20 CSR 2110-4.020 - Moderate Sedation
(1) Because
sedation and general anesthesia are a continuum, it is not always possible to
predict how an individual patient will respond. Hence, practitioners intending
to produce a given level of sedation should be able to diagnose and manage the
physiologic consequences (rescue) for patients whose level of sedation becomes
deeper than initially intended. For all levels of sedation, the practitioner
must have the training, skills, drugs, and equipment to identify and manage
such an occurrence until either assistance arrives (emergency medical service)
or the patient returns to the intended level of sedation without airway or
cardiovascular complication.
(2) No
dentist shall administer enteral and/or parenteral moderate sedation unless the
dentist possesses a moderate sedation permit issued by the Missouri Dental
Board. (A dentist is not required to possess a permit for the prescription or
administration of drugs prescribed for minimal sedation and/or pain control.)
This permit shall be renewed by June 1 every five (5) years from the year of
issuance.
(3) No dentist shall
prescribe sedative agents for enteral moderate sedation unless the dentist
possesses an enteral or parenteral moderate sedation permit issued by the
Missouri Dental Board. No dentist shall prescribe parenteral moderate sedation
agents unless the dentist possesses a parenteral moderate sedation permit
issued by the Missouri Dental Board.
(4) No dentist shall administer moderate
sedation to a pediatric patient, as defined in
20 CSR
2110-4.010, unless the dentist possesses a pediatric
moderate sedation permit. A dentist possessing a pediatric moderate sedation
permit may administer moderate sedation using either enteral or parenteral
techniques; however, techniques utilizing intravenous administration are
restricted to qualified deep sedation/general anesthesia providers as defined
in 20 CSR
2110-4.040. Moderate sedation services provided to
pediatric patients shall be done in accordance with current American
Academy of Pediatric Dentistry Guidelines for Monitoring and Management of
Pediatric Patients Before, During, and After Sedation for Diagnostic and
Therapeutic Procedures.
(5) No dental office shall be the site for
the administration of enteral, parenteral, or pediatric moderate sedation
without being issued a moderate sedation site certificate by the Missouri
Dental Board. This site certificate shall be renewed by June 1 every five (5)
years from the year of issuance. The dentist-in-charge is responsible for
submitting the application and maintaining the documentation as required in
sections (12) and (14) of this rule.
(6) If the primary administrator of enteral,
parenteral, or pediatric moderate sedation in a dental office is a certified
registered nurse anesthetist, the operating dentist must possess the
appropriate moderate sedation permit for the service being provided.
(7) If the primary administrator of enteral,
parenteral, or pediatric moderate sedation in a dental office is an
anesthesiologist or a certified registered nurse anesthetist, the operating
dentist must order the anesthesia services and is responsible for the readiness
of the dental office, preoperative patient evaluation and appropriate medical
consultations, the coordination of and emergency preparedness of the sedation
team, and the maintenance of appropriate records. The dentist must evaluate the
patient prior to the procedure, remain in the dental office, and evaluate the
patient prior to discharge.
(8) To
qualify for a permit to administer enteral moderate sedation, a dentist shall-
(A) Document satisfactory completion of-
1. An enteral moderate sedation training
course consistent with the American Dental Association Guidelines for
Teaching Pain Control and Sedation to Dentists and Dental Students;
or
2. An ADA-accredited
post-doctoral training program that affords training necessary to administer
enteral moderate sedation; or
3. An
enteral moderate sedation course approved by the Missouri Dental
Board;
(B) Document-
1. Current certification in Advanced Cardiac
Life Support (ACLS); and
2.
Completion during the past five (5) years of a minimum of fifteen (15) hours of
other board-approved continuing education pertaining to airway management in
sedated patients.
3. Additional
hours, not to exceed five (5), acquired beyond the required number may be
carried forward into the renewal cycle; and
(C) Successfully complete an evaluation by
consultants appointed by the board.
(9) To qualify for a permit to administer
parenteral moderate sedation, a dentist shall-
(A) Document satisfactory completion of a
parenteral moderate sedation training program that includes:
1. Sixty (60) hours of didactic training in
pain and anxiety control and related subjects in accordance with current
guidelines of the ADA for teaching pain control and sedation to dentists and
dental students;
2. Successful
management of parenteral moderate sedation in twenty (20) dental patients.
