These regulations are promulgated pursuant to the authority conferred under R.I. Gen. Laws Chapter 5-31.1, and are established for the purpose of adopting prevailing standards governing the licensure of dentists, dental hygienists, Public Health Dental Hygienists and Dental Anesthesia Assistant National Certification Examination (DAANCE)-certified maxillofacial surgery assistants; the practice of dentistry as it pertains to dentists, dental hygienists and dental assistants; continuing education for dentists, dental hygienists, and DAANCE-certified maxillofacial surgery assistants; the administration of general anesthesia/deep sedation, moderate sedation, minimal sedation and/or nitrous oxide sedation; and to establish administrative procedures for the implementation of the statutory and regulatory provisions.

A. These regulations hereby adopt and incorporate by reference the Center for Disease Control and Prevention’s “Summary of Infection Prevention Practices in Dental Health Care Settings” (2016), not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these regulations.

B. These regulations hereby adopt and incorporate 29 C.F.R. § 1910 (2018) by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these regulations.

C. These regulations hereby adopt and incorporate by reference the American Dental Association’s “Guidelines for the Use of Sedation and General Anesthesia by Dentists” (2016), not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these regulations.

D. These regulations hereby adopt and incorporate by reference the American Dental Association’s “Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students” (2016), not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these regulations.

E. These regulations hereby adopt and incorporate 21 C.F.R. §§ 1300-1316 (2018) by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these regulations.

F. These regulations hereby adopt and incorporate by reference the National Institute for Occupational Safety and Health’s “Controlling Exposures to Nitrous Oxide during Anesthetic Administration” (1994), not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these regulations.

G. These regulations hereby adopt and incorporate by reference the National Institute for Occupational Safety and Health’s “Control of Nitrous Oxide in Dental Operatories” (1996), not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these regulations.

H. These regulations hereby adopt and incorporate ASA Physical Status Classification System for Dental Patient Care (2017) by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these regulations.

I. These regulations hereby adopt and incorporate the American Academy of Pediatrics, American Academy of Pediatric Dentistry, Guidelines for Monitoring and Management of Pediatric Patients Before, During and After Sedation for Diagnostics and Therapeutic Procedures (2016), by reference, not including any further editions or amendments thereof and only to the extent that the provisions therein are not inconsistent with these regulations.

A. Wherever used in this Part the following terms shall be construed to mean:

1. "Act" refers to R.I. Gen. Laws Chapter 5-31.1, entitled “Dentists and Dental Hygienists". Also known as the Dental Practice Act.

2. "Adult" means a person thirteen (13) years of age or older.

3. "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 of this Part, of applicants seeking a permit to administer or to permit the administration of general anesthesia/deep sedation, moderate sedation, minimal sedation or nitrous oxide sedation. 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 Diplomates of the National Dental Board of Anesthesiology or 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 sedation.

4. "Analgesia" means the diminution or elimination of pain.

5. "Biennial" means occurring every second (2nd) year.

6. "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.

7. "Competency" means displaying special skill or knowledge derived from training and experience.

8. “Continuous” means prolonged without any interruption at any time.

9. “DAANCE-certified maxillofacial surgery assistant” means a person currently certified by the American Association of Oral and Maxillofacial Surgeons to provide supportive anesthesia care.

10. "DANB-certified assistant" means a person currently certified by the Dental Assisting National Board, Inc. (DANB), or its successor agency, holding the certified Dental Assistant (CDA) certification in general dental assisting duties or another DANB certification in a specific area of advanced or specialty practice, and employed for the purpose of assisting a dentist in the performance of procedures/duties related to dental care in accordance with the provisions of this Part.

11. “Dental administrator” means the Administrator of the Rhode Island Board of Examiners in Dentistry.

12. “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.

13. “Dental assistant" means a person not currently certified by the Dental Assisting National Board, Inc. (DANB) holding the certified Dental Assistant (CDA) certification in general dental assisting duties or another DANB certification in a specific area of advanced or specialty practice, and employed for the purpose of assisting a dentist in the performance of procedures/duties related to dental care in accordance with the provisions of this Part.

14. "Dental auxiliary personnel" refers to a dental hygienist, a public-health dental hygienist, a DANB-certified assistant, a DAANCE-certified maxillofacial surgery assistant or a dental assistant.

15. "Dental hygienist" means an individual licensed under the provisions of the Act to practice dental hygiene.

16. "Dental office or facility" means a place, however named, where a dentist actively, regularly, and personally practices dentistry, pursuant to the provisions of R.I. Gen. Laws § 5-31.1-1(16).

17. "Dentist" means an individual licensed under the provisions of the Act to practice dentistry in Rhode Island.

18. “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.

19. “Department” means the Rhode Island Department of Health.

20. “Digital scan” means a virtual computer generated replica of the hard and soft tissue of the mouth using lasers or other optical scanning devices.

21. “Director” means the Director of the Rhode Island Department of Health.

22. “Enteral” means any technique of administration in which the agent is absorbed through the gastrointestinal tract.

23. "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.

24. “Homebound” means an individual confined to his or her home if the individual has a condition, due to illness or injury, that restricts the ability of the individual to leave his or her home except with the assistance of another individual or the aid of a supportive device or if an individual has a condition such that leaving his or her home is medically contraindicated. While an individual does not have to be bedridden to be considered “confined to his home”, the condition of the individual should be such that there exists a normal inability to leave home and that leaving home requires a considerable and taxing effort by the individual and/or others.

25. “Immediately available” means on site in the facility and available for immediate use.

26. “Impression” means an imprint or negative likeness of teeth and/or other tissues of the oral cavity from which a positive reproduction may be made.

27. “Infection control” refers to policies and procedures used to minimize the risk of spreading infections, within the dental healthcare setting. Compliance is based on conformance with current recommendations developed by the Centers for Disease Control and Prevention (CDC) and published in the document entitled “Guidelines for Infection Control in Dental Health-Care Settings” and incorporated in this Part.

28. “Inhalation” means a technique of administration in which a gaseous or volatile agent is introduced into the lungs and whose primary effect is due to the absorption through the gas/blood interface.

29. "License", as used in this Part, is not synonymous with “registration.”

30. "Local anesthesia" means the elimination of sensation, especially pain, in one part of the body by the topical application or regional injection of a drug.

31. "Minimal sedation" means a state of sedation in which the patient is at a minimally depressed level of consciousness. This state is produced through a pharmacological dosage less than or equal to the U.S. FDA maximum recommended dose along with nitrous oxide. Characteristics of minimal sedation include:

a. Patient retains the ability to independently and continuously maintain an airway and respond normally to tactile stimulation and verbal command;

b. Although cognitive function and coordination may be modestly impaired, ventilatory and cardiovascular functions are unaffected;

c. Patients whose only response is reflex withdrawal from repeated painful stimuli would not be considered to be in a state of minimal sedation;

d. If more than one enteral drug is administered to achieve the desired effect, with or without the concomitant use of nitrous oxide, the guidelines for moderate sedation must apply.

32. “Mobile dental facility” or “MDF” means any self-contained facility where dentistry will be practiced which may be driven, moved, towed, or transported from one location to another. See definition of Portable Dental Operation in § 2.3(A)(39) of this Part.

33. “Mobile dental facility (MDF) director” or “Portable dental operation (PDO) director” means a dentist who is currently licensed to practice dentistry in the State of Rhode Island or a public health dental hygienist practicing pursuant to R.I. Gen. Laws § 5-31.1-39 for the purposes of providing dental hygiene services in public health settings who is responsible for dental services provided by the MDF or PDO.

34. “Mobile dental facility (MDF) permit holder” or “portable dental operation (PDO) permit holder” means a dentist who is currently licensed to practice dentistry in the State of Rhode Island or a public health dental hygienist in whose name the MDF and/or PDO Facility Permit is issued. Where the MDF or PDO is not wholly owned by a dentist(s) or public health dental hygienist licensed to practice in the State of Rhode Island, the owner(s) shall apply for a license to operate as a healthcare facility unless the entity is exempt from such licensure.

35. "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.

36. "Nitrous oxide sedation" 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. However, consciousness may be moderately impaired.

37. “Operating dentist” means the dentist with primary responsibility for providing dental care.

38. “Parenteral” means a technique of administration in which the drug bypasses the gastrointestinal (GI) tract [i.e., intramuscular (IM), intravenous (IV), intranasal (IN), submucosal (SC), intraosseous (IO)].

39. “Portable dental operation” or “PDO” means any non-facility where dental equipment utilized in the practice of dentistry is transported to and utilized on a temporary basis at an out-of-office location. See related definitions under Mobile Dental Facility (MDF).

40. “Public health dental hygienist” or “PHDH” means a registered dental hygienist who holds a valid license to practice in the State of Rhode Island and who has a minimum of three (3) years of full-time or an equivalent four thousand five hundred (4500) hours of clinical experience and who has the fulfilled the necessary training requirements and who works in a public health setting pursuant to a written collaborative agreement with a local or state government agency or institution or a dentist who holds a valid license issued in the State of Rhode Island pursuant to this Part.

41. “Public health setting” includes, but is not limited to, residences of the homebound, schools, Head Start programs, nursing homes and long-term care facilities, licensed clinics, community health centers, hospitals, medical facilities, prisons, residential treatment facilities, federal, state or local public health programs, mobile dental facilities and portable dental programs.

42. “Qualified dentist” means a dentist providing sedation and anesthesia in compliance with this Part.

43. “Qualified provider” means a licensed healthcare provider providing sedation and anesthesia services at a specific dental facility site holding the necessary Facility Host Permit pursuant to § 2.11.4(E) of this Part, in compliance with applicable rules and regulations for their profession.

44. "Supervision" includes four (4) types of supervision for all dental auxiliary personnel 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. “Direct visual supervision” means supervision by an oral and maxillofacial surgeon (with a permit to administer deep sedation and general anesthesia) by verbal command and under direct line of sight.

45. “Time-oriented anesthesia record” means documentation at appropriate time intervals of drugs, doses and physiologic data obtained during patient monitoring.

46. “Titration” means administration of incremental doses of an intravenous or inhalation drug until a desired effect is reached.

47. “Transdermal” means a route of administration whereby the active pharmacological ingredients are transmitted across the skin.

48. "Unprofessional conduct" shall include, but not be limited to, the provisions of R.I. Gen. Laws § 5-31.1-10, and is further defined as failure to conform to the Category IC recommendations of the Centers of Disease Control Guidelines for Infection Control in Dental Health-Care Settings incorporated by reference at § 2.2(A) of this Part, or its amendments.

49. “Written collaborative agreement” or “WCA” means a written agreement that complies with R.I. Gen. Laws § 5-31.1-39(c). Written Collaborative Agreement (WCA) with a Public Health Dental Hygienist is between a public health dental hygienist and a local or state government agency or institution or with a licensed dentist who holds a valid Rhode Island license and who agrees to provide the appropriate level of communication and consultation with the public health dental hygienist to ensure patient health and safety.

2.4.1 License Requirements

No person shall perform any act which constitutes the practice of dentistry in Rhode Island unless such person is duly licensed in accordance with the regulatory and statutory provisions of the Act as a dentist, dental hygienist, a public health dental hygienist, or a DAANCE-certified maxillofacial surgery assistant. Furthermore, dental hygienists, public health dental hygienists, or a DAANCE-certified maxillofacial surgery assistant, dental assistants and DANB-certified assistants shall perform only those auxiliary dental services, procedures and duties, and under the specified type of supervision, as set forth in § 2.10.2 of this Part. Exempt from these requirements are those persons listed in R.I. Gen. Laws § 5-31.1-37

2.4.2 Pain Assessment

All health care providers licensed in Rhode Island to provide health care services and all health care facilities licensed under R.I. Gen. Laws Chapter 23-17 shall assess patient pain in accordance with the requirements of the rules and regulations for Pain Management, Opioid Use and the Registration of Distributors of Controlled Substances in Rhode Island (Part 20-20-4 of this Title) promulgated by the Department.

2.4.3 Latex

Any dentist, dental hygienist, a public health dental hygienist, dental assistant, or a DAANCE-certified maxillofacial surgery assistant 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 (Part 20-15-3 of this Title) promulgated by the Department.

2.4.4 Scheduled Controlled Substances

All actions related to the ordering, prescribing, dispensing, administration, inventory and storage or administration of controlled substances shall be in conformity with the provisions of R.I. Gen. Laws Chapter 21-28, “Controlled Substances Act” and 21 C.F.R. §§ 1300-1316 incorporated in § 2.2(E) of this Part.

