Part V.
State Board of Dental Examiners
Chapter 109.
Conduct
Subchapter L. Anesthesia and Anesthetic Agents
22 TAC §109.171
The State Board of Dental Examiners proposes amendments to
§109.171, concerning the effective date of §109.171, §109.172,
§109.173, §109.174, and §109.175.
Douglas A. Beran, Executive Director, State Board of Dental Examiners,
has determined that for the first five-year period the rule is in effect there
will be no fiscal implications for state or local government as a result of
enforcing the rule.
Mr. Beran has determined that for each year of the first five years the
rule is in effect the public benefit anticipated as a result of enforcing
the rule will be that the proposed amendment to §109.171 clarifies the
effective dates amended rules affecting anesthesia procedures.
There will be no effect on small and large businesses and on persons who
are required to comply with the rule as proposed.
Comments on the proposal may be submitted to Mei Ling Clendennen, Executive
Assistant, State Board of Dental Examiners, 333 Guadalupe, Tower 3, Suite
800, Austin, Texas 78701, 512-463-6400. To be considered all comments must
be received by the State Board of Dental Examiners on or before May 17, 1999.
The amended rule is proposed under Texas Government Code, §2001.021
et. seq.; Texas Civil Statutes, Article 4543 §2 and 4551d which provide
the State Board of Dental Examiners with the authority to adopt and promulgate
rules consistent with the Dental Practice Act.
The proposed amended rule does not affect other statutes, articles, or
codes.
§109.171.Effective Date.
Unless specifically provided otherwise, the provisions of rules
109.172, 109.173, 109.174, and 109.175 of this title (relating to Anesthesia
and Anesthetic Agents) that require equipment and/or certifications not required
by those rules that were in effect on September 1, 1998, shall not be enforced
until September 1, 2000. All other provisions of subchapter L of this chapter,
as amended become effective as provided by law.
[
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of the Secretary of State, on
April 5, 1999.
TRD-9902004
Douglas A. Beran, Ph.D.
Executive Director
State Board of Dental Examiners
Earliest possible date of adoption: May 16, 1999
For further information, please call: (512) 463-6400
22 TAC §109.172
The State Board of Dental Examiners proposes amendments to
§109.172, concerning definitions.
Douglas A. Beran, Executive Director, State Board of Dental Examiners,
has determined that for the first five-year period the rule is in effect there
will be no fiscal implications for state or local government as a result of
enforcing the rule.
Mr. Beran has determined that for each year of the first five years the
rule is in effect the public benefit anticipated as a result of enforcing
the rule will be that §109.172 clarifies certain definitions relative
to administration of anesthesia.
There will be no effect on small and large businesses and on persons who
are required to comply with the rule as proposed.
Comments on the proposal may be submitted to Mei Ling Clendennen, Executive
Assistant, State Board of Dental Examiners, 333 Guadalupe, Tower 3, Suite
800, Austin, Texas 78701, 512-463-6400. To be considered all comments must
be received by the State Board of Dental Examiners on or before May 17, 1999.
The amended rule is proposed under Texas Government Code, §2001.021
et. seq.; Texas Civil Statutes, Article 4543 §2 and 4551d which provide
the State Board of Dental Examiners with the authority to adopt and promulgate
rules consistent with the Dental Practice Act.
The proposed amended rule does not affect other statutes, articles, or
codes.
§109.172.Definitions.
The following words and terms, when used in
subchapter L, Anesthesia
and Anesthetic Agents
[
(1)
Analgesia - the diminution
or elimination of pain
[
(2)
Competent - displaying special skill
or knowledge derived from training and experience.
(3)
[
(4)
Continual - repeated regularly and
frequently in a steady succession.
(5)
Continuous - prolonged without any
interruption at any time.
(6)
[
(7)
[
(8)
Enteral - any technique of administration
in which the agent is absorbed through the gastrointestinal (GI) tract or
oral mucosa (i.e., oral, rectal, sublingual)
.
(9)
Facility - the primary office where
a permit holder practices dentistry and provides anesthesia services.
(10)
Facility inspection - an on-site
inspection to determine if a facility is supplied, equipped, staffed, and
maintained in a condition to support provision of anesthesia services that
meet the minimum standard of care; may be required by the State Board of Dental
Examiners prior to the issuance of a sedation/anesthesia permit or any time
during the term of the permit if the holder of or applicant for a permit owns
or operates a primary facility or satellite facility.
(11)
[
(12)
Immediately available - on-site in
the facility and available for immediate use.