Management of parenteral moderate sedation is defined as performing and being
responsible for all aspects of the sedation procedure from patient selection to
patient discharge post sedation for each of the twenty (20) dental
patients;
3. General anesthesia
training in a hospital accredited by The Joint Commission in which there is
four (4) weeks documented operating room clinical experience in airway
management;
4. Certification of
competency by the course director in airway management; and
5. Certification of competency by the course
director in parenteral moderate sedation;
(B) Document current certification in
Advanced Cardiac Life Support (ACLS); and
(C) Successfully complete an on-site
evaluation by consultants appointed by the board. On-site evaluations shall be
conducted in accordance with
20 CSR
2110-4.030.
(10) To qualify for a permit to administer
pediatric moderate sedation, a dentist shall-
(A) Document satisfactory completion of an
ADA-accredited post-doctoral training program that is a minimum of twelve (12)
continuous months in length and which affords comprehensive and appropriate
training necessary to administer and manage moderate sedation in pediatric
patients. This program shall include:
1. A
minimum of sixty (60) hours of didactic training in pain and anxiety control in
pediatric patients;
2. Successful
management of moderate sedation in twenty (20) pediatric dental patients.
Management is defined as responsible for all aspects of the sedation procedure
from patient selection to patient discharge post sedation;
3. General anesthesia training in which there
is four (4) weeks documented clinical experience in airway
management;
4. Certification of
competency by the course director in airway management; and
5. Certification of competency by the course
director in pediatric moderate sedation;
(B) Document current certification in
Advanced Cardiac Life Support (ACLS) course or Pediatric Advanced Life Support
(PALS); and
(C) Successfully
complete an on-site evaluation by consultants appointed by the board. On-site
evaluations shall be conducted in accordance with
20 CSR
2110-4.030.
(11) To qualify for a moderate sedation site
certificate-
(A) The dentist-in-charge of the
dental office shall document that-
1. The
primary administrator of enteral, parenteral, or pediatric moderate sedation is
a qualified sedation provider as set forth in
20 CSR
2110-4.010(1)(CC);
2. All moderate sedation team members (two
(2) minimum) and the dentist possess and maintain current certification in the
American Heart Association's Basic Life Support for the Healthcare Provider
(BLS) or an equivalent certification approved by the Missouri Dental Board.
Board-approved courses are those that meet the American Heart Association
guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular
care (ECC) and provide written and manikin testing on the course material by an
instructor who is physically present with the students. Online only courses
will not be accepted to satisfy the BLS requirement or ACLS;
3. All moderate sedation team members,
including the dentist, if s/he does not possess an active moderate sedation
permit, have completed a board-approved course in monitoring sedated patients
during the past five (5) years;
4.
The dental office is properly maintained and equipped as set forth in
20 CSR
2110-4.030; and
5. The dental office has written protocols
for sedation of dental patients as set forth in
20 CSR
2110-4.030, including but not limited to, the
following:
A. Preoperative patient evaluation
and selection prior to enteral, parenteral, or pediatric moderate
sedation;
B. Informed consent
procedures;
C. Sedation monitoring
procedures;
D. Maintaining
appropriate records during sedation procedures;
E. Patient discharge assessment;
and
F. Responding to emergencies
incident to the administration of enteral, parenteral, or pediatric moderate
sedation; and
(B) The dental office shall undergo a
facility inspection as set forth in
20 CSR
2110-4.030 to confirm the adequacy of the dental
office and the qualifications of the sedation team.
(12) The board shall issue an enteral,
parenteral, or pediatric moderate sedation permit upon receipt of a completed
application form, payment of the appropriate fee specified in
20 CSR
2110-2.170, proof of having met the requirements of
sections (7), (8), or (9) of this rule, and determination that the applicant is
a licensee in good standing. To be in good standing the licensee's dental
license(s) must be current and not under restriction or discipline in any
state. The requirements of this section must be completed within one (1) year
of the date of submission of the application form.
(13) The board shall issue a moderate
sedation site certificate upon receipt of a completed application form, payment
of the appropriate fee specified in
20 CSR
2110-2.170, and proof of having met the requirements
of section (10) of this rule. The requirements of this section must be
completed within one (1) year of the date of submission of the application
form.
(14) To renew a permit to
administer enteral, parenteral, or pediatric moderate sedation a dentist shall,
at least ninety (90) days prior to the expiration of the current permit-
(A) Submit a completed renewal application
form provided by the board;
(B)
Submit to the board a minimum of five (5) unedited, complete patient records of
the permitted dentist administering enteral, parenteral, or pediatric moderate
sedation in the dental office from the preceding five (5) years, documenting
management of moderate sedation patients in accordance with the criteria set
forth in 20
CSR 2110-4.030;
(C) Submit the renewal fee specified in
20 CSR
2110-2.170 payable to the Missouri Dental Board;
and
(D) Document-
1. Current certification in Advanced Cardiac
Life Support (ACLS); and
2.