2.4.5 Volunteer Dental/Dental Hygiene Permit

A. Notwithstanding any other provision of the Act or this Part, 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.

1. Services provided pursuant to a volunteer dental/dental hygiene permit shall be limited to:

a. A free clinic or similar charitable medical/dental event providing free health care services; or

b. The Special Olympics or similar athletic event attracting a large number of out-of- state participants; or

c. Participation in A Mission of Mercy program.

2. Application: An applicant for a volunteer dental/ dental hygiene permit shall submit the following information to the Board at least sixty (60) days prior to the event:

a. A copy of the application form to the Board and a letter of good standing from the state where the applicant is currently licensed: and

b. 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

c. A 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.

2.4.6 Qualifications for Licensure for Dentists

A. An applicant seeking licensure to practice dentistry in the state of Rhode Island shall:

1. Be of good moral character;

2. Be eighteen (18) years of age or over;

3. 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;

4. Have passed to the satisfaction of the Board the required examinations in accordance with § 2.5 of this Part or met the requirements for endorsement stipulated in § 2.5(A)(1)(c)((3)) of this Part; and

5. Be in good standing in each state in which he/she holds a license, which shall include a Board query to the National Practitioners Databank.

2.4.7 Application for License and Fee

A. Application for license shall be made on forms provided by the Board, which shall be completed 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):

1. A copy of the applicant’s state driver’s license, a state-issued identification card or such other identification papers acceptable to the Director that include birthdate and a picture;

2. Supporting official transcript of grades and/or verification of graduation signed by the dean or registrar of the dental school;

3. National board results in accordance with § 2.5(A)(1)(b) of this Part submitted either with application or submitted by the National Dental Examination Commission to the Board;

4. The results of the American Board of Dental Examiners (ADEX) examination or other dental examination organizations (as required in § 2.5(A) of this Part) submitted directly to the Board by the Commission on Dental Competency Assessment, or by the board of the other dental examination organizations;

5. Verification that the licensee is in good standing in state(s) where licensed [if licensed in another state(s)];

6. The application fee (non-refundable) as set forth in the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (part 10-05-2 of this Title) in accordance with R.I. Gen. Laws § 5-31.1-6.

A. 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 Rhode Island pursuant R.I. Gen. Laws § 5-31.1-6; and:

1. The Board requires each applicant to:

a. Have graduated from a school of dentistry in accordance with § 2.4.6(A)(3) of this Part; 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 ADEX exam, including the periodontal examination portion within five (5) years from the date of application for licensure in Rhode Island; or

(1) 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 ADEX Examination, including the periodontal examination portion using the internal weighting and scoring methods the CDCA uses to score the ADEX Examination in Dentistry; and

(2) Have successfully passed a comprehensive examination in applied clinical diagnosis and treatment planning (CDCA Dental Simulated Clinical Exercise {DSCE} written) with an earned score of seventy-five percent (75%); or

(3) Hold a current license in good standing to practice dentistry in another state for five (5) years immediately prior to submitting an application for licensure in RI. Said state shall have required successful completion of a clinical exam, not part of the applicant’s training program, to be considered for RI licensure.

2. Applicants shall submit to the Board, the application accompanied with the appropriate documentation as set forth in § 2.4.7 this Part.

3. Sites and schedules of examinations may be obtained directly from the examination service(s) referred to above or from the Board.

A. Continuing education for dentists requires those professionals to maintain a systematic course of continual learning as a condition to maintain their professional license. In addition, continuing education is an effective way for dental professionals to sustain knowledge of current and evolving tools, techniques, technology, innovative medications and in-depth information on emerging topics that will enhance their professional skills and abilities.

B. Pursuant to the provisions of R.I. Gen. Laws § 5-31.1-7, all dentists licensed to practice in Rhode Island under the provisions of the Act and this Part, 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 this Part 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).

C. 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.

D. At the time of license renewal, each licensee shall be required to attest to the fact that he or she has complied with the continuing education requirements established by this Part. 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.

E. All dentists practicing in a dental setting shall receive a minimum of one (1) hour per year of training on the CDC Infection Control Guidelines.

F. All dentists practicing in a dental setting shall hold a current certificate of completion from an approved course in Basic Life Support (BLS) for Healthcare Providers that includes a hands-on skill component and conforms to the current American Heart Association Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC), and is offered by any accredited agency approved by the Board.

G. If the applicant attests to completion of the prescribed course(s) of continuing dental education as set forth in § 2.16 of this Part, as approved by the Board, and is in compliance with the provisions of R.I. Gen. Laws § 5-31.1-7, the Board shall issue the applicant a license registration for a two (2) year period in accordance with the requirements of § 2.6.1 of this Part.

H. Licensure renewal shall be denied to any applicant who fails to attest to the completion of continuing dental education as required by § 2.6(D) of this Part.

I. Notwithstanding the provisions of § 2.4.6(A) of this Part, no license to practice dentistry in Rhode Island 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 this Part.

J. 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 this Part.

2.6.1 Issuance and Renewal of License

A. A license shall be issued by the Board to an applicant found to have satisfactorily met all requirements of this Part. Said license, unless sooner suspended or revoked, shall expire biennially on the 30th of June of the even numbered years.

B. Every person so licensed who desires to renew his or her license must 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 Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title). 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.

1. For those licensees who 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 Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title).

C. Pursuant to the provisions of R.I. Gen. Laws § 5-31.1-21, 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 Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title), reinstate any license (certificate) revoked under the provisions of the Act and this Part.

D. Inactive Status

1. Dentists not intending to practice in Rhode Island may request on a biennial basis to be placed on inactive status. Such requests shall be made in writing to the dental administrator and shall be accompanied by a fee as set forth in the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title).

2. Persons on inactive status may be reinstated by paying the current annual registration fee and shall meet such requirements established by the Act and as prescribed in this Part, including attesting to completion of the required continuing dental education courses as specified in § 2.6(A) of this Part.

2.7.1 License Requirements

A. No person shall perform any act which constitutes the practice of dental hygiene or public health dental hygiene in Rhode Island unless such person is duly licensed in accordance with the Act and this Part as a dentist, dental hygienist, or a public health dental hygienist.

1. Furthermore, dental hygienists, dental assistants and DANB-certified assistants, DAANCE-certified maxillofacial surgery assistants or dental assistants, shall perform only those auxiliary dental services, procedures/duties, and under the specified type of supervision, as set forth in § 2.10.2 of this Part. Exempt from these requirements, are those persons listed in R.I. Gen. Laws § 5-31.1-37.

2.7.2 Qualifications for Licensure for Dental Hygienists

A. An applicant seeking licensure to practice dental hygiene in Rhode Island shall:

1. Be of good moral character;

2. Be eighteen (18) years of age or over;

3. Have graduated from a program for dental hygienists accredited by the Commission on Dental Accreditation or its designated agency and approved by the Board;

4. Have passed to the satisfaction of the Board the required examinations in accordance with § 2.5 of this Part or met the requirements for endorsement stipulated in § 2.5(A)(1)(c)((3)) of this Part; and

5. Be in good standing in each state in which he/she holds a license.

2.7.3 Application for Licensure and Fee

A. Application for licensure must be made on forms provided by the Board which shall be completed 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):

1. A copy of the applicant’s state driver’s license, a state-issued identification card or other such identification papers acceptable to the Director that include birthdate and a picture.

2. Supporting official transcript of education credentials signed by the dean or registrar of the program of dental hygiene;

3. National board results in accordance with § 2.5(A)(1)(a) of this Part, (submitted either with the application or submitted by the National Board Dental Hygiene Examination to the Board);

4. The results of the American Board of Dental Examiners (ADEX) examination (formerly Northeast Regional Board of Dental Examiners, Inc., examination (NERB)) or other dental examination organizations (as required in § 2.5(A) of this Part) submitted directly by the Commission on Dental Competency Assessment (CDCA) (formerly the Board of Northeast Regional Board of Dental Examiners, Inc.) or by the board of the other dental examination organizations;

5. Verification that the licensee is in good standing in state(s) where licensed [if licensed in another state(s)]; and

6. The application fee as set forth in the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title) in accordance with R.I. Gen. Laws § 5-31.1-6.

2.7.4 Examination for Licensure as a Dental Hygienist

A. 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 Rhode Island pursuant to R.I. Gen. Laws § 5-31.1-6, and:

B. The Board requires each applicant to:

1. Have graduated from an accredited program for dental hygienists in accordance with § 2.4.6(A)(3) of this Part; and

2. Have passed the National Board Dental Hygiene Examination; and

3. Have passed ADEX examination given by the Commission on Dental Competency Assessment (CDCA) on Dental Hygiene (formerly the Northeast Regional Board Examination in Dental Hygiene (NERB)) including the computer simulation Northeast Regional Board Examination in Dental Hygiene within five (5) years prior to from the date of application for licensure in Rhode Island; or

4. Have 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 that the Commission on Dental Competency Assessment (CDCA, formerly NERB) uses to score the ADEX Examination in Dental Hygiene, and

5. Have passed a simulated patient clinical exercise (CDCA Computer Simulated Clinical Examination {CSCE} written) with an earned score of seventy-five percent (75%); or

6. Hold a current license in good standing to practice dental hygiene in another state for five (5) years that required the successful completion of a clinical board examination in order to be eligible for licensure;

C. Applicants shall submit to the Board, the application accompanied with the appropriate documentation as set forth in § 2.7.3 of this Part.

D. Sites and schedules of examinations may be obtained directly from the examination service(s) referred to above.

2.7.5 Continuing Education--Dental Hygienists

A. Continuing education for dental hygienists requires those professionals to maintain a systematic course of continual learning as a condition to maintain their professional license. In addition, continuing education is an effective way for dental professionals to obtain knowledge of current and evolving tools, techniques, technology, innovative medications and in-depth information on emerging topics that will enhance their professional skills and abilities. Pursuant to the provisions of R.I. Gen. Laws § 5-31.1-7, all dental hygienists licensed to practice in Rhode Island under the provisions of the Act and this Part, 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 in § 2.16 of this Part and approved by the Board. Continuing education requirements cited in this Part 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).

B. All dental hygienists practicing in a dental setting shall receive a minimum of one (1) hour per year of training on the CDC Infection Control Guidelines.

C. All dental hygienists practicing in a dental setting shall hold a current certificate of completion in Basic Life Support (BLS) for the Healthcare Provider that includes a hands-on skill component and conforms to the current American Heart Association Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) offered by any accredited agency approved by the Board.

D. If the applicant attests to completion of prescribed course(s) of continuing education and is in compliance with the provisions of R.I. Gen. Laws § 5-31.1-6, the Board shall issue the applicant a license registration for a two (2) year period in accordance with the requirements of this Part.

E. 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.

1. These documents shall 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 in this Part. Failure to produce satisfactory documentation of completion of continuing education requirements upon request by the Board may constitute grounds for disciplinary action.

F. 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 this Part.

1. Notwithstanding the provisions of § 2.6(G) of this Part, no license to practice dentistry or dental hygiene in Rhode Island shall be refused, nor shall any license be suspended or revoked, except as:

a. provided for in the Act; and

b. failure to attest to completion of continuing education as provided by this Part.

G. 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 this Part.

2.7.6 Issuance and Renewal of License – Dental Hygienists

A. A license shall be issued by the Board to an applicant found to have satisfactorily met all the requirements of this Part. Said license unless sooner suspended or revoked shall expire biennially on the 30th of June of each even-numbered year.

B. 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 Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title). 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.

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 Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title).

C. Pursuant to the provisions of section R.I. Gen. Laws § 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 Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title), reinstate any license (certificate) revoked under the provisions of the Act and this Part.

2.7.7 Inactive Status

A. Dental hygienists not intending to practice in this state may request on a biennial basis to be placed on inactive status. Such requests shall be made in writing to the dental administrator and shall be accompanied by a fee as set forth in the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title).

B. Persons on inactive status may be reinstated by paying the current annual registration fee and shall meet such requirements established by the Act and as prescribed in this Part, including attesting to completion of the required continuing dental education courses relevant to the practice of dental hygiene as specified in § 2.8.2 of this Part.

