216-RICR-40-05-2. Dentists, Dental Hygienists, and Dental Assistants (version Amendment, 12/10/2012 to 06/04/2017)

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 January 2002 (re-filing in accordance with the provisions of section 42-35-4.1 of the Rhode Island General Laws, as amended) October 1989 November 2004 February 1991(E) February 2006 June 1991(E) September 1991 (E) January 1992 (E) April 1992 January 2007 (re-filing in accordance with the provisions of section 42-35-4.1 of the Rhode Island General Laws, as amended) February 1993 September 2007 April 1996 September 2011 July 1999 January 2012 (re-filing in accordance with the provisions of section 42-35-4.1 of the Rhode Island General Laws, as amended) November 2001 September 2012 i INTRODUCTION These amended Rules and Regulations Pertaining to Dentists - Dental Hygienists -and Dental Assistants [R5-31.1-DHA] 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, moderate sedation, minimal 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 §§42-35-3(a)(3) and (a)(4) of the General Laws of Rhode Island, as amended, the following were given consideration in arriving at the amended regulations: (1) Alternative approaches to the regulations; (2) Duplication or overlap with other state regulations; and (3) Significant economic impact on small business. Based on the available information, no known overlap, duplication or alternative approach was identified. Upon promulgation of these amendments, these amended regulations shall supersede all previous Rules and Regulations Pertaining to Dentists - Dental Hygienists and Dental Assistants 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 1.0 Definitions 1 PART II Dentists/Licensing Requirements 4 2.0 License Requirements 4 2.5 Volunteer Dental/Dental Hygiene Permit 4 3.0 Qualifications 5 4.0 Application/Fee 5 5.0 Examinations 6 5.2 Continuing Education 7 6.0 Issuance and Renewal of License 8 PART III Dental Hygienists/Licensing Requirements 10 7.0 License Requirements 10 8.0 Qualifications 10 9.0 Application/Fee 10 10.0 Examinations 11 10.2 Continuing Education 12 11.0 Issuance and Renewal of License 13 PART IV Delegable/Non-Delegable Procedures/ Duties - Supervision 15 12.0 General Requirements 15 12.1 Dental Hygienists 15 12.2 Certified Dental Assistants & Dental Assistants 15 13.0 Delegable Procedures/Duties 16 14.0 Non-Delegable (Exclusionary) Procedures/Duties 17 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 20 19.0 Inspections 21 20.0 Inactive Status 21 21.0 General Anesthesia/Deep Sedation, Moderate Sedation, Minimal Sedation or Nitrous Oxide Analgesia Services 21 22.0 Administration of Local Anesthesia by Dental Hygienists 23 22.1.1 Administration of Nitrous Oxide by Dental Hygienists 25 23.0 Physical Facility, Equipment & Safety 26 24.0 Violations & Sanctions 29 PART VI Record Keeping and Disclosure 30 25.0 Dental Records 30 26.0 [REMOVED] PART VII Violations, Sanctions, Severability 32 27.0 Denial, Suspension or Revocation of License, Violations & Sanctions 32 28.0 Rules Governing Practices & Procedures 34 29.0 Severability 34 References 35 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 of the General Laws of Rhode Island, as amended, entitled "Dentists and Dental Hygienists". 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, moderate sedation, minimal 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, moderate sedation, minimal sedation or nitrous oxide analgesia. 1.3 "Biennial" means occurring every second (2nd) year. 1.4 "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. 1.5 "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. 1.6 “Dental administrator” means the Administrator of the Rhode Island Board of Examiners in Dentistry. 1.7 “Deep sedation” means a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. 1.8 "Dental assistant" means a person not 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. 2 1.9 "Dental auxiliary personnel" refers to a dental hygienist, a certified dental assistant or a dental assistant. 1.10 "Dental hygienist" means an individual licensed under the provisions of the Act to practice dental hygiene. 1.11 "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 Act. 1.12 "Dentist" means an individual licensed under the provisions of the Act to practice dentistry in this state. 1.13 "Dentistry" means the evaluation, diagnosis, prevention and/or treatment (non-surgical, surgical or related procedures) of diseases, disorders and/or conditions of the oral cavity, cranio-maxillofacial area and/or the adjacent and associated structures and their impact on the human body, including any service or product that may change the anatomy, appearance or arrangement of teeth provided by a dentist, within the scope of his or her education, training and experience, in accordance with the ethics of the profession and applicable law. 1.14 "General anesthesia" means a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired. 1.15 “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. 1.16 "License", as used herein, is synonymous with "registration.” 1.17 "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. 1.18 "Minimal sedation" means a minimally depressed level of consciousness, produced by a pharmacological method, that retains the patient’s ability to independently and continuously maintain an airway and respond normally to tactile stimulation and verbal command. Although cognitive function and coordination may be modestly impaired, ventilatory and cardiovascular functions are unaffected. 1.19 "Moderate sedation" means a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. 3 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 “RIGL” means the General Laws of Rhode Island, as amended. 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 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 “These Regulations” mean all parts of Rhode Island Rules and Regulations Pertaining to Dentists, Dental Hygienists and Dental Assistants [R5-31.1-DHA]. 