Exposure to Waste Anesthetic Gases and Vapors" of the National Institute for Occupational Safety and Health (NIOSH); and c) the Rhode Island Fire Safety Code where flammable anesthetics are present. 23.2 In order to ensure the protection and safety of patients receiving nitrous oxide analgesia in a dental office, the following requirements shall be applied in determining the adequacy and safety of the physical facility and equipment: a) equipment must have a fail-safe system that is appropriately checked and calibrated; b) equipment must have an appropriate scavenging system; c) if nitrous oxide and oxygen delivery equipment capable of delivering less than 25% 26 oxygen is used, an in-line oxygen analyzer must be used; d) facilities and equipment must conform to the standards for "Occupational Exposure to Waste Anesthetic Gases and Vapors" of the National Institute for Occupational Safety and Health (NIOSH); and e) where flammable anesthetics are present, facilities and equipment must conform to the Rhode Island Fire Safety Code. Facility Permit 23.3 Prior to the administration of general anesthesia/deep sedation, inhalation conscious sedation, combined conscious sedation, parenteral conscious sedation, or nitrous oxide analgesia in a dental office by a qualified dentist as described in section 16.0 above and/or a Board certified or Board eligible anesthesiologist employed by or practicing in conjunction with a dentist, each office site must obtain a facility permit to allow the administration of these anesthesia services on the premises. 23.3.1 A facility permit is issued for one office site, and is non-transferable. 23.3.1 a) Those dental office sites in which all anesthesia services are administered by a licensed dentist approved by the Board to administer anesthesia services as described in section 15.2 (above) shall be exempt from the requirements of section 23.3 herein. 23.3.2 Application for a permit shall be made on forms provided by the Board. These forms shall be completed, notarized and submitted to the Board thirty (30) days prior to the scheduled date of the Board meeting. Such application shall be accompanied by: a) the permit fee (non-refundable and non-returnable) as determined annually by the Director of Health in consultation with the Board, made payable by check to the General Treasurer, State of Rhode Island; and, b) such other information as may be deemed necessary and as may be requested by the Board. 23.3.3 Upon receipt of an application for a facility permit as described above, the Board, with the advice of the advisory consultant(s), may issue a permit to an applicant found to meet all the prescribed requirements herein. Said permit unless sooner suspended or revoked shall expire five (5) years from the date of issuance. a) To renew such permit, the applicant shall file with the Board a renewal application at least one (1) month before the date of expiration of the permit, duly executed together with the renewal fee as determined annually by the Director of Health in consultation with the Board, made payable by check to the General Treasurer, state of Rhode Island. Upon receipt of such renewal application and payment of any fee, a renewal shall be issued effective for five (5) years from the date of renewal, unless sooner suspended or revoked. 27 b) Any applicant allowing this permit to lapse through accident, mistake or unforseen cause by failing to renew the permit on or before the expiration date, may be reinstated upon filing an application with payment of the current renewal fee in accordance with section 23.3.3 (a) above. 23.3.4 Those dental offices holding facility permits as described above may be subject to inspections as described in section 19.0 above. Section 24.0 Violations & Sanctions 24.1 Failure to comply with any of the provisions of Part V herein shall be cause for denial, revocation or suspension of permit for the administration of general anesthesia/deep sedation, inhalation conscious sedation, parenteral conscious sedation, or nitrous oxide analgesia, and of disciplinary action in accordance with section 27.0 herein. 24.2 Furthermore, all hearings and reviews pertaining to the requirements as set forth herein, shall be subject to the provisions of section 28.0 of these rules and regulations. 28 PART VI Record Keeping and Disclosure Section 25.0 Availability of Dental Records 25.1 A licensed dentist and/or other licensee shall maintain a dental record for each patient which is adequate to enable the licensee and/or another licensee to provide proper diagnosis and treatment. The dentist must maintain a patient's written dental record and radiographs (x-rays) for a minimum of five (5) years from the date of the last dental visit, in accordance with section 23-3-26 of the General Laws, entitled "Vital Records." Records of minors shall be kept for at least five (5) years after such minor shall have reached the age of 18 years. Records must be maintained in a manner which permits the patient and/or successor dentist access to these records. 25.1.1 At a minimum, said records must include: a) the name, address and date of birth of the patient and, if a minor, the name of the parent or guardian; b) the patient’s medical history; c) a record of results of a clinical examination, where appropriate, or an indication of the patient’s chief complaint; d) a treatment plan, where appropriate; e) the dates of each patient visit and a description of the treatment or services rendered at each visit; f) a description of all radiographs taken and diagnostic models made, properly identified with the patient’s name and date; g) the date, dosage and amount of any medication or drug prescribed, dispensed or administered to the patient; and, h) a record of any recommendations or referrals for treatment or consultation by a specialist, including those which were refused by the patient. 