2.7.8 Continuing Education and Training of Dental Assistants

All dental assistants practicing in a dental setting shall hold a current certificate of completion. Basic Life Support (BLS) for the Healthcare Provider that includes a hands-on skill component and conforms to the current American Heart Association Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) offered by any accredited agency approved by the Board. Additionally, all dental assistants practicing in a dental setting shall receive a minimum of one (1) hour per year of training on the CDC Infection Control Guidelines.

2.8.1 License Requirements

A. No person shall perform any act which constitutes the practice of certified maxillofacial surgery assisting in Rhode Island unless such person is duly licensed in accordance with the Act and this Part as a DAANCE-certified maxillofacial surgery assistant.

1. Furthermore, dental hygienists, public health dental hygienists, DAANCE-certified maxillofacial surgery assistants, DANB-certified assistants and dental assistants, shall perform only those auxiliary dental services, procedures/duties, and under the specified type of supervision, as set forth in § 2.8 of this Part. Those persons listed in R.I. Gen. Laws § 5-31.1-37 are exempt from these requirements.

2.8.2 Qualifications for Licensure- DAANCE-certified Maxillofacial Surgery Assistant

A. An applicant seeking licensure to practice maxillofacial surgery assisting in Rhode Island shall:

1. Be of good moral character;

2. Be eighteen (18) years of age or over;

3. Have successfully completed an approved program for Dental Anesthesia Assistants National Certification Examination (DAANCE) accredited by the American Association of Oral and Maxillofacial Surgeons or its designated agency;

4. Be certified as a dental anesthesia assistant by the American Association of Oral and Maxillofacial Surgeons or its designated agency;

5. Hold a current certificate of completion of an approved course in Advanced Cardiac Life Support (ACLS); and be in good standing in each state in which he/she holds a license.

2.8.3 Application for Licensure and Fee

A. Application for licensure shall be made on forms provided by the Board which shall be completed 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):

1. A copy of the applicant’s state driver’s license, a state-issued identification card or such other identification papers acceptable to the Director that include birthdate and a picture;

2. Supporting official documentation of certification by Dental Anesthesia Assistants National Certification Examination;

3. Supporting documentation of certificate of completion of an approved course in Advanced Cardiac Life Support (ACLS).

4. Verification that the licensee is in good standing in state(s) where licensed [if licensed in another state(s)]; and

5. 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 (Part 10-05-2 of this Title) in accordance with R.I. Gen. Laws § 5-31.1-6.

2.8.4 Continuing Education--DAANCE-Certified maxillofacial surgery assistants

A. Continuing education for DAANCE-certified maxillofacial surgery assistants requires those professionals to maintain a systematic course of continual learning as a condition to maintain their professional license. In addition, continuing education is an effective way for dental professionals to sustain knowledge of current and evolving tools, techniques, technology, innovative medications and in-depth information on emerging topics that will enhance their professional skills and abilities.

B. Pursuant to the provisions of R.I. Gen. Laws § 5-31.1-7, all DAANCE-certified maxillofacial surgery assistants licensed to practice in Rhode Island under the provisions of the Act and this Part, 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 certified maxillofacial surgery assistants, according to the criteria in § 2.16 of this Part. Continuing education requirements cited in this Part shall be pro-rated 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).

C. All DAANCE-certified maxillofacial surgery assistants practicing in a dental setting shall receive a minimum of one (1) hour per year of training on the CDC Infection Control Guidelines.

D. All DAANCE-certified maxillofacial surgery assistants practicing in a dental setting shall hold a current certificate of completion of an approved course in Advanced Cardiac Life Support (ACLS) for the Healthcare Provider that includes a hands-on skill component and conforms to the current American Heart Association Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) offered by any accredited agency approved by the Board.

E. If the applicant attests to completion of prescribed course(s) of continuing education and is in compliance with the provisions of R.I. Gen. Laws § 5-31.1-6, the Board shall issue the applicant a license registration for a two (2) year period in accordance with the requirements of § 2.6.1 of this Part.

F. It shall be the sole responsibility of the individual DAANCE-certified maxillofacial surgery assistant 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.

G. These documents shall be safeguarded by the DAANCE-certified maxillofacial surgery assistant 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 in this Part. Failure to produce satisfactory documentation of completion of continuing education requirements upon request by the Board may constitute grounds for disciplinary action.

H. Licensure renewal shall be denied to any applicant who fails to attest to completion of continuing education courses relevant to the practice of maxillofacial surgery assisting as required by this Part.

I. Notwithstanding the provisions of § 2.8.4(F) and 2.8.4(G) of this Part, no license to practice dentistry or dental hygiene or maxillofacial surgery assisting in Rhode Island 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 this Part.

J. 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 this Part.

2.8.5 Issuance and Renewal of License – DAANCE- Certified Maxillofacial Surgery Assistant

A. A license shall be issued by the Board to an applicant found to have satisfactorily met all the requirements of this Part. Said license unless sooner suspended or revoked shall expire biennially on the 30th of June of each even-numbered year.

B. 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 in consultation with the Board, and as set forth in the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title). 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.

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 Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title).

C. Pursuant to the provisions of R.I. Gen. Laws § 5-31.1-21, the registration certificate of all DAANCE-certified maxillofacial surgery assistants whose renewals accompanied by the prescribed fee are not filed on or before the 1st day of July of each even numbered year, shall be automatically revoked. The Board may in its discretion and upon the payment by the DAANCE-certified maxillofacial surgery assistant of the current licensure (registration) fee plus an additional fee as set forth in the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title), reinstate any license (certificate) revoked under the provisions of the Act and this Part.

D. Inactive Status

1. DAANCE-Certified maxillofacial surgery assistants not intending to practice in Rhode Island may request on a biennial basis to be placed on inactive status. Such requests shall be made in writing to the dental administrator and shall be accompanied by a fee as set forth in the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title).

2. Persons on inactive status may be reinstated by paying the current annual registration fee and shall meet such requirements established by the Act and as prescribed in this Part, including attesting to completion of the required continuing dental education courses relevant to the practice of maxillofacial surgery assisting as specified in § 2.8.4 of this Part.

2.9.1 Qualifications

A. A public health dental hygienist may provide dental services which are educational, preventive, therapeutic, prophylactic and intra-oral in nature as may be authorized by the Board and may perform all tasks as set forth under the Act and this Part.

B. Educational requirements for the Public Health Dental Hygiene Practitioner

1. Prior to practicing as a public health dental hygienist a dental hygienist shall complete a minimum of twelve (12) hours of continuing education as follows:

a. A minimum of six (6) hours of hands-on experience in a public health setting.

b. Successful completion of the following courses within twenty-four (24) months prior to license issuance:

(1) Public Health Fundamentals:

(AA) CDC Guidelines (Infection Control);

(BB) Risk management for practice in a public health setting; and

(CC) Management of medical emergencies.

(DD) The courses specified by §§ 2.9.1(B)(1)(b)((1))(AA) through (CC) of this Part must be by an educational institution with a program accredited by the Commission on Dental Accreditation, or by a program approved by the Board.

2. The public health dental hygienist shall permanently retain documentation demonstrating compliance of continuing educational requirement including a signed affidavit that confirms successful completion.

C. A public health dental hygienist practicing in a public health setting may perform those services which are authorized by the Board to be provided in a public health setting, pursuant to a written collaborative agreement (WCA).

D. A registered dental hygienist practicing in a public health setting may provide dental hygiene services including placement of sealants, without first having a dentist examine the patient, pursuant to a written collaborative agreement (WCA).

E. Public health dental hygienists shall maintain current malpractice insurance.

2.9.2 Application Process

A. Application for licensure shall be made on forms provided by the Board

B. Rhode Island Registered Dental Hygienists shall provide the following documents with their application:

1. Verification that their license is in good standing in state(s) where licensed [if licensed in another state(s)];

2. Verification that they have worked full time as a Registered Dental Hygienist for at least three (3) years full time or have completed at least 4500 hours of clinical experience;

3. Verification of additional training as set forth in § 2.9 of this Part;

4. The application fee as set forth in the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title) in accordance with R.I. Gen. Laws § 5-31.1-6.

C. Applicants holding a Dental Hygienist License from another state shall provide the following documents with their application:

1. A state driver’s license, a state-issued identification card or such other identification papers acceptable to the Director that include birthdate and a picture;

2. Verification that the licensee is in good standing in state(s) where licensed [if licensed in another state(s)];

3. Verification that they have:

a. Worked full time as a Registered Dental Hygienist for at least three (3) years full time; or

b. Have completed at least four thousand five hundred (4500) hours of clinical experience; or

c. Hold a current license in good standing to practice Public Health Dental Hygiene or equivalent, as determined by the Board, in another state for five (5) years that required the successful completion of a clinical board examination in order to be eligible for licensure.

4. Verification of additional training as set forth in § 2.9.9 of this Part; and the application fee as set forth in the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title) in accordance with R.I. Gen. Laws § 5-31.1-6.

2.9.3 Written Collaborative Agreement (WCA) with a Public Health Dental Hygienist

A. A public health dental hygienist shall:

1. Enter into a written collaborative agreement (WCA) which complies with the requirements of R.I. Gen. Laws § 5-31.1-39(c) and § 2.9.3(C) of this Part before rendering treatment to provide any dental hygiene services in a public health setting pursuant to the collaborative agreement;

2. Maintain contact and document communication with the dentist with whom the public health dental hygienist has entered into a written collaborative agreement (WCA) as set forth within that agreement.

3. Practice in accordance with R.I. Gen. Laws § 5-31.1-39 and this Part;

4. Practice in accordance with systems, policies and procedures established pursuant to the Board, the Act and this Part.

5. Obtain written and signed informed consent from the patient or legal representative which complies with R.I. Gen. Laws § 23-4.6-1 and the Board regulations which informs the patient or legal representative that the services provided by the public health dental hygienist are not a substitute for a dental examination by a dentist and informs the patient that the patient or legal representative should obtain, or should have had a dental examination by a dentist within ninety (90) days.

6. Provide each patient with a written Information Sheet at the conclusion of the patient’s visit. Said Information Sheet shall, at a minimum, include the following:

a. Results of the dental hygiene evaluation;

b. The name(s) of the public health dental hygienists and any licensed dentist and other dental auxiliaries who provided services;

c. A description of the treatment rendered including, but not limited to, billable service codes and fees associated with treatment, and tooth numbers, when appropriate;

d. Information on how to contact the public health dental hygienist, public health setting’s program director, mobile dental facility or portable dental operation permit holder;

e. If necessary, provide a referral for emergency assessment by a dentist;

f. When a referral is made, the patient or legal representative shall be referred to the patient’s regular dentist if one is identified. If none is identified, then the patient or legal representative shall be provided with the names of dentist(s), community health center(s) or dental school clinic(s) located within a reasonable geographic distance from the patient’s home and with whom the public health dental hygienist or dental health services program has communicated with regarding the acceptance of referrals;

g. The name and signature of the public health dental hygienist; and

h. If the patient or legal representative has given consent for an institutional facility (e.g. school, nursing home) to access the patient’s dental health records, then the dental hygienist shall also provide the institution with a copy of the Information Sheet for each patient.

B. A dentist entering into a written collaborative agreement (WCA) with a public health dental hygienist may, but is not required to, provide subsequent dental treatment to patients served under said agreement.

C. Written Collaborative Agreement (WCA). The collaborative agreement between a public health dental hygienist and a municipality or state agency or institution, or with a licensed dentist who holds a valid Rhode Island dental license shall, at a minimum address all of the following:

1. Identify by name(s) the dentist(s) who shall be available to provide the appropriate level of communications and consultation with the public health dental hygienist to ensure patient health and safety;

2. Describe, with specificity how communication and consultation between the dentist and public health dental hygienist will be accomplished including the frequency and arrangements for back-up coverage when the dentist is not accessible to provide communication and consultation (e.g. during vacation, illness);

3. Provide the names, license numbers, address(es), telephone and facsimile number(s) and emergency contact information for the dentist(s) and public health dental hygienist;

4. Identify entity(ies) and geographic area(s) where public health dental hygienist services will be provided pursuant to the collaborative agreement;

5. Specify the dental hygiene procedures to be provided and the populations to be served pursuant to the collaborative agreement;

6. Specify and describe responsibilities for creating, maintaining, storing, retrieving and providing for the confidentiality of patient records;

7. Specify and describe responsibilities for establishing systems, policies and procedures to ensure compliance with Board regulations, including but not limited to requirements of Mobile and Portable Dentistry as may be applicable;

8. Specify and describe responsibilities for developing, implementing, and maintaining emergency medical protocols and for the provision of periodic review and training on same;

9. Include any considerations for age-related procedure-specific protocols as may be deemed necessary by the dentist or public health dental hygienist;

10. Include any considerations for medically-compromised patients as may be deemed necessary by the dentist or public health dental hygienist;

11. Outline responsibilities for billing and reimbursement for services rendered by the dental hygienist in the public health setting, if indicated;

12. Identify a process for the public health dental hygienist to legally obtain prescription products (e.g. chemotherapeutics, fluoride varnish) pertinent to the provision of dental hygiene services and which are to be utilized when rendering services in a public health setting; and

13. Term of the collaborative agreement, if applicable.

D. The dentist and public health dental hygienist shall review and update the written collaborative agreement on an annual basis, as a minimum frequency.