1.24 "Unprofessional conduct" shall include, but not be limited to, the provisions of §5-31.1-10 of the Act, 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 in these Regulations. REMAINDER OF PAGE INTENTIONALLY LEFT BLANK 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 §13.0, Part IV of these Regulations. Exempt from these requirements are those persons listed in §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 RIGL Chapter 23-17 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. Scheduled Controlled Substances 2.4 All actions related to the storage or administration of controlled substances shall be in conformity with the provisions of RIGL Chapter 21-28 and 21 CFR sections 1300-1316 [Reference 9]. Volunteer Dental/Dental Hygiene Permit 2.5 Notwithstanding any other provision of the Act or these Regulations, the Board may issue a volunteer dental/dental hygiene permit that allows an out-of-state dentist/dental hygienist to provide dental or dental hygiene services in Rhode Island without obtaining a Rhode Island license. (a) Services provided pursuant to a volunteer dental/dental hygiene permit shall be limited to: (1) A free clinic or similar charitable medical event providing free health care services; or (2) The Special Olympics or similar athletic event attracting a large number of out-of- state participants; or (3) Participation in the Mission of Mercy program. 5 (b) Application: An applicant for a volunteer dental permit shall submit the following information to the Board at least sixty (60) days prior to the event: (1) A copy of the applicant’s current dental/dental hygienist license or a letter of good standing from the state where the applicant is currently licensed: and (2) A letter, signed by an authorized representative of the sponsoring agency, which specifies the date(s) and location(s) of the event, and the type(s) of volunteer dental or dental hygiene services that will be provided; and (3) A notarized statement, signed by both the applicant and an authorized representative of the sponsoring agency, which specifies that it has been agreed between the parties that no compensation shall be paid for any dentistry or dental hygiene services rendered in Rhode Island while in possession of a volunteer dental permit. 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 §5.0 of these Regulations or met the requirements for endorsement stipulated in §5.1.1(d) of these Regulations; and (e) be in good standing in each state in which he/she holds a license. Section 4.0 Application for License and Fee 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. 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; 6 (d) national board results in accordance with §5.1.1(b) of these Regulations 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 §5.1 of these Regulations) 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 (non-refundable) as set forth in the Rules and Regulations Pertaining to the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health in accordance with §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 §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 §3.1(c) of these Regulations; 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; or (1) 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 7 (2) 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 §4.0 of these Regulations. 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 §5-31.1-7 of the Act, all dentists licensed to practice in this state under the provisions of the Act and these Regulations, on or before the first (1st) 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 in these Regulations 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 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 established by these Regulations. 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 (a) 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. (b) Effective 1 July 2012, all dentists practicing in a dental setting shall hold a current certificate of completion from an approved course in Basic Cardiac Life Support (BCLS). 8 5.2.3 If the applicant attests to 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 §5-31.1-7 of the Act, the Board shall issue the applicant a license registration for a two (2) year period in accordance with the requirements of §6.0 of these Regulations. 5.2.4 Licensure renewal shall be denied to any applicant who fails to attest to completion continuing dental education as required by these Regulations. (a) Notwithstanding the provisions of §5.2.3 of these Regulations, 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 attest to completion of continuing dental education as required by these Regulations. 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 of these Regulations’ 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 of these Regulations. Said license unless sooner suspended or revoked shall expire biennially on the 30th of June of the even numbered years. 6.2 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 attestation to completion of continuing education requirement and the renewal fee as determined biennially by the Director of Health in consultation with the Board, and as set forth in the Rules and Regulations Pertaining to the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health. 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. 6.2.1 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 as set forth in the Rules and Regulations Pertaining to the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health. 6.3 Pursuant to the provisions of §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 July of the even numbered years 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 as set forth in the Rules and Regulations Pertaining to the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health reinstate any license (certificate) revoked under the provisions of the Act and these Regulations. 9 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 as set forth in the Rules and Regulations Pertaining to the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health. 