(13)
Inhalation - a technique of administration
in which a gaseous or volatile agent is introduced into the pulmonary tree
and whose primary effect is due to absorption through the pulmonary bed (e.g.
nitrous oxide/oxygen sedation).
(14)
[
(15)
[
(16)
[
(17)
[
(18)
Parenteral - a technique
of administration in which the drug bypasses the gastrointestinal (GI) tract,
i.e., intramuscular (IM), intravenous (IV), intranasal (IN), submucosal (SM),
subcutaneous (SC).
(19)
Patient Physical Status
Classification:
(A)
ASA - American Society of Anesthesiologists
(B)
ASA I - a normal health patient
(C)
ASA II - a patient with mild systemic disease
(D)
ASA III - a patient with severe systemic disease
(E)
ASA IV - a patient with severe systemic disease
that is a constant threat to life
(F)
ASA V - a moribund patient who is not expected
to survive without the operation
(G)
ASA VI - a declared brain-dead patient whose
organs are being removed for donor purposes
(H)
E - emergency operation of any variety (used
to modify the ASA I - ASA VI).
(20)
[
(21)
Portability - the ability of a permit
holder to provide permitted anesthesia services in a location other than a
facility or satellite facility.
(22)
Satellite facility - an additional
office or offices owned or operated by the permit holder, or owned or operated
by a professional organization through which the permit holder practices dentistry,
or a licensed hospital facility.
(23)
[
(24)
Time-oriented anesthesia record -
documentation at appropriate intervals of drugs, doses and physiologic data
obtained during patient monitoring.
(25)
Topical Anesthesia - the elimination
of sensations, especially pain, in one part of the body by the topical application
of a drug.
(26)
Transdermal/transmucosal - a technique
of administration in which the drug is administered by patch or iontophoresis.
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed with the Office of the Secretary of State, on
April 5, 1999.
TRD-9902005
Douglas A. Beran, Ph.D.
Executive Director
State Board of Dental Examiners
Earliest possible date of adoption: May 16, 1999
For further information, please call: (512) 463-6400
22 TAC §109.173
The State Board of Dental Examiners proposes amendments to
§109.173, concerning minimum standard of care.
Douglas A. Beran, Executive Director, State Board of Dental Examiners,
has determined that for the first five-year period the rule is in effect there
will be no fiscal implications for state or local government as a result of
enforcing the rule.
Mr. Beran has determined that for each year of the first five years the
rule is in effect the public benefit anticipated as a result of enforcing
the rule will be that §109.173 communicates unambiguously that practicing
dentists must follow generally accepted protocols and/or standards of care
for management of complications and emergencies and informed consent will
be required only where there is a reasonable probability of complications
from a procedure.
There will be no effect on small and large businesses and on persons who
are required to comply with the rule as proposed.
Comments on the proposal may be submitted to Mei Ling Clendennen, Executive
Assistant, State Board of Dental Examiners, 333 Guadalupe, Tower 3, Suite
800, Austin, Texas 78701, 512-463-6400. To be considered all comments must
be received by the State Board of Dental Examiners on or before May 17,1999.
The amended rule is proposed under Texas Government Code, §2001.021
et. seq.; Texas Civil Statutes, Article 4543 §2 and 4551d which provide
the State Board of Dental Examiners with the authority to adopt and promulgate
rules consistent with the Dental Practice Act.
The proposed amended rule does not affect other statutes, articles, or
codes.
§109.173.Minimum Standard of Care.
Each dentist licensed by the [
(1)
(No change.)
(2)
Shall maintain and review an initial medical history
and
perform
limited physical evaluation for all dental patients
to wit:
(A)
(No change.)
(B)
The initial limited physical examination
should
[
(3)
(No change.)
(4)
Shall, for office emergencies:
(A)-(B)
(No change.)
(C)
provide training to dental office personnel in emergency
procedures which shall include, but not necessarily be limited to, basic cardiac
life support, inspection and utilization of emergency equipment in the dental
office, and office procedures to be followed in the event of an emergency
as determined by a reasonable and prudent dentist in the same or similar circumstances;
and
(D)
shall adhere to generally accepted protocols
and/or standards of care for management of complications and emergencies.
(5)
Shall
sucessfully
complete a
current
course in basic cardiopulmonary resuscitation [
(6)
Should maintain a written informed consent for
all procedures where a reasonable possibility of complications from the procedure
exists, and such consent should disclose risks or hazards that could influence
a reasonable person in making a decision to give or withhold consent.
[
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed with the Office of the Secretary of State, on
April 5, 1999.