Completion during the past five (5) years of a minimum of fifteen (15) hours of
other board-approved continuing education pertaining to airway management in
sedated patients.
3. Additional
hours, not to exceed five (5), acquired beyond the required number may be
carried forward into the renewal cycle.
(15) To renew a moderate sedation site
certificate the dentist-in-charge shall, at least ninety (90) days prior to the
expiration of the current site certificate-
(A) Submit a completed renewal application
form provided by the board;
(B)
Submit the renewal fee specified in
20 CSR
2110-2.170 payable to the Missouri Dental
Board;
(C) Attest that the primary
administrator of enteral, parenteral, or pediatric moderate sedation is a
qualified sedation provider as set forth in
20 CSR
2110-4.010(1)(CC);
(D) Document that the sedation team, as well
as the permitted dentist, possess and maintain current certification in the
American Heart Association's Basic Life Support for the Healthcare Provider
(BLS) or an equivalent certification approved by the Missouri Dental Board.
Board-approved courses are those that meet the American Heart Association
guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular
care (ECC) and provide written and manikin testing on the course material by an
instructor who is physically present with the students. Online only courses
will not be accepted to satisfy the BLS requirement, or the American Red Cross
recognized equivalent certification, or ACLS;
(E) Document that all moderate sedation team
members, including the operating dentist, if s/he does not possess an active
moderate sedation permit, have completed a board-approved course in monitoring
sedated patients during the past five (5) years; and
(F) Undergo a facility inspection as set
forth in 20
CSR 2110-4.030 to confirm the adequacy of the dental
office and the qualifications of the sedation team.
(16) Each dentist possessing a permit to
administer enteral, parenteral, or pediatric moderate sedation shall maintain
current certification in Advanced Cardiac Life Support (ACLS) at all times the
sedation permit is active.
(17) A
dentist holding a current enteral conscious sedation permit on or before the
effective date of this rule is authorized to perform all means of enteral
moderate sedation set forth in
20 CSR
2110-4.010(1)(L) and, upon renewal,
will receive a permit to administer enteral moderate sedation upon compliance
with the renewal requirements set forth in section (13) of this rule.
(18) A dentist holding a current parenteral
conscious sedation permit on or before the effective date of this rule is
authorized to perform all means of parenteral moderate sedation set forth in
20 CSR
2110-4.010(1)(Y) and, upon renewal,
will receive a permit to administer parenteral moderate sedation upon
compliance with the renewal requirements set forth in section (13) of this
rule.
(19) A dental office holding
a current conscious sedation site certificate on or before the effective date
of this rule is authorized to be the site for the administration of enteral,
parenteral, or pediatric moderate sedation and, upon renewal, will receive a
moderate sedation site certificate.
(20) A dentist holding a permit of
authorization for the administration of parenteral moderate sedation may use
enteral moderate sedation without a permit for enteral moderate sedation. A
dentist holding a permit of authorization for the administration of deep
sedation/general anesthesia under 20 CSR 21104.040 may use enteral, parenteral,
and/or pediatric moderate sedation without a permit for enteral, parenteral,
and/or pediatric moderate sedation.
(21) The dentist-in-charge of a dental office
in receipt of a moderate sedation site certificate must ensure that the
moderate sedation team meets the clinical requirements and the dental office
meets the standards for utilization as set forth in
20 CSR
2110-4.030.
(22) At any time, the board may inspect a
dental office where enteral, parenteral, or pediatric moderate sedation is
administered in order to verify compliance with the minimum requirements of
this rule.
(23) If at any time the
board learns that a dentist who holds a permit to administer enteral,
parenteral, or pediatric moderate sedation, or a moderate sedation site
certificate has failed to meet the minimum qualifications set out in this rule,
the board may pursue disciplinary action in accordance with section
332.321, RSMo.
(24) Due to narrow therapeutic dose ranges
for moderate sedation, use of thiopental, methohexital, and propofol for
moderate sedation of dental patients will be restricted to qualified deep
sedation/general anesthesia providers as defined in
20 CSR
2110-4.040.
(25) The provisions of this rule are declared
severable. If any provision of this rule is held invalid by a court of
competent jurisdiction, the remaining provisions of this rule shall remain in
full force and effect unless otherwise determined by a court of competent
jurisdiction.
Notes
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