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 in these Regulations, including attesting to completion of the required continuing dental education courses as specified in §5.2.1 of these Regulations. REMAINDER OF PAGE INTENTIONALLY LEFT BLANK 10 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 Regulations. Exempt from these requirements, are those persons listed in §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 §10.0 of these Regulations or met the requirements for endorsement stipulated in §10.1.1(d) of these Regulations; 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. 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 §10.1.1(a) of these Regulations, (submitted either with the application or submitted by the National Board Dental Hygiene Examination to the Board); 11 (e) The results of the Northeast Regional Board of Dental Examiners, Inc., examination or other dental examination organizations (as required in §10.1 of these Regulations) 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 as set forth in the Rules and Regulations Pertaining to the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health in accordance with §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 §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 §8.1(c) of these Regulations; 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 (1) 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 (2) have successfully passed a simulated patient clinical exercise (NERB Computer Simulated Clinical Examination {CSCE} written) with an earned score of seventy-five percent (75%); or 12 (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 §9.0 of these Regulations. 10.1.3 Sites and schedules of examinations may be obtained directly from the examination service(s) referred to above. 10.2 Continuing Education--Dental Hygienists 10.2.1 Pursuant to the provisions of §5-31.1-7 of the Act, all dental hygienists licensed to practice in this state under the provisions of the Act and these Regulations, shall, on or before the first (1st) 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 in these Regulations 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 (a) 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. (b) Effective 1 July 2012. all dental hygienists practicing in a dental setting shall hold a current certificate of completion of an approved course in Basic Cardiac Life Support (BCLS). 10.2.3 If the applicant attests to completion of prescribed course(s) of continuing education and is in compliance with the provisions of §5-31.1-6 of the Act, the Board shall issue the applicant a license registration for a two (2) year period in accordance with the requirements of §6.0 of these Regulations. 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 requirements upon request by the Board may constitute grounds for disciplinary action. 13 10.2.5 Licensure renewal shall be denied to any applicant who fails to attest to completion of continuing education courses relevant to the practice of dental hygiene as required by these Regulations. (a) Notwithstanding the provisions of §10.2.4(a) of these Regulations, 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 attest to completion of continuing education as provided by these Regulations. 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 of these Regulations. 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 of these Regulations. Said license unless sooner suspended or revoked shall expire biennially on the 30th of June of each even-numbered year. 11.2 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 attestation to completion of continuing education requirements and the renewal fee as determined biennially by the Director of Health in consultation with the Board, and as set forth in the Rules and Regulations Pertaining to the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health. 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. 11.2.1 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 as set forth in the Rules and Regulations Pertaining to the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health. 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 July of each even numbered year, 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 as set forth in the Rules and Regulations 14 Pertaining to the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health reinstate any license (certificate) revoked under the provisions of the Act and these Regulations. 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 as set forth in the Rules and Regulations Pertaining to the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health. 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 in these Regulations, including attesting to completion of the required continuing dental education courses relevant to the practice of dental hygiene as specified in §14.0 of these Regulations. REMAINDER OF PAGE INTENTIONALLY LEFT BLANK 15 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 §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 §13.0 of these Regulations. 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 §14.0 of these Regulations. 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 §13.0 of these Regulations. 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 §14.0 of these Regulations. 12.3 All procedures/duties performed by dental auxiliaries shall be performed under the direct supervision of a dentist, unless otherwise specified in §13.0 of these Regulations. 12.4 Any reversible intraoral procedure not specifically enumerated as delegable or non-delegable (exclusionary) pursuant to §13.0 and §14.0 of these Regulations, 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. 16 Section 13.0 Delegation of Duties 13.1 A dentist may delegate to auxiliary personnel those procedures which the dentist may deem advisable, except for those procedures excluded in §14 of these Regulations. 