E. The dentist and public health dental hygienist shall immediately notify each other and, if applicable, the municipality, state agency or institution involved in the collaborative agreement of any disciplinary action imposed by the Board or any other governmental agency against his/her license to practice dentistry or dental hygiene in the State of Rhode Island.

F. A copy of the written collaborative agreement shall be maintained by the municipality, state agency or institution, licensed dentist and the public health dental hygienist. Upon written request, said agreement shall be made available to the Board, or to a patient who received treatment pursuant to the agreement or his/her legal representative.

G. Each public health dental hygienist shall maintain the following data to be reported to the Rhode Island Department of Health Oral Health Program on forms and in accordance with procedures and timelines established by that program:

1. The dates of each session with name and address of the site where public health dental hygiene services were provided; and

2. The number of patients served.

2.9.4 Availability of Dental Records

A. Request for Copy of Dental Record. The public health dental hygienist shall provide upon request by a patient or a specifically authorized person, a complete copy of the patient’s dental record in accordance with R.I. Gen. Laws § 5-31.1-10 (10) A copy of the patient record including radiographs and other images, shall be provided within a reasonable amount of time not to exceed thirty (30) calendar days from the date of the request. The public health dental hygienist may charge a reasonable fee for the expense of providing a patient’s dental record, not to exceed the cost of either labor and/or material incurred in the copying of the patient record, radiographs and models. The Public Health Dental Hygienist shall not require payment for dental services rendered as a condition of providing a copy of the dental record.

B. Treatment in a School Setting. Where consent has been granted by the patient or legal representative, a copy of the patient’s summary of care or other written summary of the screening, examination, or treatment shall be provided to the official designated by the school.

C. Treatment in a Nursing Home or Residential Treatment Facility. A copy of the patient’s summary of care or other written summary of the screening, examination, or treatment shall be provided to the official designated by the facility or institution and shall be made part of the patient record maintained by the nursing home or residential facility

D. Electronic patient records shall comply with the requirements of HIPAA and the Confidentiality of Health Care Communications and Information Act, R.I. Gen. Laws Chapter 5-37.3 and shall be unalterable and producible in paper form upon request.

2.9.5 Content of Patient Records

A. The patient record shall be a complete record of all patient contact, including, but not limited to, a general description of the patient’s medical and dental history and status at time of examination, assessments and /or diagnosis provided by a dentist, patient education, treatment plan, referral for specialty treatment, medications administered and prescribed, pre- and post-treatment instructions and information conveyed to the patient. Patient records shall be legible and clear in meaning to a subsequent examining or treating dentist, the patient, dental auxiliary or other authorized persons.

B. Public health dental hygienist proprietary forms shall include language as approved by the Board.

2.9.6 Required Referrals

Public health dental hygienists will refer patients without a dental provider to a public or private dentist with the goal of establishing a dental home for the patient. When the public health dental hygienist determines at a subsequent appointment that there are conditions present which require evaluation for treatment, and the patient has not seen a dentist as referred, the dental hygienist will make every practical or reasonable effort to schedule the patient with a Rhode Island dentist or local private dentist volunteer for an examination, treatment plan and follow up care, or a community health center if available.

2.9.7 Radiograph

Digital radiographs shall be conducted pursuant to the regulations for Radiation (Subchapter 20 of this Chapter). The collaborating and currently licensed Rhode Island dentist shall evaluate the radiographs within thirty (30) days of exposure.

2.9.8 Temporary Restorative Procedures

A public health dental hygienist, as defined by this Part may perform reversible procedures including but not limited to temporary restorative procedures without a dentist present under protocols developed by the Board of Dentistry as outlined in § 2.17 of this Part.

2.9.9 Continuing Education Requirements

A. Public health dental hygienists; prior to renewal of licensure shall obtain a minimum of six (6) hours of continuing education in courses related to public health. These six (6) hours are included in the required twenty (20) hours of continuing education required every two (2) years following the criteria listed in § 2.16 of this Part. The following public health topics are recommended:

1. Home & Community – Based Care

a. Youth Services

(1) School-based care

(2) Head Start & Early Head Start

(3) Day Care

2. Eldercare Services

3. Community- based settings (e.g. nursing homes, assisted living)

4. Homebound – All Populations (including individuals with disabilities)

B. Third Party Payment Models & Business 101

C. Grant Writing 101

D. Diversity Training & Case Management Concepts

2.10.1 General Requirements

A. Dental Hygienists. Pursuant to R.I. Gen. Laws § 5-31.1-33, 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 § 2.10.2 of this Part. Such dental procedures/duties may be delegated by the dentist and performed under the direction of the dentist, in accordance with the provisions of the Act and this Part.

1. Nothing in this section shall be construed to authorize a licensed dental hygienist or public health dental hygienist to perform any of the non-delegable (exclusionary) procedures/ duties as set forth in § 2.10.3 of this Part.

B. DANB-Certified Assistants, DAANCE-Certified Maxillofacial Surgery Assistants and Dental Assistants. A dentist may delegate to a DANB-certified assistant, DAANCE-certified maxillofacial surgery 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 § 2.10.2 of this Part. Provided, however, oral prophylaxis shall be performed only by a licensed dentist or a licensed dental hygienist.

1. Nothing in this section shall authorize a DANB- certified assistant or a dental assistant to perform any of the non-delegable (exclusionary) procedures/duties as set forth in § 2.10.3 of this Part.

C. All procedures/duties performed by dental auxiliaries shall be performed under the direct supervision of a dentist, unless otherwise specified in § 2.10.2 of this Part.

D. Any reversible intraoral procedure not specifically enumerated as delegable or non- delegable (exclusionary) pursuant to §§ 2.10.2 and 2.10.3 of this Part, may be delegated to any category of dental auxiliary, (dental hygienist, public health dental hygienist, DANB-certified assistant, DAANCE-certified maxillofacial surgery assistant and dental assistant) based on the discretion of the delegating dentist, the education and training and competency of the dental auxiliary.

E. 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.

2.10.2 Delegable Procedures/Duties

A. A dentist may delegate to auxiliary personnel those procedures which the dentist may deem advisable, except for those procedures excluded in § 2.10.3 of this Part. Any delegated procedures shall be both the responsibility of and under the specified supervision of the dentist.

1. Dental Hygienist and Public Health Dental Hygienist. A dental hygienist or a public health 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 DANB-certified assistant or a dental assistant. These procedures may be accomplished under general supervision, in a dental office, and under general supervision of the dentist.

2. DANB-Certified Assistant

a. A DANB-certified 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, coronal polishing, placing and/or removing retraction cord; fluoride treatments; and placement or removal of bonded orthodontic attachments and/or cementation or removal of orthodontic bands provided:

(1) Such procedures were incorporated into the academic training from which the DANB-certified assistant graduated; OR

(2) Provided he/she has completed academic clinical training to clinical competence.

3. The DANB- certified assistant may not perform any of the procedures specifically listed for a dental hygienist, nor any irreversible intraoral procedures.

4. Dental Assistant. A dental assistant may perform reversible intraoral procedures under the direct supervision of the dentist. He or she may not perform any of the procedures listed specifically for a licensed dental hygienist or DANB-certified assistant nor any irreversible intraoral procedures.

a. A dental assistant may perform a final digital scan with final inspection and approval of the dentist.

B. Dentists licensed pursuant to R.I. Gen. Laws § 5-31.1-6 may delegate to any dental hygienists licensed pursuant to R.I. Gen. Laws § 5-31.1-6 who are employed on a regular basis by such dentists any procedures which he or she may deem advisable; including those procedures specified under § 2.10.2 of this Part 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 R.I. Gen. Laws Chapter 23-17 without the on-site direct supervision of a dentist licensed pursuant to R.I. Gen. Laws § 5-31.1-6, those dental services, procedures and duties that he or she has been educated to perform and which are authorized by the Board or through R.I. Gen. Laws § 5-31.1-39.

C. Delegable procedures and duties for DAANCE-certified maxillofacial surgery assistants are set forth in R.I. Gen. Laws § 5-31.1-31.

2.10.3 Non-Delegable (Exclusionary) Procedures/Duties

A. Notwithstanding the provisions of § 2.14 of this Part, nothing in this Part authorizes a dental hygienist, public health dental hygienist, DANB-certified 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, or nitrous oxide plus medication;

5. Administering sedative inhalants;

6. Taking conventional/ physical 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 of sutures;

11. 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 R.I. Gen. Laws § 40-20-1;

12. Perform direct pulp capping procedures;

13. Orthodontic arch wire detailing with the exception of minor adjustments to eliminate pain or discomfort;

14. Flush root canal;

15. Temporary wire ligation; and

16. Use of a rotary instrument in the oral cavity unless licensed or certified under the provisions of the Act and this Part. (See also § 2.10.2(A)(2)(b) of this Part).

2.11.1 General Requirements

A. Any dentist licensed to practice dentistry in Rhode Island pursuant to R.I. Gen. Laws § 5-31.1-6, who holds an individual anesthesia permit, may administer anesthesia or sedation as authorized by his or her category of individual permit at any facility which has been issued a corresponding facility permit by the Board.

B. Notwithstanding the foregoing, any licensed dentist who intends to administer anesthesia services within a dental office in Rhode Island who has been issued an individual permit and has not been issued a facility permit shall only be permitted to do so by prior approval of the Board.

C. As a condition for approval for an Individual Anesthesia Permit or a Facility Anesthesia Permit, the Board, or its designee, shall conduct an onsite inspection with the applicant of all equipment, medications, and staff utilized for the purpose of administering deep sedation/general anesthesia and moderate sedation. Emergency scenario must be performed, with staff, as well as observation of actual surgical cases where appropriate. Said equipment shall meet all applicable requirements of this Part.

D. 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.

E. For all levels of sedation, the qualified dentist must have the training, skill, 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 complications.

2.11.2 Professional Permitting Requirements

A. The Board shall issue the following permits to qualified Dentists and Facilities:

1. Individual Anesthesia Permit:

a. Authorizes a Qualified Dentist, licensed by the State, to administer one or all of the following levels of sedation, which shall be delineated on the permit: minimal and nitrous oxide-oxygen alone, or in conjunction with a local anesthetic, moderate, deep sedation and/or general anesthesia, in a dental facility that has the required Facility Permit for the type of anesthesia or sedation being administered in compliance with this Part.

2. Portable Individual Anesthesia Permit:

a. Authorizes a trained Dentist Anesthesiologist to perform sedation services at any dental facility with the appropriate Facility Host Permit.

3. Pediatric Individual Anesthesia Permit: Authorizes a Qualified Dentist with additional training in pediatric sedation as set forth in this Part, licensed by the State of Rhode Island, to Administer moderate sedation to patients under the age of thirteen (13) in a dental facility that has the required Pediatric Facility Permit in compliance with this Part.

4. Facility Permit: Authorizes the administration of one or all of the following levels of sedation, which shall be delineated on the Permit: minimal and nitrous oxide-oxygen alone, or in conjunction with a local anesthetic, moderate, deep sedation and/or general anesthesia, by the onsite Qualified Dentist.

5. Facility Host Permit (H Permit): Authorizes the administration of moderate and deep sedation and/or general anesthesia at the specific site named on the Permit by the Qualified Providers.

6. Pediatric Facility Permit: Authorizes the administration of anesthesia to patients under the age of thirteen (13) by an onsite Qualified Dentist or Qualified Provider at the specific site named on the Permit.

2.11.3 Qualifications for Individual Anesthesia Permit

A. All applicants for anesthesia individual permits must have been issued a Rhode Island license to practice dentistry pursuant to R.I. Gen. Laws § 5-37.1-6; and meet the individual qualifications for the permit they are seeking.