TRD-9902006
Douglas A. Beran, Ph.D.
Executive Director
State Board of Dental Examiners
Earliest possible date of adoption: May 16, 1999
For further information, please call: (512) 463-6400
22 TAC §109.174
The State Board of Dental Examiners proposes amendments to
§109.174, concerning sedation, anesthesia permits.
Douglas A. Beran, Executive Director, State Board of Dental Examiners,
has determined that for the first five-year period the rule is in effect there
will be no fiscal implications for state or local government as a result of
enforcing the rule.
Mr. Beran has determined that for each year of the first five years the
rule is in effect the public benefit anticipated as a result of enforcing
the rule will be that §109.174 will assure that the overall quality of
anesthesia procedures meets the standard of care.
The effect on small businesses that are required to comply with the rule
as proposed shall be their staffs remain qualified to meet the standard of
care for anesthesia procedures or such businesses shall not be authorized
by the State Board of Dental Examiners to perform anesthesia procedures. The
fiscal impact on small businesses required to comply with the rule as proposed
will be contingent upon each business' cost of permits and staff training
for the anesthesia procedure authorized by the State Board of Dental Examiners
and concomitant costs associated with each permitted procedure, e.g., equipment
and staff. Such costs assure a minimum quality of care that is reasonable
for the public safety. These costs, however, are not so negative as to impact
the economic viability of a small business. Therefore, the State Board of
Dental Examiners has determined that compliance with the proposed rule will
not have an adverse economic impact on small businesses as the cost of compliance
will be minimal.
Comments on the proposal may be submitted to Mei Ling Clendennen, Executive
Assistant, State Board of Dental Examiners, 333 Guadalupe, Tower 3, Suite
800, Austin, Texas 78701, 512-463-6400. To be considered all comments must
be received by the State Board of Dental Examiners on or before May 17,1999.
The amended rule is proposed under Texas Government Code, §2001.021
et. seq.; Texas Civil Statutes, Article 4543 §2 and 4551d which provide
the State Board of Dental Examiners with the authority to adopt and promulgate
rules consistent with the Dental Practice Act.
The proposed amended rule does not affect other statutes, articles, or
codes.
§109.174.Sedation/Anesthesia Permit.
(a)
The [
(b)
[
(1)
A permit may be obtained by completing
an application form approved by the State Board of Dental Examiners, a copy
of which may be obtained from the SBDE.
(2)
The application form must be filled
out completely and appropriate fees paid.
(3)
Prior to issuance of a sedation/anesthesia
permit the Board may require that the applicant undergo a facility inspection
or further review of anesthesia credentials. The SBDE may direct an Anesthesia
Consultant, who has been appointed by the Board, to assist in this inspection
or review. The applicant will be notified in writing if an inspection is required
and provided with the name of an Anesthesia Consultant who will coordinate
the inspection. The applicant must make arrangements for completion of the
inspection within 180 days of the date the notice is mailed. An extension
of no more than 90 days may be granted if the designated Anesthesia Consultant
requests one.
(4)
An applicant for a sedation/anesthesia
permit must be licensed and in good standing with the State Board of Dental
Examiners. For purposes of Rules 109.171 through 109.175, of this title (relating
to Anesthesia and Anesthetic Agents) "good standing" means that a licensee
is not suspended, whether or not the suspension is probated. Applications
from licensees who are not in good standing will not be approved.
(c)
Any dentist approved by the [
(d)
Once a permit is issued, the State Board of Dental
Examiners upon payment of required fees shall automatically renew the permit
annually unless after notice and opportunity for hearing the Board finds the
permit holder has, or is likely to provide anesthesia services in a manner
that does not meet the minimum standard of care. At such hearing the Board
shall consider factors including patient complaints, morbidity, mortality,
and anesthesia consultant recommendations.
[
(e)
Annual dental license renewal certificates shall include
the annual permit renewal, except as provided for in subsection (d) of this
section and shall be assessed an annual renewal fee of $5.00 payable with
the license renewal. New permit fees are $28.75 payable with the application
for permit.
[
(f)
Permit Restrictions:
[
(1)
A sedation/anesthesia permit is valid for
the dentist's facility, if any, as well as any satellite facility.