25.1.2 Upon a patient's written request, a dentist shall provide a patient or another specifically authorized person with a complete copy of and a detailed summary of the patient's dental record, which includes all relevant data. 25.1.3 A dentist may charge a reasonable fee for the expense of providing a patient's dental record, not to exceed cost. The dentist shall not require prior payment of charges for dental services as a condition for providing a copy of the dental record. 25.1.4 Dentists shall maintain patient confidentiality in the storage and transfer of records pursuant to the provisions Chapter 5-37.3 of the General Laws, entitled "Confidentiality of Health Care Information Act." 29 25.1.5 A dentist or other licensee treating the patient shall sign or initial the patient’s dental record after each procedure or visit. Section 26.0 Scheduled Controlled Substances: Inventory Record Requirements 26.1 All actions related to the storage, dispensing or administering of controlled substances must be in conformity with the provisions of Chapter 21-28 of the General Laws. 26.2 When a controlled substance is stocked in a dental office for dispensing or administering to a patient, an accurate inventory of the drug shall be maintained and include all of the following information: a) the date and quantity of the drug purchased; b) the amount, dosage and date dispensed or administered; c) the name of the patient to whom it was dispensed or administered. 26.3 The inventory record shall be available for inspection for no less than two (2) years. 26.4 The inventory record shall be in addition to the dental treatment records. 30 PART VII Violations, Sanctions, Severability Section 27.0 Denial, Revocation or Suspension of License/Violations and Sanctions 27.1 Any dentist or dental hygienist may have his or her license revoked or suspended by the Board: if said person has been found guilty of unprofessional conduct, which shall include, but not be limited to those items listed in section 5-31.1-10 of the General Laws and as stated below: a) Fraudulent or deceptive procuring or use of a license or limited registration; b) All advertising of dental or dental hygiene business which is intended or has a tendency to deceive the public or a dentist advertising as a specialty in an area of dentistry unless the dentist: (i) Is a diplomate of or a fellow in a specialty board accredited or recognized by the American Dental Association; or (ii) Has completed a post graduate program approved by the Commission on Dental Accreditation of the American Dental Association; c) Conviction of a crime involving moral turpitude; conviction of a felony; conviction of a crime arising out of the practice of dentistry or of dental hygiene; d) Abandonment of patient; e) Dependence upon controlled substances, habitual drunkenness or rendering professional services to a patient while the dentist or dental hygienist, or limited registrant is intoxicated or incapacitated by the use of drugs; f) Promotion by a dentist, dental hygienist, or limited registrant of the sale of drugs, devices, appliances, or goods or services provided for a patient in a manner as to exploit the patient for the financial gain of the dentist, dental hygienist, or limited registrant; g) Immoral conduct of a dentist, dental hygienist, or limited registrant in the practice of dentistry or dental hygiene; h) Willfully making and filing false reports or records in the practice of dentistry or dental hygiene; i) Willful omission to file or record, or willfully impeding or obstructing a filing or recording, or inducing another person to omit to file or record dental or other reports as required by law; j) Failure to furnish details of a patient's dental record to succeeding dentists, or dental care facility upon proper request pursuant to the Act; k) Solicitation of professional patronage by agents or persons or profiting from acts of those representing themselves to be agents of the licensed dentist, dental hygienist, or 31 limited registrant; l) Division of fees or agreeing to split or divide the fees received for professional services for any person for bringing to or referring a patient; m) Agreeing with clinical or bioanalytical laboratories to accept payments from those laboratories for individual tests or test series for patients, or agreeing with dental laboratories to accept payment from those laboratories for work referred; n) Willful misrepresentation in treatments; o) Practicing dentistry with an unlicensed dentist or practicing dental hygiene with an unlicensed dental hygienist except in an accredited training program, or with a dental assistant in accordance with the rules and regulations of the Board or aiding or abetting those unlicensed persons in the practice of dentistry or dental hygiene; p) Gross and willful overcharging for professional services; including filing of false statements for collection of fees for which services are not rendered or willfully making or assisting in making a false claim or deceptive claim or misrepresenting a material fact for use in determining rights to dental care or other benefits; q) Offering, undertaking, or agreeing to cure or treat disease by a secret method, procedure, treatment, or medicine; r) Professional or mental incompetence; s) Incompetent, negligent, or willful misconduct in the practice of dentistry or dental