B. Applicants for a Nitrous Oxide Individual Anesthesia Permit must meet the following qualifications:

1. Have satisfactorily completed a minimum of fourteen (14) hours of nitrous oxide sedation training program from a CODA, PACE, or CERP approved advanced education program and whose training program is consistent with the provisions of the Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students (2016) incorporated by reference at § 2.2(J) of this Part, and which included experience in the administration of nitrous oxide sedation.

2.. Have fulfilled one of the following requirements set forth in §§ 2.11.3(C), (D), or (E) of this Part; and

C. Applicants for an Individual Anesthesia Permit in Minimal Sedation must demonstrate competency by having successfully completed:

1. Training in minimal sedation consistent with that prescribed in the ADA Guidelines for Teaching Pain Control and Sedation to Dentist and Dental Students (2016) incorporated by reference in § 2.2(D) of this Part; or

2. Comprehensive training in minimal sedation that satisfies the requirements described in the Minimal Sedation section of the ADA Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students at the time training was commenced; or

3. An advanced education program accredited by the Commission on Dental Accreditations that affords comprehensive and appropriate training necessary to administer and manage minimal sedation commensurate with these guidelines; and

4. A current certification in Basic Life Support (BLS) for Healthcare Providers; and

5. Successful completion of a respiratory rescue course employing high fidelity human manikins intended for dental professionals.

D. Applicants for an Individual Anesthesia Permit in Moderate Sedation must meet the following criteria:

1. Have successfully completed a minimum of sixty (60) hours of Moderate Sedation training to include a combination of enteral and parenteral sedation course in addition to management of at least twenty (20) adult case experiences as provided by the ADA Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students (2016) incorporated by reference in § 2.2(J) of this Part; and

2. Have completed a board approved simulation course that uses high fidelity human simulation.

3. Have a current certification in ACLS.

E. Applicants for Pediatric Individual Anesthesia Permit for Moderate Sedation must meet the following criteria:

1. To administer moderate sedation to all patients up to the age of twenty-one (21) as well as Special Health Care Needs (SHCN) patients of any age (as defined by the American Academy of Pediatric Dentistry Guidelines incorporated by reference in § 2.2(I) of this Part, applicants must have fulfilled one of the following education and training requirements:

a. Have completed a CODA-approved Pediatric Residency Program or are candidates or Diplomates of the American Board of Pediatric Dentistry (ABPD); or

b. Have completed a post-doctoral training program in Oral and Maxillofacial Surgery; or

c. Have completed a post-doctoral training program in Dental Anesthesiology.

2. Dentists who are Diplomates of the American Board of Pediatric Dentistry (ABPD), may administer moderate sedation to all patients up to age twenty-one (21) as well as Special Health Care Needs (SHCN) patients (as defined by the American Academy of Pediatric Dentistry Guidelines incorporated by reference in § 2.2(I) of this Part), of any age.

3. Dentists who hold a pediatric Moderate Sedation Permit and wish to treat children thirteen (13) years of age or over must also obtain an Adult Moderate Sedation Permit.

4. A separate Pediatric Individual Anesthesia Permit for Moderate Sedation Permit is not required for a dentist who holds a Deep Sedation/General Anesthesia Permit.

F. Applicants for Individual Anesthesia Permit in General Anesthesia/Deep Sedation must meet the following criteria:

1. Have completed a Board approved simulation course that uses high fidelity human simulation, and fulfilled one of the following education and training requirements:

a. Completion of an advanced training program in anesthesia and related subjects beyond the undergraduate dental curriculum; or

b. Completion of a post-doctoral training program (e.g. Oral and Maxillofacial Surgery (OMFS) or Dental Anesthesiology (DA)) which affords comprehensive appropriate training necessary to administer and manage general anesthesia/deep sedation.

2. Hold a current certification in ACLS.

G. Applicants for a Pediatric Individual Anesthesia Permit to administer or to authorize the administration of deep sedation/general anesthesia to pediatric patients must meet all the foregoing requirements and:

1. Maintain current American Heart Association (AHA) Advanced Cardiovascular Life Support (ACLS)/Pediatric Advanced Life Support (PALS) certification;

2. Be a candidate for or hold current board certification by the American Board of Oral and Maxillofacial Surgery (ABOMS), or

3. Be a candidate or diplomate of the American Dental Board of Anesthesiology (ADBA), or

4. Proof of education or training commensurate with the type of individual permit sought, as follows:

a. Completed an education program accredited by the ADA’s Commission on Dental Accreditation (CODA) that provides comprehensive training necessary to administer and manage general anesthesia and deep sedation.

H. Applicants for a Portable Individual Anesthesia Permit:

1. A Qualified Provider who is transporting and utilizing equipment necessary to provide sedation and anesthesia services at a specific dental facility site holding the necessary Facility Host Permit must obtain both a Portable Individual Anesthesia Permit as well as hold an Individual Anesthesia Permit for the designated level of anesthesia that will be provided.

2. An applicant for a Portable Individual Anesthesia Permit must meet the following criteria:

a. Must hold a valid Rhode Island Dental License;

b. Must have current certification in ACLS and PALS; and

c. Must hold a valid Individual Anesthesia Permit for the level of sedation to be administered.

3. Successful completion of an on-site evaluation performed by a Board appointed office evaluation team, of all mobile equipment, including medications, and staff to be utilized in the administration of anesthesia services in a host facility. Evaluations and inspections shall be at the time of application, at renewal, or as requested by the Board.

2.11.4 Qualifications for a Facility Permit

A. Qualifications for Nitrous Oxide Facility Permit:

1. An applicant for licensure shall submit to the Board written evidence on forms furnished by the Board that said applicant:

a. Has a Rhode Island license to practice dentistry pursuant to R.I. Gen. Laws § 5-37.1-6;

b. Has a nitrous oxide sedation individual permit in accordance with the requirements set forth in § 2.11.3(B) of this Part; and

c. Has submitted a duly executed nitrous oxide sedation self-assessment form that complies with the standards established by the Board.

B. Qualifications for a Minimal Sedation Facility Permit:

1. Approval for a Minimal Sedation facility permit shall require the following prerequisites:

a. A Rhode Island license to practice dentistry pursuant to R.I. Gen. Laws § 5-37.1-6; and

b. A nitrous oxide sedation individual permit in accordance with the requirements set forth in § 2.11.3(B) of this Part; and

c. Submission of a duly executed minimal sedation self-assessment form that complies with the standards established by the Board.

C. Qualifications for a Moderate Sedation Facility Permit:

1. Rhode Island license to practice dentistry pursuant to R.I. Gen. Laws § 5-37.1-6;

2. A moderate sedation individual permit in accordance with the requirements set forth in § 2.11.3(D) of this Part; and

3. Successful completion of an on-site office evaluation performed by an office evaluation team approved by the Board and the Director.

a. An office evaluation team shall consist of two or more persons chosen and approved by the Board and the Director. At least one of the evaluators must hold an Individual General Anesthesia Permit. At least one member of the team must have substantial experience in the administration of the method of delivery of anesthesia or sedation used by the dentist being evaluated.

b. The board may appoint a licensee member of the board to serve as a consultant at any evaluation.

4. An applicant for a Facility Permit to administer moderate sedation shall obtain a written agreement from a hospital to accept emergency patients, or show evidence of membership on a hospital staff.

D. Qualifications for a General Anesthesia/Deep Sedation Facility Permit:

1. Rhode Island license to practice dentistry pursuant to R.I. Gen. Laws § 5-37.1-6;

2. A general anesthesia/deep sedation individual permit in accordance with the requirements set forth in § 2.11.3(E) of this Part; and

3. Successful completion of an on-site office evaluation performed by an office evaluation team appointed by the Board and the Director.

4. An applicant for a Facility Permit to administer deep sedation or general anesthesia shall obtain written agreement from a hospital to accept emergency patients, or show evidence of membership on a hospital staff.

E. Qualifications for a Facility Host Permit (H Permit):

1. An applicant pursuing a Facility Host Permit (H Permit) authorizing the administration of moderate or deep anesthesia and/or general anesthesia at the specific site named on the permit by a Qualified provider who is not the Operating Dentist must submit an attestation to the safety of all equipment used in connection with the administration of anesthesia.

2. An applicant for a Facility Host Permit to administer moderate sedation, deep sedation, or general anesthesia shall obtain written agreement from a hospital to accept emergency patients, or show evidence of membership on a hospital staff.

3. Successful completion of an on-site office evaluation performed by an office evaluation team appointed by the Board and the Director.

2.11.5 Application

A. Application for a permit shall be made on forms provided by the Board which shall be completed 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):

1. Supporting official transcripts of verification of the qualification requirements as set forth in §§ 2.11.2, 2.11.3, and 2.11.4 of this Part;

2. A statement attesting that he or she 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 sedation; and

3. The permit fee, where applicable, as determined annually by the Director of Health in consultation with the Board and as set forth in the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title); and

4. Such other information as may be deemed necessary and as may be requested by the Board.

2.11.6 Issuance and Renewal of Permit

A. 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 sedation, 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 this Part. Said permit unless sooner suspended or revoked shall expire on June 30 of each even numbered year.

B. 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 in consultation with the Board and as set forth in the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title). 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.

C. 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 § 2.11.6(B) of this Part.

2.11.7 Inspections

A. The Board may, through appointed advisory consultants, conduct such inspections and investigations as deemed necessary by the Board to ensure compliance with the requirements of this Part.

B. Refusal to permit an inspection shall constitute a valid ground for permit denial, suspension or revocation.

C. Every applicant shall be given notice by the Board of all deficiencies reported as a result of an inspection or investigation.

2.11.8 Inactive Status

A. 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 sedation 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.

B. 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 Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title). 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.

2.11.9 Personnel Requirements for Nitrous Oxide Sedation, Minimal Sedation, Moderate Sedation, and General Anesthesia/Deep Sedation

A. Personnel

1. A dentist administering or permitting the administration of nitrous oxide sedation, minimal sedation, moderate sedation, and general anesthesia/deep sedation must ensure that there is a sufficient number of members on the team of auxiliary personnel to assist in handling procedures and emergencies.

B. Minimal Sedation:

1. At least one additional person trained in Basic Life Support (BLS) for providers must be present in addition to the dentist.

C. Moderate Sedation:

1. During the administration of moderate sedation, the dentist must ensure that there are a minimum of three (3) trained individuals present and on the team of auxiliary personnel:

a. At least one staff member shall be designated as the patient monitor. The patient monitor may assist in the delivery of anesthesia under the personal supervision of the operating dentist. The provider must be trained in Advanced Cardiac Life Support (ACLS) and if they are treating a patient less than thirteen (13) years old they must be trained in Pediatric Advanced Life Support (PALS).

b. The second staff member must have ACLS and PALS training.

c. The third member of the team must be trained in BLS for providers and must be present in the facility. This staff member must be immediately available in case of emergency or if the staff member in charge of monitoring is involved in interruptible patient related tasks of short duration.

2. A dentist administering or permitting the administration of moderate sedation to pediatric patients must meet the requirements set forth in § 2.11.3(F) of this Part.

3. A Qualified Provider administering anesthesia in a host facility must attest to the adequacy and competency of the host facility and staff.

D. General Anesthesia/Deep Sedation:

1. The dentist administering General Anesthesia/Deep Sedation shall hold a current certificate in Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS), as described in the ADA Guidelines for the Use of Sedation and General Anesthesia by Dentist incorporated by reference in § 2.2(C) of this Part.