(2)
Portability of a sedation/anesthesia
permit will be granted to a dentist who, after September 1, 2000, applies
for portability if the dentist is granted:
(A)
a deep sedation/general anesthesia permit; or
(B)
an intravenous parenteral conscious sedation
permit if training for the permit was obtained on the basis of completion
of
(i)
a specialty program approved by the Commission
on Dental Accreditation of the American Dental Association, or
(ii)
a general practice residency, approved by the
Commission on Dental Accreditation of the American Dental Association, or
(iii)
an advanced education in general dentistry
program, approved by the Commission on Dental Accreditation of the American
Dental Association, or
(iv)
a Continuing Education (CE) program specifically
approved by the SBDE. The board may approve a graduate of a CE program under
this subsection only if the applicant can demonstrate administration of intravenous
parenteral conscious sedation in at least 30 cases that are documented showing
provision of anesthesia services in keeping with the standard of care as determined
by one or more of the SBDE's anesthesia consultants; and the applicant establishes
that the program consisted of
(I)
sixty hours of didactic courses;
(II)
administration of intravenous parenteral conscious
sedation in at least 20 cases where the applicant was the anesthesia provider.
(3)
When anesthesia services
are provided by a dentist at a location other than a facility or a satellite
facility, the dentist shall strictly adhere to all rules of the State Board
of Dental Examiners which may apply. The dentist shall ascertain that the
location is supplied, equipped, staffed and maintained in a condition to support
provision of anesthesia services that meet the standard of care.
(4)
A dentist holding a permit
to administer parenteral conscious sedation on the effective date of this
rule who is qualified by training or experience to administer intravenous
parenteral conscious sedation anesthesia on a portable basis, and who desires
to do so must file with the State Board of Dental Examiners proof of completion
of:
(A)
a specialty program approved by the Commission
on Dental Accreditation of the American Dental Association, or
(B)
a general practice residency approved by the
Commission on Dental Accreditation of the American Dental Association, or
(C)
an advanced education in a general dentistry
program approved by the Commission on Dental Accreditation of the American
Dental Association, or
(D)
a Continuing Education program and administration
of intravenous parenteral conscious sedation in at least 30 cases that are
documented showing provision of anesthesia services in keeping with the standard
of care as determined by one or more of the SBDE's anesthesia consultants.
(E)
The records of all dentists permitted to administer
parenteral conscious sedation will be annotated showing whether portability
status is granted.
(F)
Any applicant whose request for portability
is not granted on the basis of the application will be provided an opportunity
for hearing pursuant to Texas Government Code, Section 2001 et.seq.
(5)
A dentist holding
a permit to administer parenteral deep sedation/general anesthesia on the
effective date of this rule who desires to provide anesthesia on a portable
basis must file with the State Board of Dental Examiners a request for a portability
designation.
(A)
The records of all dentists permitted to administer
parenteral deep sedation/general anesthesia will be annotated showing whether
portability status is granted.
(B)
Any applicant whose request for portability
status is not granted on the basis of the application will be provided an
opportunity for hearing pursuant to Texas Government Code, Section 2001 et.seq.
(6)
The Board may elect to issue
a temporary sedation/anesthesia permit which will expire on a date certain.
A full sedation/anesthesia permit may be issued after the dentist has complied
with requests of the Board which may include, but shall not be limited to,
review of the dentist's anesthetic technique, facility inspection and/or review
of patient records to ascertain that the minimum standard of care is being
met. If a full permit is not issued, the temporary permit will expire on the
stated date, and no further action by the State Board of Dental Examiners
will be required, and no hearing will be conducted.
(g)
Educational/Professional requirements for sedation/anesthesia
permits:
[
(1)
Nitrous Oxide/Oxygen Inhalation
Conscious Sedation
(A)
To administer nitrous oxide/oxygen inhalation
conscious sedation, the dentist must satisfy one of the following criteria:
(i)
must have completed training consistent with
that described in Part I or Part III of the American Dental Association (ADA)
Guidelines for Teaching the Comprehensive Control of Pain and Anxiety in Dentistry;
or
(ii)
must have completed an ADA accredited post-doctoral
training program which affords comprehensive and appropriate training necessary
to administer and manage nitrous oxide/oxygen inhalation conscious sedation.
(B)
The following shall apply to the administration
of nitrous oxide/oxygen inhalation conscious sedation in the dental office:
(i)
provision of nitrous oxide/oxygen inhalation
conscious sedation by another duly qualified dentist or physician anesthesiologist
requires the operating dentist and his/her clinical staff to maintain current
expertise in Basic Life Support (BLS);
(ii)
when a Certified Registered Nurse Anesthetist
(CRNA) is permitted to function under the supervision of a dentist, in the
dental office, provision of nitrous oxide/oxygen inhalation conscious sedation
by a CRNA shall require the operating dentist to have completed training in
nitrous oxide/oxygen inhalation conscious sedation, and to be permitted for
its utilization.