hygiene, which includes the rendering of unnecessary dental services and any departure from or the failure to conform to the minimal standards of acceptable and prevailing dental or dental hygiene practice in his or her area of expertise as is determined by the Board. The Board need not establish actual injury to the patient in order to adjudge a dentist, dental hygienist or limited registrant guilty of the previously named misconduct; t) Failure to comply with the provisions of Chapter 4.7 of Title 23; u) Revocation, suspension, surrender, or limitation of privilege based on quality of care provided or any other disciplinary action against a license to practice dentistry or dental hygiene in another state or jurisdiction, or revocation, suspension, surrender, or other disciplinary action as to membership on any dental staff or in any dental or professional association or society for conduct similar to acts or conduct which would constitute grounds for action as prescribed in the Act; v) Any adverse judgment, settlement, or award arising from a dental liability claim related to acts or conduct similar to acts or conduct which would constitute grounds for action as defined in the Act or regulations adopted herein; w) Failure to furnish the Board, its dental administrator, investigator, or representatives, information legally requested by the Board; 32 x) Violation of any provision(s) of the Act or the rules and regulations of the Board or any rules and regulations promulgated by the Director or of an action, stipulation or agreement of the Board; y) Cheating on or attempting to subvert the licensing examination; z) Violating any state or federal law or regulation relating to controlled substances; aa) Failure to maintain standards established by peer review boards, including, but not limited to, standards related to proper utilization of services, and use of nonaccepted procedure and/or quality of care; bb) Malpractice as defined in § 5-37-1(8) of the Rhode Island General Laws, as amended. cc) No person licensed to practice dentistry in the state of Rhode Island may permit a non- dentist who operates a dental facility in the form of a licensed out patient health care center or management service organization to interfere with the professional judgment of the dentist in the practice. 27.2 Furthermore, any violation pursuant to any provisions of the Act and the rules and regulations herein, may be cause for denial, revocation or suspension of license or for imposing such other penalties as prescribed in the Act. 27.3 Any hearings or reviews required under statutory or regulatory provisions herein shall be held in accordance with the provisions of the Act and of the Administrative Procedures Act, Chapter 42-35 of the General Laws of Rhode Island, as amended. Section 28.0 Rules Governing Practices and Procedures 28.1 All hearings and reviews required under the provisions of Chapter 5-31.1 of the General Laws of Rhode Island, as amended, shall be held in accordance with the provisions of the Rules and Regulations of the Rhode Island Department of Health Regarding Practices and Procedures Before the Department of Health and Access to Public Records of the Department of Health (R42-35-PP). Section 29.0 Severability 29.1 If any provisions of these rules and regulations or the application thereof to any person or circumstance shall be held invalid such invalidity shall not affect the provisions or application of the rules and regulations which can be given effect, and to this end the provisions of the rules and regulations are declared to be severable. 33 REFERENCES 1. Blood borne Pathogens, Occupational Safety and Health Administration (OSHA), 29 Code of Federal Regulations, section 1910.1030, Revised July 1, 2003. Available online: http://www.gpoaccess.gov/cfr/retrieve.html 2. Rules and Regulations of the Rhode Island Department of Health Regarding Practices and Procedures Before the Department of Health and Access to Public Records of the Department of Health (R42-35-PP), Rhode Island Department of Health, April 2004 and subsequent amendments thereto. Available online: http://www.rules.state.ri.us/rules/released/pdf/DOH/DOH_2945.pdf 3. Guidelines for Infection Control in Dental Health Care Settings---2003. Centers for Disease Prevention and Control, MMWR Recommendations and Reports, December 19, 2003/ 52 (RR17);1-61. Available online: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm 4. Rules and Regulations Related to Pain Assessment (R5-37.6-PAIN), Rhode Island Department of Health, May 2003 and subsequent amendments thereto. Available online: http://www.rules.state.ri.us/rules/released/pdf/DOH/DOH_2531.pdf 5. Rules and Regulations Pertaining to the Use of Latex Gloves by Health Care Workers, in Licensed Health Care Facilities, and by Other Persons, Firms, or Corporations Licensed or Registered by the Department (R23-73-LAT), Rhode Island Department of Health, May 2002 and subsequent amendments thereto. Available online: http://www.rules.state.ri.us/rules/released/pdf/DOH/DOH_2008_.pdf 6. American Dental Association: Guidelines for the Use of Conscious Sedation, Deep Sedation and General Anesthesia for Dentists, October 2003. Available online: http://www.ada.org/prof/resources/positions/statements/anesthesia_guidelines.pdf 7. American Dental Association: Guidelines for Teaching the Comprehensive Control of Anxiety and Pain in Dentistry, October 2003. Available online: http://www.ada.org/prof/resources/positions/statements/anxiety_guidelines.pdf 8. The North East Regional Board (NERB) website: http://www.nerb.org/ dentists-final-feb06.doc Tuesday, February 07, 2006