2. An Oral and Maxillofacial Surgeon holding a Permit issued by the Board for the administration of general anesthesia/deep sedation may employ and utilize the services of a DAANCE-certified maxillofacial surgery assistant in accordance with the following criteria:

a. Satisfactory evidence of completion of a Dental Anesthesia Assistants National Certification Examination (DAANCE)-certified surgical assistant training course prepared and administrated by the American Association of Oral and Maxillofacial Surgeons and recertification in the DAANCE training program every five (5) years; and

b. Completion of a board of examiners in dentistry-approved Advanced Cardiac Life Support (ACLS) course and/or Pediatric Advanced Life Support (PALS) and recertification in advanced cardiac Life Support (ACLS) and/or Pediatric Advanced Life Support (PALS) every two (2) years; and

c. The valid Deep Sedation/ General Anesthesia Individual Permit by the Oral and Maxillofacial Surgeon where the DAANCE assistant will be performing his or her services; and

d. Direct supervision by an Oral and Maxillofacial Surgeon holding a valid General Anesthesia/Deep Sedation Permit; and

e. Direct visual supervision by an Oral and Maxillofacial Surgeon holding a valid General Anesthesia/Deep Sedation Permit where the DAANCE- certified maxillofacial assistant is performing the following tasks:

(1) Following instructions to prepare and assist in the administration of medications:

(2) Adjusting the rate of intravenous fluid infusion beyond a keep-open rate;

(3) Adjusting an electronic device to provide medications, such as an infusion pump; or

(4) Assisting with preparation/delivery/infusion/administration of emergency medications in order to assist the Oral and Maxillofacial Surgeon in an emergency.

f. The Oral and Maxillofacial Surgeon shall remain immediately available in the facility for the patient, and the DAANCE-certified maxillofacial surgery assistant for evaluation and treatment until the patient meets discharge criteria; and

g. The DAANCE-certified maxillofacial surgery assistant who is assigned to monitoring the patient may not have any other responsibilities while monitoring the patient under general anesthesia/Deep Sedation; and

h. The licensed provider will be responsible for the patient’s recovery; and

i. Peri-operative monitoring consisting of at least continuous electrocardiogram, monitoring of blood pressure, pulse oximetry, and end-tidal carbon dioxide consistent with published national standards adopted by the American Association of Oral and Maxillofacial Surgeons in conjunction with the American Society of Anesthesiologists; and

j. The conclusion of the peri-operative monitoring period shall be at the discretion of the licensed provider, using the modified Aldrete scale/scoring system. The patient may then be transferred to a discharge area and shall no longer require continuous monitoring.

3. Supervision. A DAANCE-certified maxillofacial surgery assistant shall perform the functions authorized by the Act and this Part only by delegation or authority from the Oral and Maxillofacial Surgeon and under the appropriate level of direct or direct visual supervision, and provided the Oral and Maxillofacial Surgeon is acting within the scope of his or her license. The responsibility for monitoring a patient and determining the selection of the drug, dosage, and timing of all anesthetic mediations rests solely with the Oral and Maxillofacial surgeon.

4. A dentist administering or permitting the administration of deep sedation/general anesthesia to pediatric patients must ensure that at least three (3) trained individuals are present, one of whom may be the dentist operator:

a. An individual, trained in Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS), other than the dentist operator, to continually observe vital signs, airway patency, and adequacy of ventilation;

b. An individual who is trained in Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS) and is skilled in airway management; and

c. An individual, trained in Basic Life Support (BLS), who must remain in attendance in the discharge area until the patient is approved for discharge by a Qualified Provider.

5. A Qualified Provider administering anesthesia in a host facility must attest to the adequacy and competency of the host facility and staff.

6. 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 2016) incorporated by reference in § 2.2(C) of this Part.

7. The dentist administering or permitting the administration of moderate sedation shall hold a current certificate in Advanced Cardiac Life Support, as described in the most current version of the American Dental Association, Guidelines for the Use of Sedation and General Anesthesia by Dentists (October 2016) incorporated by reference in § 2.2(C) of this Part.

8. 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 2016) incorporated by reference in § 2.2(C) of this Part.

9. The dentist administering or permitting the administration of nitrous oxide sedation shall hold a current certificate in Basic Life Support (BLS).

10. Each member of the team of auxiliary personnel shall hold a current certificate in Basic Life Support (BLS).

E. Management of Services:

1. Written policies and procedures shall be established regarding:

a. the administration of general anesthesia/deep sedation, moderate sedation, minimal sedation or nitrous oxide sedation;

b. maintenance of safety controls;

c. qualifications and supervision of the team of auxiliary personnel involved in the general anesthesia/deep sedation, moderate sedation, minimal sedation or nitrous oxide sedation service.

2. 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 sedation, 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 sedation. In the case of a minor, consent from a parent or legal guardian shall 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 sedation;

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 sedation, and/or Board certified or Board eligible anesthesiologists, employed by or practicing in conjunction with a dentist shall remain on the premises of the dental office until the patient has been discharged from the dentist’s (or anesthesiologist’s) care.

F. Monitoring and Documentation

1. 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 shall 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 shall be observed. For minimal sedation the dentist shall continuously auscultate breath sounds or monitor end-tidal CO2. For deeper levels of sedation, continuous monitoring of end-tidal CO2 is required.

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 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.

2. 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 age and size appropriate equipment for establishing a patent airway and providing positive pressure ventilation with oxygen.

A. A dental hygienist shall be qualified to administer local anesthesia only after successfully completing a course in local anesthesia that:

1. Is offered by an institution accredited by the Commission on Dental Accreditation of the American Dental Association;

2. Is a minimum of twenty (20) didactic hours and twelve (12) clinical hours;

3. Includes no less than the following topics:

a. Neurophysiology of pain and pain control;

b. Pharmacology of local anesthetic solutions and drug interactions;

c. Potential local and systemic complications;

d. Medical and dental indications and contraindications and emergency management;

e. Medical and dental history and assessment;

f. Safe assembly and handling of a syringe;

g. Location of anatomical landmarks associated with local anesthesia;

h. Injection techniques;

i. Clinical experience with maxillary and mandibular injections by administering infiltration and block injections;

j. Legal issues associated with local anesthesia administration by a dental hygienist;

k. Record keeping.

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 local anesthesia shall have successfully completed a local anesthesia examination administered by the CDCA.

C. A dental hygienist qualified to administer local anesthesia shall do so only under the indirect supervision of a licensed 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.

D. 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 § 2.12(A) of this Part, a course that meets such requirements shall be successfully completed before local anesthesia may be administered by the dental hygienist.

E. 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 § 2.12(A) of this Part, including successful completion of the local anesthesia portion of the CDCA examination or successful completion of a substantially similar examination in the alternate jurisdiction.

2.12.2 Application for Permit

A. Application for a two-year permit shall be made on forms provided by the Board which shall be completed 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):

1. Local anesthesia. Supporting official transcripts of verification of the qualification requirements as set forth in § 2.12 of this Part;

2. Nitrous Oxide. Supporting official transcripts of verification of the qualification requirements as set forth in § 2.13.3 of this Part;

3. 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;

4. 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;

5. Local anesthesia. A payment as set forth in the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title) for a two (2) year permit;

6. Nitrous Oxide. A payment as set forth in the Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title) for a two (2) year permit; and

7. Such other information as may be deemed necessary and as may be requested by the Board.

2.12.3 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 fifteen (15) didactic hours and five (5) clinical hours;

3. Includes no less than the following topics:

a. Nitrous oxide techniques;

b. Pharmacology of nitrous oxide;

c. Nitrous oxide sedation medical emergency techniques; and

d. 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 CDCA

C. A dental hygienist qualified to administer nitrous oxide shall do so only under the direct supervision of a dentist.

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 § 2.12(A) of this Part, 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 § 2.12(A) of this Part, including successful completion of the nitrous oxide portion of the CDCA examination or successful completion of a substantially similar examination in the alternate jurisdiction.

2.13.1 Equipment Requirements for Nitrous Oxide Sedation, Minimal Sedation, Moderate Sedation, or General Anesthesia/Deep Sedation Services

A. In order to ensure the protection and safety of patients receiving general anesthesia/deep sedation, moderate sedation, minimal sedation, or nitrous oxide sedation in a dental office, the following standards shall be applied in determining the adequacy and safety of the physical facility and equipment.

1. The current standards of the American Dental Association, Guidelines for the Use of Sedation and General Anesthesia by Dentists (2016) incorporated by reference in § 2.2(C) of this Part including but not limited to the following equipment requirements:

a. Equipment shall have a fail-safe system that is appropriately checked and calibrated;

b. Equipment shall have an appropriate scavenging system; and

c. If nitrous oxide and oxygen delivery equipment capable of delivering less than 25% oxygen is used, an in-line oxygen analyzer shall be used;

2. The standards for “Occupational Exposure to Waste Anesthetic Gases and Vapors" of the National Institute for Occupational Safety and Health (NIOSH) incorporated by reference in § 2.2(F) of this Part; and

3. The Rhode Island Fire Safety Code where flammable anesthetics are present.

B. The licensed dentist administering or permitting the administration of nitrous oxide sedation shall meet the following equipment requirements:

1. Automated external defibrillator (AED);

2. Gas delivery machines checked and calibrated periodically as required by manufacturer;

3. Equipment capable of delivering positive pressure ventilation;

4. Gas delivery system must have the following:

a. An oxygen fail-safe system;

b. Safety keyed hose attachment;

c. Capability to administer one hundred percent (100%) oxygen in all rooms in which nitrous oxide is administered;

d. Storage signage for nitrous oxide/oxygen tanks in compliance with applicable safety codes;

e. Adequate waste gas scavenging system;

f. Autoclavable or disposable hoods.

C. Minimal Sedation:

1. The dentist administering or permitting the administration of minimal sedation shall have the following age and size appropriate equipment:

a. Sphygmomanometer;

b. Automatic External Defibrillator (AED); and

c. Appropriate emergency drugs as determined by the Board.

D. Moderate Sedation:

1. A dentist administering or permitting the administration of moderate sedation shall have the following age and size appropriate equipment:

a. Sphygmomanometer and stethoscope;

b. Pulse Oximeter;

c. Capnograph;

d. AED; and

e. Appropriate emergency drugs as determined by the Board.

2. The equipment necessary for monitoring end-tidal CO2 and auscultation of breath sounds must be immediately available.

3. The equipment necessary to administer positive pressure ventilation.

4. An appropriate scavenging system must be available if gases other than oxygen or air are used.

5. The equipment necessary to establish intravascular or intraosseous access must be available until the patient meets discharge criteria.

6. When inhalation equipment is used, it must be a fail-safe system that is appropriately checked and calibrated. The equipment must also have a functioning device that prohibits the delivery of less than thirty percent (30%) oxygen.

E. General Anesthesia/Deep Sedation:

1. The dentist administrating or permitting the administration of general anesthesia/general anesthesia shall have the following equipment:

a. A positive-pressure oxygen delivery system suitable for the patient being treated must be immediately available.

b. When inhalation equipment is used, it must be a fail-safe system that is appropriately checked and calibrated in accordance with manufacturer’s recommendations. The equipment must also have a functioning device that prohibits the delivery of less than thirty percent (30%) oxygen.

c. An appropriate scavenging system must be available if gases other than oxygen or air are used.

d. The equipment necessary to establish intravenous access must be available.

e. Equipment and drugs necessary to provide advanced airway management.

f. Resuscitation medications and a defibrillator must be immediately available.

g. The dentist administering or permitting the administration of general anesthesia/deep sedation shall have equipment as referenced in the Office Inspection Form approved by the Board.

2.13.2 Clinical Guidelines

A. General Anesthesia/Deep Sedation

1. Patient History and Evaluation: Patients considered for deep sedation or general anesthesia must undergo an evaluation prior to the administration of any sedative. This must consist of their medical history and medication use and NPO (nothing by mouth) status. In addition, patients with considerable medical considerations (e.g., ASA Ill, IV of the ASA Physical Status Classification System for Dental Patient Care 2017, incorporated by reference above in § 2.2(H) of this Part), may also require consultation with their primary care physician or consulting medical specialist Assessment of Body Mass Index (BMI) should be considered part of a pre-procedural workup.

2. Preoperative Evaluation and Preparation

a. The patient, parent (if a minor), legal guardian or care giver must be advised regarding the procedure associated with the delivery of any sedative or anesthetic agent and informed consent for the proposed sedative/anesthesia must be obtained.

b. A focused physical evaluation must be performed as deemed appropriate.

c. Baseline vital signs including body weight, height, blood pressure, pulse rate, respiration rate, and blood oxygen saturation by pulse oximetry must be obtained unless invalidated by the patient, procedure or equipment. In addition, body temperature should be measured when clinically appropriate.

d. Pre-operative verbal and written instructions must be given to the patient, escort, legal guardian or care-giver, including pre-operative fasting instructions based on the ASA Summary of Fasting and Pharmacological Recommendations.

e. An intravenous line, which is secured throughout the procedure, must be established except as provided in part IVC.6 “Special Needs Patients" of the American Dental Association Guidelines for the Use of Sedation and General Anesthesia by Dentists (2016) incorporated by reference in § 2.2(C) of this Part.