(2)
Parenteral Conscious
Sedation
(A)
To administer parenteral conscious sedation,
the dentist must satisfy one of the following criteria:
(i)
completion of a comprehensive training program
in parenteral conscious sedation that satisfies the requirement described
in Part III of the American Dental Association (ADA) Guidelines for Teaching
the Comprehensive Control of Pain and Anxiety in Dentistry at the time training
was commenced; or
(ii)
completion of an ADA accredited post-doctoral
training program which affords comprehensive and appropriate training necessary
to administer and manage parenteral conscious sedation.
(B)
The following shall apply to the administration
of parenteral conscious sedation in the dental office:
(i)
provision of parenteral conscious sedation by
another duly qualified dentist or physician anesthesiologist requires the
operating dentist and his/her clinical staff to maintain current expertise
in Basic Life Support (BLS);
(ii)
when a Certified Registered Nurse Anesthetist
(CRNA) is permitted to function under the supervision of a dentist, in the
dental office, provision of parenteral conscious sedation by a CRNA shall
require the operating dentist to have completed training in parenteral conscious
sedation, and to be permitted for its utilization;
(iii)
a dentist administering parenteral conscious
sedation must document current, successful completion every three years of
an advanced emergency procedures course approved by the State Board of Dental
Examiners or an Advanced Cardiac Life Support (ACLS) course, or a Pediatric
Advanced Life Support (PALS) or age appropriate equivalent course.
(3)
Parenteral Deep
Sedation/General Anesthesia
(A)
To administer parenteral deep sedation/general
anesthesia, the dentist must satisfy one of the following criteria:
(i)
completion of an advanced training program in
anesthesia and related subjects beyond the undergraduate dental curriculum
that satisfies the requirements described in Part II of the American Dental
Association (ADA) Guidelines for Teaching the Comprehensive Control of Pain
and Anxiety in Dentistry at the time training was commenced; or,
(ii)
completion of an ADA accredited post-doctoral
training program which affords comprehensive and appropriate training necessary
to administer and manage parenteral deep sedation/general anesthesia.
(B)
The following shall apply to the administration
of parenteral deep sedation/general anesthesia in the dental office:
(i)
provision of parenteral deep sedation/general
anesthesia by another duly qualified dentist or physician anesthesiologist
requires the operating dentist and his/her clinical staff to maintain current
expertise in Basic Life Support (BLS);
(ii)
when a Certified Registered Nurse Anesthetist
(CRNA) is permitted to function under the supervision of a dentist, in the
dental office, provision of parenteral deep sedation/general anesthesia by
a CRNA shall require the operating dentist to have completed training in parenteral
deep sedation/general anesthesia, and to be permitted for its utilization;
(iii)
a dentist administering parenteral deep sedation/general
anesthesia must document current, successful completion every three years
of an advanced emergency procedures course approved by the State Board of
Dental Examiners or an Advanced Cardiac Life Support (ACLS) course, or a Pediatric
Advanced Life Support (PALS) or age appropriate equivalent course.
[
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of the Secretary of State, on
April 5, 1999.
TRD-9902007
Douglas A. Beran, Ph.D.
Executive Director
State Board of Dental Examiners
Earliest possible date of adoption: May 16, 1999
For further information, please call: (512) 463-6400
22 TAC §109.175
The State Board of Dental Examiners proposes amendments to
§109.175, concerning permit requirements and clinical provisions.
Douglas A. Beran, Executive Director, State Board of Dental Examiners,
has determined that for the first five-year period the rule is in effect there
will be no fiscal implications for state or local government as a result of
enforcing the rule.
Mr. Beran has determined that for each year of the first five years the
rule is in effect the public benefit anticipated as a result of enforcing
the rule will be that §109.175 will assure that the overall quality of
anesthesia procedures meets the standard of care.
The effect on small businesses that are required to comply with the rule
as proposed shall be their staffs remain qualified to meet the standard of
care for anesthesia procedures or such businesses shall not be authorized
by the State Board of Dental Examiners to perform anesthesia procedures. The
fiscal impact on small businesses required to comply with the rule as proposed
will be contingent upon each business' cost of permits and staff training
for the anesthesia procedure authorized by the State Board of Dental Examiners
and concomitant costs associated with each permitted procedure, e.g., equipment
and staff. Such costs assure a minimum quality of care that is reasonable
for the public safety. These costs, however, are not so negative as to impact
the economic viability of a small business. Therefore, the State Board of
Dental Examiners has determined that compliance with the proposed rule will
not have an adverse economic impact on small businesses as the cost of compliance
will be minimal.