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: (1) Such procedures were incorporated into the academic training from which the certified dental assistant graduated; OR (2) 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 §5-31.1-6 of the Act may delegate to any dental hygienists licensed pursuant to §5-31.1-6 of the Act who are employed on a regular basis by such dentists any procedures which he or she may deem advisable; including those procedures specified under §13.0 of these Regulations 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 RIGL Chapter 23-17 without the on-site direct supervision of a dentist licensed pursuant to §5- 31.1-6 of the Act, those dental services, procedures and duties that he or she has been educated to perform and which are authorized by the Board. REMAINDER OF PAGE INTENTIONALLY LEFT BLANK 17 Section 14.0 Non-Delegable (Exclusionary) Procedures/Duties 14.1 Notwithstanding the provisions of §12.0 and §13.0 of these Regulations, nothing in these 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 general anesthesia/deep sedation, moderate sedation and/or minimal sedation; (5) Administering inhalants or inhalation conscious sedation agents. [Not applicable to dental hygienists licensed pursuant to §22.1.1 of these Regulations.]; (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 §F.2.3 of the Rules and Regulations for the Control of Radiation (R23-1.3-RAD), Rhode Island Department of Health Office of Facilities Regulation, Radiation Control Program; (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 these Regulations. (See also §13.1.2(b) of these Regulations). REMAINDER OF PAGE INTENTIONALLY LEFT BLANK 18 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, moderate sedation, minimal 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, moderate sedation, minimal sedation or nitrous oxide analgesia in his or her dental office. 15.2 Any licensed dentist permitted to administer general anesthesia/deep sedation, moderate sedation, minimal 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 §23.3 of these Regulations, 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, may inspect all equipment utilized for the purpose of administering general anesthesia/deep sedation, moderate sedation, minimal sedation or nitrous oxide analgesia. Said equipment shall meet all applicable requirements of §23.1 and §23.2 of these Regulations. 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, moderate sedation, minimal 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, moderate sedation, minimal 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 the American Dental Association Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students (October 2007) [Reference 7]; or 19 (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 Pain Control and Sedation to Dentists and Dental Students (October 2007) [References 7]; or (d) be employed or practice in conjunction with a Board certified or Board eligible anesthesiologist. 16.1.2 For Moderate Sedation: (a) be licensed as a dentist in this state; and (b) satisfy one of the following education and training requirements: (1) completion of a comprehensive training program in moderate sedation consistent with that prescribed in the ADA Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students (October 2007) [References 7]; or (2) completion of an ADA accredited post-doctoral training program which affords comprehensive and appropriate training necessary to administer and manage moderate sedation; or, (3) meet one of the requirements as set forth in §§16.1.1(b) through (d) of these Regulations. 16.1.3 For Minimal Sedation: (a) be licensed as a dentist in this state; and (b) satisfy one of the following education and training requirements: (1) completion of a comprehensive training program in minimal sedation that satisfies the requirements described in the ADA Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students (October 2007) [References 7]; (2) 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 minimal sedation; or, (3) meet one of the requirements as set forth in §§16.1.1(b) through (d) or §§16.1.2(b) through (d) of these Regulations. 16.1.4 [REMOVED] 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 §§16.1.1(b) through (d) or §§16.1.2(b) through (d) or §§16.1.3(b) through (d) of these Regulations; 20 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 Pain Control and Sedation to Dentists and Dental Students (October 2007) [Reference 7] 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): (a) Supporting official transcripts of verification of the qualification requirements as set forth in §16.1.1 or §16.1.2 or §16.1.3 or §16.1.5 of these Regulations; (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, moderate sedation, minimal 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 and as set forth in the Rules and Regulations Pertaining to the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health; 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, moderate sedation, minimal 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 on June 30 of each even numbered year. 18.2 Every person issued a permit who desires to renew his or her permit shall file with the Board one (1) month before the date of expiration of permit, a renewal application duly executed together with the renewal fee, where applicable, as determined biennially by the Director of Health in consultation with the Board and as set forth in the Rules and Regulations Pertaining to the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health. Upon receipt of such renewal application and payment of any fee, a renewal shall be issued effective for two (2)years from the date of renewal, unless sooner suspended or revoked. 21 18.3 Any person who allows his or her permit to lapse through accident, mistake or unforeseen 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 §18.2 of these Regulations. 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. 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, moderate sedation, minimal 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, as set forth in the Rules and Regulations Pertaining to the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health. 