3. Monitoring and Documentation

a. Monitoring. A Qualified Dentist or Qualified Provider administering deep sedation/general anesthesia/deep sedation must remain in the operatory room until the patient meets the criteria for recovery. The Qualified Dentist or Qualified Provider must not leave the facility until he or she has personally observed that the patient meets the criteria for discharge and has signed off on the patient's release. Monitoring must include:

(1) Oxygenation: the color of mucosa, skin, or blood should be continuously evaluated, Oxygen saturation must be evaluated continuously by pulse oximetry.

(2) Ventilation: Intubated patient: End-tidal CO2 must be continuously monitored and evaluated. Non-intubated patients: End-tidal CO2 must be continuously monitored and evaluated unless precluded or invalidated by the nature of the patient, procedure, or equipment. In addition, ventilation should be monitored and evaluated by continuous observation of qualitative signs, including auscultation of breath sounds with a precordial or pretracheal stethoscope.

(3) Respiratory rate must be continuously monitored and evaluated.

(4) Circulation: The dentist shall continually evaluate heart rate and rhythm via ECG throughout the procedure, as well as pulse rate via pulse oximetry.

(5) The Qualified Dentist or Qualified Provider must continually evaluate blood pressure.

(6) Temperature: A device capable of measuring body temperature must be readily available during the administration of deep sedation or general anesthesia. The equipment to continuously monitor body temperature should be available and must be performed whenever triggering agents associated with malignant hypothermia are administered.

b. Documentation

(1) Documentation of compliance with manufacturers' recommended maintenance of monitors, anesthesia delivery systems, and other anesthesia-related equipment should be maintained. A pre-procedural check of equipment for each administration must be performed.

(2) Appropriate time-oriented anesthetic record must be maintained, including the names of all the drugs, dosages and their administration times, including local anesthetics and monitored physiological parameters.

(3) Pulse oximetry and end-tidal CO2 measurements, heart rate, and respiratory rate must be continuously monitored. Blood pressure must be continually monitored. If continuous monitoring is not possible in pediatric or special needs patients, the reason why must be documented.

4. Recovery and Discharge

a. Oxygen and suction equipment must be immediately available in the discharge area and operatory.

b. The patient shall have continuous supervision until oxygenation, ventilation, and circulation are stable and the patient is appropriately responsive for discharge from the facility.

c. The Qualified Dentist or Qualified Provider or appropriately trained clinical staff must continually monitor the patient's blood pressure, heart rate, oxygenation and level of consciousness.

d. The Qualified Dentist or Qualified Provider shall determine and document that oxygenation, ventilation, and circulation are stable prior to discharge.

e. The Qualified Dentist or Qualified Provider or his or her designee shall provide explanation and documentation of postoperative instructions to the patient and/or responsible adult at the time of discharge.

f. If a pharmacological reversal agent is administered before discharge criteria have been met, the patient must be monitored for a longer period than usual before discharge, since re-sedation may occur once the effect of the reversal agent has waned.

5. Emergency Management

a. The Qualified Dentist or Qualified Provider is responsible for sedative/anesthetic management, adequacy of the facility and staff, diagnosis and treatment of emergencies related to the administration of deep sedation or general anesthesia and providing the equipment, drugs and protocols for patient rescue except as required for the Facility Host Permit.

b. The Board certified or Board eligible anesthesiologist, employed by or practicing in conjunction with a dentist must remain on the premise of the dental office until the patient has been discharged from the dentist's (or anesthesiologist's) care.

c. Proper documentation must include the following:

(1) Maintenance of an appropriate time-oriented anesthetic record including monitoring of blood pressure every five (5) minutes.

(2) Record of the individuals present during the administration of the anesthetic prepared by the dentist.

(3) Recording of all events relative to the administration of nitrous oxide, minimal sedation, moderate sedation, or deep sedation/general anesthesia.

(4) Written report(s) of any morbidity requiring hospitalization or mortality occurring in the dental office as a result of minimal sedation or nitrous oxide sedation, moderate sedation, or deep sedation/general anesthesia.

B. Moderate Sedation

1. Patient History and Evaluation:

a. Patients considered for moderate sedation must be suitably evaluated prior to the start of any sedation procedure. In healthy or medically stable individuals (ASA I, II of ASA Physical Status Classification System for Dental Patient Care 2017, incorporated by reference in § 2.2(H) of this Part) this may consist of a review of their current medical history and medication use.

b. In addition, patients with multiple medical comorbidities (ASA III, IV of ASA Physical Status Classification System for Dental Patient Care 2017, incorporated by reference in § 2.2(H) of this Part) may require consultation with his or her primary care provider or consulting medical specialist.

2. Pre-operative Evaluation and Preparation is pursuant to the requirements of § 2.13.2(A)(2) of this Part.

3. Monitoring and Documentation

a. Monitoring

(1) A Qualified Dentist or Qualified Provider administering moderate sedation must remain in the operatory room to monitor the patient continuously until the patient meets the criteria for recovery. When active treatment concluded and the patient recovers to a minimally sedated level a qualified auxiliary may be directed by the dentist to remain with the patient and continue to monitor them as explained in the guidelines until they are discharged from the facility. The dentist must not leave the facility until he or she has personally observed that the patient meets the criteria for discharge and has signed off on the patient's release. Monitoring must include:

(AA) Consciousness: Level of sedation (e.g., responsiveness to verbal command) must be continually assessed.

(BB) Oxygenation: Oxygen saturation must be evaluated by pulse oximetry continuously.

(CC) Ventilation: The dentist must observe chest excursions continually. The dentist must monitor ventilation and/or breathing by monitoring end-tidal CO2 unless precluded or invalidated by the nature of the patient, procedure or equipment Ventilation should be monitored by continuous observation of qualitative signs, including auscultation of breath sounds with precordial or pretracheal stethoscope or as needed if CO2 capnograph is used.

(DD) Vital signs including blood pressure must be obtained and recorded continually.

(EE) Circulation: The Qualified Dentist or Qualified Provider or appropriately trained clinical staff must continually monitor the patient's blood pressure and level of consciousness. Oxygenation and heart rate must be continuously monitored.

b. Documentation

(1) Appropriate time-oriented anesthesia record must be maintained, including the names of all drugs, dosages and their administration times, including local anesthetics, dosages and monitored physiological parameters.

(2) Pulse oximetry, heart rate, respiratory rate, blood pressure and level of consciousness must be recorded continually.

4. Recovery and Discharge

a. Oxygen and suction equipment must be immediately available if a separate discharge area is utilized.

b. The Qualified Dentist or Qualified Provider or appropriately trained clinical staff must continuously oxygenation and continually monitor the patient's blood pressure, heart rate, and level of consciousness.

c. Post-operative written instructions must be signed by the Qualified Dentist or Qualified Provider. The written and verbal instructions must be given to the patient, parent, escort, legal guardian or care-giver.

d. If a pharmacological reversal agent is administered before discharge criteria have been met, the patient must be monitored for a longer period than usual before discharge, since re-sedation may occur once the effect of the reversal agent has waned.

5. Emergency Management

a. If a patient enters a deeper level of sedation than the dentist is qualified to provide, the dentist must stop the dental procedure until the patient is returned to the intended level of sedation.

b. The Qualified Dentist or Qualified Provider is responsible for the sedative management, adequacy of the facility and staff, diagnosis and treatment of emergencies related to the administration of moderate sedation and providing the equipment, drugs, and protocol for patient rescue.

C. Minimal Sedation

1. Patient History and Evaluation

a. Patients considered for minimal sedation must be suitably evaluated prior to the start of any sedation procedure. In healthy or medically stable individuals (ASA I, II of ASA Physical Status Classification System for Dental Patient Care 2017, incorporated by reference in § 2.2(H) of this Part) this may consist of a review of their current medical history and medication use.

b. In addition, patients with multiple medical comorbidities (ASA III, IV of ASA Physical Status Classification System for Dental Patient Care 2017, incorporated by reference in § 2.2(H) of this Part) may require consultation with his or her primary care provider or consulting medical specialist.

2. Pre-Operative Preparation

a. Informed consent must be obtained from the patient, person designated as the patient’s power of attorney for healthcare, or parent if the patient is a minor.

b. Patient evaluation must be obtained unless invalidated by the nature of the patient, procedure, or equipment. Body temperature must be measured when clinically indicated.

c. An appropriate focused physical evaluation must be performed.

e. Pre-operative verbal and written instructions must be given to the patient, parent, escort, guardian or care giver.

3. Monitoring and Documentation

a. Monitoring. A dentist, or at the dentist's direction, an appropriately trained individual, must remain in the operatory during active sedation to monitor the patient on a continual basis until the patient meets the criteria for discharge. The appropriately trained individual must be familiar with monitoring techniques and equipment. Monitoring must include:

(1) Consciousness: Level of sedation (e.g., responsiveness to verbal command) must be continually assessed.

(2) Oxygenation: Oxygen saturation by pulse oximetry may be clinically useful and should be considered.

(3) Ventilation: The dentist and/or appropriately trained individual must observe chest excursions. The dentist and/or appropriately trained individual must verify respirations.

(4) Circulation: Blood pressure and heart rate must be evaluated pre-operatively, post-operatively and intraoperatively as necessary (unless patient is unable to tolerate such monitoring).

b. When administering nitrous oxide, the gas must be turned off when the dentist or dental hygienist administering the drug leaves the room. A dental assistant must stay in the room to monitor the patient if the dentist or dental hygienist is not physically present.

c. Documentation: An appropriate sedation record must be maintained, including names of all drugs administered, time administered and route of administration including local anesthetics, dosages, and monitored physiological parameters.

4. Recovery and Discharge

a. Oxygen and suction equipment must be immediately available if a separate discharge area is utilized.

b. The Qualified Dentist or Qualified Provider or appropriately trained clinical staff must monitor the patient during recovery until the patient is ready for discharge by the dentist.

c. The Qualified Dentist or Qualified Provider must determine and document that level of consciousness, oxygenation, ventilation and circulation are satisfactory prior to discharge, using an Aldrete score, or a similar set of standards approved by the board.

d. Post-operative verbal and written instructions must be given to the patient, parent, escort, legal guardian, or caregiver.

D. Nitrous Oxide Sedation. When administering nitrous oxide, the gas must be turned off when the dentist or dental hygienist administering the drug leaves the room. A dental assistant must stay in the room to monitor the patient if the dentist or dental hygienist is not physically present.

E. Dental Pediatric Anesthesia.

1. A Pediatric Individual Anesthesia Permit for Moderate Sedation is required for:

a. The administration of Nitrous Oxide-Oxygen sedation in a concentration higher than fifty percent (50%) or the administration of a lower concentration of Nitrous Oxide-Oxygen Analgesia via face mask, which may produce general anesthesia.

b. The administration of Nitrous Oxide-Oxygen while the child is under the influence of any other sedative agent.

c. Treatment of children younger than eighteen (18) months old, with moderate sedation, may only be administered by a Deep Sedation/General Anesthesia permit holder.

2. Patient History and Evaluation as well as Pre-Operative Evaluation and Preparation are pursuant to the requirements of §§ 2.13.2(B)(1) and (2) of this Part.

3. Monitoring Equipment

a. Ventilation, oxygenation circulation and level of consciousness must be monitored continuously.

b. Continuous monitoring of oxygen saturation, heart rate, respiratory rate and end tidal carbon dioxide must be provided via the following monitors:

(1) Pulse oximeter

(2) Capnograph

(3) Continual monitoring (every 5-10 minutes) of blood pressure with size appropriate cuff is mandatory.

(4) Continuous monitoring with pulse oximetry, and capnography and continual intermediate monitoring of blood pressure with size appropriate cuff must be employed, unless precluded or invalidated by the nature of the patient, procedure or equipment, which should be specifically noted in the patient record.

c. Heart rate, respiratory rate, blood pressure, oxygen saturation, and expired carbon dioxide values should be recorded, at minimum every ten (10) minutes in a time-based record.

d. Continuous monitoring of heart rate and oxygen saturation must be maintained in the recovery area with presence of at least one trained individual. Vital signs should be recorded at specific intervals (every 10-15) minutes, until discharge criteria are met. The dentist must not leave the facility until the patient meets the criteria for discharge and is discharged from the facility.

e. In addition the equipment requirements noted in AAP and American Academy of Pediatric Dentistry guidelines, oxygen and suction equipment must be immediately available in the discharge area and operatory.