Comments on the proposal may be submitted to Mei Ling Clendennen, Executive
Assistant, State Board of Dental Examiners, 333 Guadalupe, Tower 3, Suite
800, Austin, Texas 78701, 512-463-6400. To be considered all comments must
be received by the State Board of Dental Examiners on or before May 17, 1999.
The amended rule is proposed under Texas Government Code §2001.021
et. seq.; Texas Civil Statutes, Article 4543 §2 and 4551d which provide
the State Board of Dental Examiners with the authority to adopt and promulgate
rules consistent with the Dental Practice Act.
The proposed amended rule does not affect other statutes, articles, or
codes.
§109.175. Permit Requirements and Clinical Provisions .
(a)
Nitrous Oxide/oxygen inhalation conscious sedation. To
induce and maintain this type of conscious sedation on patients having dental/oral
and maxillofacial surgical procedures in the State of Texas, the following
requirements must be met:
(1)
Professional requirements.
(A)
Each dentist wishing to utilize this technique must
be permitted by the State Board of Dental Examiners (SBDE) to deliver nitrous
oxide/oxygen conscious sedation after having met the Education Requirements
as detailed in rule 109.174 (g)(1) of this title (relating to Sedation/Anesthesia
Permit).
[
[
[
[
(B)
Nitrous oxide/oxygen inhalation conscious sedation
shall be induced and maintained by a dentist licensed by the State of Texas
and practicing in Texas, a physician anesthesiologist licensed by the Texas
State Board of Medical Examiners, or a Certified Registered Nurse Anesthetist
(CRNA) licensed in Texas.
[
[
(2)
Standard of care requirements.
Each dentist
must maintain the minimum standard of care as detailed in rule 109.173 of
this title (relating to Minimum Standard of Care), and shall in addition:
(A)
adhere to the clinical requirements as detailed in
paragraph (3) of this subsection;
[
(B)
maintain under continuous direct supervision auxiliary
personnel who shall be capable of reasonably assisting in procedures, problems,
and emergencies incident to the use of nitrous oxide/oxygen inhalation conscious
sedation.
[
(C)
maintain current certification in basic
cardiopulmonary resuscitation for the assistant staff by having them pass
a course sponsored by the American Heart Association or the American Red Cross;
and
(D)
not allow a nitrous oxide/oxygen inhalation
conscious sedation procedure to be performed in his/her office by a Certified
Registered Nurse Anesthetist (CRNA) unless the dentist holds a permit issued
by the State Board of Dental Examiners for the procedure being performed.
(3)
Clinical Requirements.
Each dentist must meet the following clinical requirements for utilization
of nitrous oxide/oxygen inhalation conscious sedation:
(A)
Patient Evaluation. Patients subjected to nitrous
oxide/oxygen inhalation conscious sedation must be suitably evaluated prior
to the start of any sedative procedure. In healthy or medically stable individuals
(ASA I, II), this may be simply a review of their current medical history
and medication use. However, with individuals who may not be medically stable
or who have a significant health disability (ASA III, IV) consultation with
their primary care physician or consulting medical specialist regarding potential
procedure risk should be considered.
(B)
Pre-Procedure preparation, informed consent:
(i)
the patient and/or guardian must be advised
of the procedure associated with the delivery of the nitrous oxide/oxygen
inhalation conscious sedation.
(ii)
the inhalation equipment must be evaluated
for proper operation and delivery of inhalation agents prior to use on each
patient;
(iii)
determination of adequate oxygen supply must
be completed prior to use with each patient;
(iv)
baseline vital signs should be obtained at
the discretion of the operator depending on the medical status of the patient
and the nature of the procedure to be performed.
(C)
Personnel and Equipment Requirements:
(i)
in addition to the dentist, at least one member
of the assistant staff should be present during the administration of nitrous
oxide/oxygen inhalation conscious sedation in non-emergency situations;
(ii)
the inhalation equipment must have a fail-safe
system that is appropriately checked and calibrated;
(iii)
if nitrous oxide and oxygen delivery equipment
capable of delivering less than 25% oxygen is used, an in-line oxygen analyzer
must be utilized;
(iv)
the equipment must have an appropriate nitrous
oxide/oxygen scavenging system.
(v)
regardless of the sedation/anesthesia technique,
the ability of the provider and/or the facility to deliver positive pressure
oxygen must be maintained.