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, Moderate Sedation, Minimal Sedation, or Nitrous Oxide Analgesia Services 21.1 Personnel: 21.1.1 A dentist administering or permitting the administration of general anesthesia/deep sedation, moderate sedation, minimal 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 Guidelines for the Use of Sedation and General Anesthesia by Dentists (October 2007) [Reference 6]. 22 (b) The dentist administering or permitting the administration of moderate sedation shall hold a current certificate in Basic Cardiac Life Support, as described in the most current version of the American Dental Association, Guidelines for the Use of Sedation and General Anesthesia by Dentists (October 2007) [Reference 6]. (c) The dentist administering or permitting the administration of minimal sedation shall hold a current certificate in Basic Cardiac Life Support, as described in the American Dental Association, Guidelines for the Use of Sedation and General Anesthesia by Dentists (October 2007) [Reference 6]. (d) [REMOVED] (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, moderate sedation, minimal 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, moderate sedation, minimal 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, moderate sedation, minimal sedation or nitrous oxide analgesia, and post-anesthetic evaluation; (d) Signed informed consent obtained prior to the administration of general anesthesia/deep sedation, moderate sedation, minimal 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, moderate sedation, minimal 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, moderate sedation, minimal 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 been discharged from the dentist’s (or anesthesiologist’s) care. REMAINDER OF PAGE INTENTIONALLY LEFT BLANK 23 Monitoring and Documentation 21.2.2 A dentist administering or permitting the administration of general anesthesia/deep sedation, moderate sedation or minimal 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 and Nitrous Oxide 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 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: (1) neurophysiology of pain and pain control; 24 (2) pharmacology of local anesthetic solutions and drug interactions; (3) potential local and systemic complications; (4) medical and dental indications and contraindications and emergency management; (5) medical and dental history and assessment; (6) safe assembly and handling of a syringe; (7) location of anatomical landmarks associated with local anesthesia; (8) injection techniques; (9) clinical experience with maxillary and mandibular injections by administering infiltration and block injections; (10) legal issues associated with local anesthesia administration by a dental hygienist; (11) 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. Dental hygiene faculty members who are licensed to administer local anesthesia may do so within the scope of the academic setting of which they are employed under the general supervision of the program’s consulting dentist in the event that a supervising dentist is not available. 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 §22.1 of these Regulations, 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 §22.1 of these Regulations, 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 the Board meeting. Such application shall be accompanied by the following documents (non-returnable and non-refundable): 25 (a) (1) Local anesthesia. supporting official transcripts of verification of the qualification requirements as set forth in §22.1 of these Regulations; (2) Nitrous Oxide. supporting official transcripts of verification of the qualification requirements as set forth in §22.1.1 of these Regulations; (b) (1) Local anesthesia. 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; (2) Nitrous Oxide. a statement attesting that he or she has or has not been involved in any morbidity or mortality secondary to the administration of nitrous oxide; (c) (1) Local anesthesia. a payment as set forth in the Rules and Regulations Pertaining to the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health for a two (2) year permit; (2) Nitrous Oxide. a payment as set forth in the Rules and Regulations Pertaining to the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health 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 22.1.1 Administration of Nitrous Oxide by Dental Hygienists (a) A dental hygienist shall be qualified to administer nitrous oxide only after successfully completing a course in nitrous oxide administration that: (1) is offered by an institution accredited by the Commission on Dental Accreditation of the American Dental Association; (2) is a minimum of four (4) didactic hours and four (4) clinical hours; (3) includes no less than the following topics: (i) nitrous oxide techniques; (ii) pharmacology of nitrous oxide; (iii) nitrous oxide analgesia medical emergency techniques; and (iv) selection of pain control modalities, if available. (4) provides written evidence of successful course completion provided by the sponsoring organization; and (5) current certification in basic life and cardiopulmonary resuscitation at the “health care provider” level by a nationally recognized organization. (b) A dental hygienist qualified to administer nitrous oxide shall have successfully completed a nitrous oxide examination administered by the North East Regional Board (NERB). (c) A dental hygienist qualified to administer nitrous oxide shall do so only under the direct supervision of a dentist. 26 (d) If a dental hygienist graduated from an American Dental Association accredited school of dental hygiene that did not include a course in nitrous oxide that meets the requirements of §22.1.1 of these Regulations, a course that meets such requirements shall be successfully completed before nitrous oxide may be administered by the dental hygienist. (e) A dental hygienist who has qualified to administer nitrous oxide in another jurisdiction may qualify for endorsement by the Board to perform that function by presenting written documentation of training equivalent to §22.1.1(a) of these Regulations, including successful completion of the nitrous oxide portion of the NERB examination or successful completion of a substantially similar examination in the alternate jurisdiction. 