(1) Stethoscope or precordial stethoscope/amplified, audible pretracheal stethoscope.

(2) Electrocardiographic monitor (ECG) with a minimum of 3- leads.

(3) Defibrillator with size-appropriate patches/paddles for use in pediatric patients.

(4) A device capable of measuring body temperature.

4. Personnel

a. In addition to the dentist, at least one other person trained in PALS, and capable of providing advanced airway skills must be present in the operatory at all times. It is required that at least one of the practitioners present in the room be skilled at obtaining vascular access in children. The individual assigned for monitoring may be responsible for assisting with interruptible patient-related tasks of short duration, such as holding an instrument or troubleshooting equipment for the monitoring of appropriate physiologic parameters.

b. A third individual trained in BLS Basic Life Support for Providers must be present in the facility. This staff member should be immediately available in case of emergency or if the staff member-in-charge of monitoring is involved in the dental treatment rendered, beyond interruptible patient-related tasks of short duration.

5. Discharge

a. Oxygen and suction equipment must be immediately available immediately available in the discharge area and operatory.

b. The patient shall have continuous supervision until oxygenation, ventilation, and circulation are stable and the patient is appropriately responsive for discharge from the facility.

c. The dentist or clinical staff must continually monitor the patient's blood pressure, heart rate, oxygenation and. level of consciousness.

d. The Qualified Dentist or Qualified Provider shall determine and document that oxygenation, ventilation, and circulation are stable prior to discharge.

e. The dentist or his or her designee shall provide explanation and documentation of postoperative instructions to the patient and/or responsible adult at the time of discharge.

6. Emergency Management

a. The Qualified Dentist or Qualified Provider shall be responsible for the anesthetic management, and treatment of emergencies associated with the administration of anesthesia, including immediate access to pharmacological antagonists, if any, and appropriately sized equipment for establishing a patent airway and providing positive pressure ventilation with oxygen.

b. The Facility Host Permit holder is responsible for the adequacy of the facility.

2.13.3 Facility Permit

A. Prior to the administration of general anesthesia/deep sedation, moderate sedation, minimal sedation or nitrous oxide sedation in a dental office by a qualified dentist as described in § 2.11.2 of this Part and/or a Board certified or Board eligible anesthesiologist employed by or practicing in conjunction with a dentist, each office site shall obtain a facility permit to allow the administration of these anesthesia services on the premises.

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 § 2.11.1(B) of this Part are exempt from the requirements of § 2.13.3 of this Part.

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 Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title); and

b. Such other information as may be deemed necessary and as may be requested by the Board.

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 this Part. Said permit unless sooner suspended or revoked will expire five (5) years from the date of issuance.

a. To renew such permit, the applicant will 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 Fee Structure for Licensing, Laboratory and Administrative Services Provided by the Department of Health (Part 10-05-2 of this Title). 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 § 2.13.3(A)(3) of this Part.

4. Those dental offices holding facility permits as described above may be subject to inspections as described in § 2.11.5 of this Part.

2.13.4 Violations & Sanctions

A. Failure to comply with any of the provisions of § 2.11 of this Part 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 sedation, and of disciplinary action in accordance with § 2.15.1 of this Part.

B. Furthermore, all hearings and reviews pertaining to the requirements as set forth in this Part, will be subject to the provisions of § 2.15.2 of this Part.

2.14.1 Availability of Dental Records

A. 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 shall 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 R.I. Gen. Laws § 23-3-26, entitled ”Vital Records." Records of minors shall be kept for at least five (5) years after such minor will have reached the age of eighteen (18) years. Records shall be maintained in a manner which permits the patient and/or successor dentist access to these records.

B. At a minimum, said records shall be legible and include:

1. The name, address and date of birth of the patient and, if a minor, the name of the parent or guardian and any disclosure statements, authorizations and/ or consent forms;

2. The patient’s medical history;

3. A record of results of a clinical examination, where appropriate, or an indication of the patient’s chief complaint;

4. A treatment plan, where appropriate;

5. The dates of each patient visit and a description of the treatment or services rendered at each visit;

6. A description of all radiographs taken and of diagnostic models made;

7. The date, dosage and amount of any medication or drug prescribed, dispensed or administered to the patient and Prescription Drug Monitoring Program query results, if appropriate; and,

8. A record of any recommendations or referrals for treatment or consultation by a specialist, including those which were refused by the patient.

C. 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.

D. 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.

E. Dentists shall maintain patient confidentiality in the storage and transfer of records pursuant to the provisions of R.I. Gen Laws § 5-37.3, ”Confidentiality of Health Care Information Act."

F. A dentist or other licensee treating the patient shall sign or initial the patient’s dental record after each procedure or visit.

2.15.1 Denial, Revocation or Suspension of License/Violations and Sanctions

A. Any dentist, dental hygienist, public health dental hygienist, or DAANCE-certified maxillofacial surgery assistant may have his or her license revoked or suspended by the Board: if said person has been found guilty of unprofessional conduct, which will include, but not be limited to those items listed in R.I. Gen. Laws § 5-31.1-10 and as stated below:

1. Fraudulent or deceptive procuring or use of a license or limited registration;

2. 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:

a. Is a diplomate of or a fellow in a specialty board accredited or recognized by the American Dental Association; or

b. Has completed a post graduate program approved by the Commission on Dental Accreditation of the American Dental Association;

3. 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;

4. Abandonment of patient;

5. 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;

6. Promotion by a dentist, dental hygienist, limited registrant or DAANCE-certified maxillofacial surgery assistant 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, public health dental hygienist, or limited registrant DAANCE-certified maxillofacial surgery assistant;

7. Immoral conduct of a dentist, dental hygienist, limited registrant, DAANCE-certified maxillofacial surgery assistant in the practice of dentistry dental hygiene, public health dental hygiene, or DAANCE-certified maxillofacial surgery assisting;

8. Willfully making and filing false reports or records in the practice of dentistry or dental hygiene;

9. 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;

10. Failure to furnish details of a patient's dental record to succeeding dentists, or dental care facility upon proper request pursuant to the Act;

11. 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, public health dental hygienist, limited registrant, or DAANCE-certified maxillofacial surgery assistant;

12. 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;

13. 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;

14. Willful misrepresentation in treatments;

15. 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;

16. 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;

17. Offering, undertaking, or agreeing to cure or treat disease by a secret method, procedure, treatment, or medicine;

18. Professional or mental incompetence;

19. 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, public health dental hygienist, limited registrant, or DAANCE-certified maxillofacial surgery assistant guilty of the previously named misconduct;

20. Failure to comply with the provisions of R.I. Gen. Laws Chapter 23-4.7;

21. 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 or DAANCE-certified maxillofacial surgery assisting 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;

22. 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 this Part;

23. Failure to furnish the Board, its dental administrator, investigator, or representatives, information legally requested by the Board;

24. 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;

25. Cheating on or attempting to subvert the licensing examination;

26. Violating any state or federal law or regulation relating to controlled substances;

27. Failure to maintain standards established by peer review boards, including, but not limited to, standards related to proper utilization of services, and use of non-accepted procedure and/or quality of care;

28. Malpractice as defined in R.I. Gen. Laws § 5-37-1(8).

29. 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.

30. Failure to follow current minimum infection control recommendations developed by the Centers for Disease Control and Prevention (CDC) published in the document entitled Guidelines for Infection Control in Dental Health-Care Settings and weekly spore testing.

B. Any disciplinary and/or criminal action shall be reported to the Board within twenty (20) days of adjudication

C. Furthermore, any violation pursuant to any provisions of the Act and this Part, may be cause for denial, revocation or suspension of license or for imposing such other penalties as prescribed in the Act.

2.15.2 Rules Governing Practices and Procedures

All hearings and reviews required under the provisions of the Act shall be held in accordance with the provisions of Practices and Procedures Before the Rhode Island Department of Health (Part 10-05-4 of this Title).

2.16.1 Criteria for continuing education credits developed by the Rhode Island Dental Association and approved by the Board

A. Introduction

1. Continuing education is reported biennially. The biennial accrual period for continuing education is July 1st.

2. Dentist licensees shall obtain a total of forty (40) continuing education credits every two years.

3. Dental hygienist and public health dental hygienist licensees shall obtain a total of twenty (20) continuing education credits every two years.

4. Certified maxillofacial surgery assistant licensees shall obtain a total of twenty (20) continuing education credits every two years.

B. Continuing Education Credit will be given only for the time the course was attended.

C. One (1) continuing education credit for each hour of attendance at lectures, seminars, institutes, meetings approved for credit by:

1. Accredited educational institutions.

2. Board recognized professional associations and societies. Accredited post-doctoral programs.

3. Federal, state, local governmental health agencies and health institutions.

4. Accredited community and teaching hospitals. Credit will be given only for the time the course was attended.

D. Two (2) continuing education credits for each hour of attendance at clinical or laboratory participating courses approved for credit by:

1. Accredited educational institutions.

2. Board recognized professional associations and societies (Accredited post-doctoral programs.

3. Federal, state, local governmental health agencies and health institutions.

4. Accredited community and teaching hospitals.

5. Responsibility of the Licensee. It is the responsibility of each licensee to maintain an authenticated record of all continuing education activities completed, and to submit documentation as evidence of completion of the above requirement, when requested.

2.16.2 Categories of Credit

A. The following guidelines will assist the licensee in identifying acceptable courses of continuing education activity. The licensee is free to select areas of study from within the stated categories, keeping in mind the restriction of minimum/maximum number of hours allowed in each category.

1. Educational and Scientific Courses.

a. The following amounts of continuing education credits per biennial accrual period may be obtained in this category by licensee as follows:

(1) Dentists: forty (40) hours.

(2) Dental hygienists: twenty (20) hours.

(3) Certified maxillofacial surgery assistants: twenty (20) hours.

b. This category includes educational and scientific courses sponsored by or approved by any of the following:

(1) Accredited educational institutions.

(2) Board recognized professional associations and societies. Accredited post-doctoral programs.

(3) Federal, state, local governmental health agencies and health institutions.

(4) Accredited community and teaching hospitals.

2. Self-instructed Courses

a. Successful completion of a post-test is necessary to obtain credit for self-instructional courses.

b. The number of continuing education credits will be determined by sponsor.

c. The following amounts of continuing education credits per biennial accrual period may be obtained in this category by licensee as follows:

(1) Dentists: forty (40) hours.

(2) Dental hygienists: twenty (20) hours.

(3) Certified maxillofacial surgery assistants: twenty (20) hours.

d. This category includes home study courses, correspondence courses, educational television courses, audio, and video cassettes, and Internet (web-based) courses sponsored by or approved by any of the following:

(1) Accredited educational institutions.

(2) Board recognized professional associations and societies.

(3) Accredited post-doctoral programs.

(4) Federal, state, local government health agencies and health institutions.

(5) Accredited community and teaching hospitals.

3. Papers, Publications and Scientific Presentations. A maximum of twenty-eight (28) continuing education credits per biennial accrual period may be obtained in this category.

a. Eight (8) continuing education credits for authoring an original scientific paper published in a scientific professional journal.

b. Two (2) continuing education credits for each hour of a presentation (paper, essay or formal lecture) to a recognized group of health professionals.

4. Teaching and Research Appointments. A maximum of twelve (12) continuing education credits per biennial accrual period may be obtained in this category. Any dental professional involved in teaching or research activities may receive two (2) continuing education credits for each one (1) hour of documented teaching or research time per semester in an accredited dental or dental auxiliary educational program.

5. Table Clinics, Scientific and Product Exhibits. A maximum of six (6) continuing education credits per biennial accrual period may be obtained in this category.

a. Two (2) continuing education credit hours for each presenter in a table clinic.

b. One (1) continuing education credit hour for attendance at product exhibits. Examples of product exhibits include Yankee Dental Conference Exhibits.

6. Community Service. A maximum of six (6) continuing education credits per biennial accrual period may be obtained in this category. The number of continuing education credits will be approved in advance by:

a. Accredited educational institutions.

b. Board recognized professional associations and societies. Accredited post-doctoral programs.

c. Federal, state, local governmental health agencies and health institutions.

d. Accredited community and teaching hospitals.

7. Cardio-Pulmonary Resuscitation (CPR). A maximum of three (3) continuing education credits per biennial accrual period – one (1) continuing education credit for each hour of participation – may be obtained by completion of the CPR for Healthcare Providers course.