(D)
Monitoring and Documentation:
(i)
maintain personal supervision of the patient
during induction of the nitrous oxide/oxygen inhalation conscious sedation
procedure and during maintenance of nitrous oxide/oxygen inhalation conscious
sedation for such a period of time necessary to establish pharmacologic and
physiologic vital sign stability. The dentist may delegate under direct supervision,
as defined in Rule 109.172 of this title (relating to Definitions), the monitoring
of the nitrous oxide/oxygen inhalation conscious sedation procedure to a dental
auxiliary who has been certified to monitor the administration of nitrous
oxide/oxygen inhalation conscious sedation by the State Board of Dental Examiners.
Certification is obtained by successful completion of a written examination
offered by the State Board of Dental Examiners on said subject.
(ii)
individuals present during administration should
be documented;
(iii)
maximum concentration administered must be
documented.
(E)
Recovery and Discharge:
(i)
recovery from nitrous oxide/oxygen inhalation
conscious sedation, when used alone, should be relatively quick, requiring
only that the patient remain in an operatory chair as needed;
(ii)
patients who have unusual reactions to nitrous
oxide/oxygen inhalation conscious sedation should be assisted and monitored
either in an operatory chair or recovery room until stable for discharge;
(iii)
the dentist must determine that the patient
is appropriately responsive prior to discharge.
(F)
Emergency Management. The dentist, personnel
and facility must be prepared to treat emergencies that may arise from the
administration of nitrous oxide/oxygen inhalation conscious sedation.
(b)
Parenteral conscious sedation (intravenous (IV), intramuscular
(IM), subcutaneous (SC), submucosal (SM),
intranasal (IN)
). To
induce and maintain this type of conscious sedation on patients having dental/oral
and maxillofacial surgical procedures in the State of Texas, the following
requirements must be met:
(1)
Professional Requirements:
[
(A)
each dentist wishing to utilize these techniques
must be permitted by the State Board of Dental Examiners (SBDE) to deliver
parenteral conscious sedation after having met the educational requirements
as detailed in Rule 109.174(g)(2) of this title (relating to Sedation/Anesthesia
Permit).
(B)
parenteral conscious sedation shall be
induced and maintained by a dentist licensed by the State of Texas and practicing
in Texas, a physician anesthesiologist licensed by the Texas State Board of
Medical Examiners, or a Certified Registered Nurse Anesthetist (CRNA) licensed
in Texas.
(2)
Standard of Care Requirements. Each dentist
must maintain the minimum standard of care as detailed in Rule 109.173 of
this title (relating to the Minimum Standard of Care) and shall in addition:
[
(A)
adhere to the clinical requirements as detailed in
paragraph (3) of this subsection;
[
(B)
maintain a written informed parenteral conscious sedation
consent for each dental patient on whom each procedure is performed; such
consent shall specify that the risks related to the procedure include cardiac
arrest, brain injury and death;
[
(C)
maintain a time oriented, written anesthetic record
which shall record dosages of anesthetic agents utilized and which shall include
physiologic vital sign monitoring during the course of the procedure;
[
(D)
maintain under continuous personal supervision
auxiliary personnel who shall be capable of reasonably assisting in procedures,
problems, and emergencies incident to the use of parenteral conscious sedation;
(E)
maintain current certification in basic
cardiopulmonary resuscitation for the assistant staff by having them pass
a course sponsored by the American Heart Association or the American Red Cross.
(F)
not allow a parenteral conscious sedation
procedure to be performed in his/her office by a Certified Registered Nurse
Anesthetist (CRNA) unless the dentist holds a permit issued by the State Board
of Dental Examiners for the procedure being performed.
(3)
Clinical Requirements. Each dentist must
meet the following clinical requirements for utilization of parenteral conscious
sedation:
[
(A)
Patient Evaluation. Patients subjected to parenteral
conscious sedation must be suitably evaluated prior to the start of any sedative
procedure. In healthy or medically stable individuals (ASA I, II) this may
be simply a review of their current medical history and medication use. However,
with individuals who may not be medically stable or who have a significant
health disability (ASA III, IV) consultation with their primary care physicians
or consulting medical specialists regarding potential procedure risk or special
monitoring requirements should be considered.