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, moderate sedation or minimal 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 Sedation and General Anesthesia by Dentists (October 2007) [Reference 6] including but not limited to the following equipment requirements: (1) equipment must have a fail-safe system that is appropriately checked and calibrated; (2) equipment must have an appropriate scavenging system; and, (3) 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 twenty- five percent (25%) 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. 27 Facility Permit 23.3 Prior to the administration of general anesthesia/deep sedation, moderate sedation, minimal sedation or nitrous oxide analgesia in a dental office by a qualified dentist as described in §16.0 of these Regulations 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. (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 §15.2 of these Regulations shall be exempt from the requirements of §23.3 of these Regulations. 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, and as set forth in the Rules and Regulations Pertaining to the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health; 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 of these Regulations. 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, and as set forth in the Rules and Regulations Pertaining to the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health. 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. (b) Any applicant allowing this permit to lapse through accident, mistake or unforeseen 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 §23.3.3(a) of these Regulations. 23.3.4 Those dental offices holding facility permits as described above may be subject to inspections as described in §19.0 of these Regulations. REMAINDER OF PAGE INTENTIONALLY LEFT BLANK 28 29 Section 24.0 Violations & Sanctions 24.1 Failure to comply with any of the provisions of Part V of these Regulations shall be cause for denial, revocation or suspension of permit for the administration of general anesthesia/deep sedation, moderate sedation, minimal sedation or nitrous oxide analgesia, and of disciplinary action in accordance with §27.0 of these Regulations. 24.2 Furthermore, all hearings and reviews pertaining to the requirements as set forth herein, shall be subject to the provisions of §28.0 of these Regulations. REMAINDER OF PAGE INTENTIONALLY LEFT BLANK 30 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 RIGL §23-3-26, entitled "Vital Records." Records of minors shall be kept for at least five (5) years after such minor shall have reached the age of eighteen (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 of RIGL Chapter 5-37.3, entitled "Confidentiality of Health Care Information Act." 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. 31 Section 26.0 [REMOVED] REMAINDER OF PAGE INTENTIONALLY LEFT BLANK 32 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 §5-31.1-10 of the Act 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: (1) Is a diplomate of or a fellow in a specialty board accredited or recognized by the American Dental Association; or (2) 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 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; 33 (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 RIGL Chapter 23-4.7; (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 these Regulations; (w) Failure to furnish the Board, its dental administrator, investigator, or representatives, information legally requested by the Board; (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; 34 (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 RIGL §5-37-1(8). (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 these Regulations, 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, RIGL Chapter 42-35. Section 28.0 Rules Governing Practices and Procedures 28.1 All hearings and reviews required under the provisions of the Act 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 Regulations or the application thereof to any person or circumstance shall be held invalid such invalidity shall not affect the provisions or application of these Regulations which can be given effect, and to this end the provisions of these Regulations are declared to be severable. REMAINDER OF PAGE INTENTIONALLY LEFT BLANK 35 REFERENCES 1. Blood borne Pathogens, Occupational Safety and Health Administration (OSHA), 29 Code of Federal Regulations (CFR), section 1910.1030, Revised April 3, 2006. Available online: http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&tpl=%2Findex.tpl 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 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 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 6. American Dental Association: Guidelines for the Use of Sedation and General Anesthesia by Dentists, October 2007. Available online: http://www.ada.org/prof/resources/positions/statements/anesthesia_guidelines.pdf 7. American Dental Association: Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students, October 2007. Available online: http://www.ada.org/sections/professionalResources/pdfs/anxiety_guidelines.pdf 8. The North East Regional Board (NERB) website: http://www.nerb.org/ 9. Drug Enforcement Administration, Department of Justice, 21 Code of Federal Regulations (CFR), sections 1300-1316. Available online: http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&tpl=%2Findex.tpl The revision dates of all regulations cited above were current when these amended regulations were filed with the Secretary of State. Current copies of all regulations issued by the RI Department of Health may be downloaded at no charge from the RI Secretary of State’s Final Rules and Regulations Database website: http://www.sos.ri.gov/rules/ Dental_Final_Sept2012.doc Friday, 14 September 2012