[
(B)
Pre-procedure preparation, informed consent:
[
(i)
the patient and/or guardian must be advised
of the procedure associated with the delivery of any sedative agents and the
appropriate informed consent must be obtained;
(ii)
if inhalation equipment is used in conjunction
with parenteral conscious sedation, the equipment must be evaluated for proper
operation and delivery of inhalation agents prior to use on each patient;
(iii)
determination of adequate oxygen supply
must be completed prior to use with each patient;
(iv)
baseline vital signs should be obtained;
(v)
pre-treatment physical evaluation must
be performed as deemed appropriate;
(vi)
specific dietary restrictions must be
delineated based on the technique used and patient's physical status;
(vii)
appropriate verbal or written instructions
regarding the procedure must be given to the patient and/or guardian;
(viii)
an intravenous line must be established
and secured throughout a procedure utilizing an intravenous conscious sedation
technique and should be maintained with other parenteral conscious sedation
techniques when the patient's physical or medical condition warrants, except
as provided in subparagraph (F) of this paragraph.
(C)
Personnel Requirements and Equipment:
[
(i)
during the administration of parenteral
conscious sedation the dentist and at least one member of the assistant staff
who is currently competent in Basic Life Support (BLS) must be present;
(ii)
any inhalation equipment utilized in conjunction
with parenteral conscious sedation must have a fail safe system that is appropriately
checked and calibrated;
(iii)
if nitrous oxide and oxygen delivery
equipment capable of delivering less than 25% oxygen is used, an in-line oxygen
analyzer must be utilized;
(iv)
the inhalation equipment must have an
appropriate nitrous oxide/oxygen scavenging system;
(v)
regardless of the sedation/anesthesia technique,
the ability of the provider and/or the facility to deliver positive pressure
oxygen must be maintained.
(D)
Monitoring and Documentation. Maintain personal supervision
of the patient during the induction of parenteral conscious sedation and during
maintenance of parenteral conscious sedation for a period of time necessary
to establish pharmacologic and physiologic vital sign stability. When a Certified
Registered Nurse Anesthetist (CRNA) provides the parenteral conscious sedation
care, he/she shall be under the direct supervision of the dentist in the dental
office. Delegation of personal supervision may occur if a second dentist or
physician anesthesiologist is delivering the anesthesia care.
[
(i)
Oxygenation. Color of mucosa, skin or blood
shall be continually evaluated. Oxygen saturation shall be evaluated continuously
by pulse oximetry except as provided in subparagraph (F) of this paragraph.
(ii)
Ventilation. Must perform observation
of chest excursions and/or auscultation of breath sounds.
(iii)
Circulation.
(I)
Shall take and record blood pressure and pulse
continually at least every 10 minutes;
(II)
Shall perform continuous EKG monitoring of
all patients with electrocardioscopy, except as provided in subparagraph (F)
of this paragraph. of this section.
(iv)
Documentation. A written time-oriented
anesthetic record must be maintained. Individuals present during the administration
of parenteral conscious sedation shall be documented.
(E)
Recovery and Discharge.
[
(i)
positive pressure oxygen and suction equipment must
be immediately available in the recovery area and/or operatory;
[
(ii)
continual monitoring of vital signs when the sedation/anesthesia
is no longer being administered; i.e., the patient must have continuous supervision
until oxygenation, ventilation and circulation are stable and the patient
is appropriately responsive for discharge from the facility;
[
(iii)
the dentist must determine and provide
for documentation that oxygenation, ventilation, circulation, activity, skin
color and level of consciousness are appropriate and stable prior to discharge;
(iv)
must provide explanation and documentation
of postoperative instructions to patient and/or a responsible adult at time
of discharge;
(v)
the dentist must determine that the patient
has met discharge criteria prior to leaving the office.
(F)
Special situations include multiple/combination techniques
and single dosage techniques (IN, IM and SC) and types of special patients.
In selected circumstances, parenteral conscious sedation may be utilized without
establishing an indwelling intravenous line or continuous EKG monitoring with
electrocardioscopy or pulse oximerty. These circumstances include sedation
for very brief procedures; young children managed entirely by non-intravenous
techniques; or the establishment of intravenous access, EKG monitoring, or
pulse oximetry after sedation has been induced due to poor patient cooperation.
Vital sign monitoring and IV access during special situations should in as
far as possible adhere to generally accepted standards of care. When these
situations occur, the dentist responsible for administering parenteral conscious
sedation shall document the reasons preventing the recommended preoperative
or intraoperative management.
[
(G)
Emergency Management.
[
(i)
the sedation/anesthesia permit holder/provider
is responsible for the anesthetic management, adequacy of the facility and
treatment of emergencies associated with the administration of parenteral
conscious sedation, including immediate access to pharmacologic antagonists
and equipment for establishing a patent airway and providing positive pressure
ventilation with oxygen;
(ii)
advanced airway equipment, resuscitation
medications must be available.
(iii)
a defibrillator should be immediately
available when ASA I and ASA II status patients are consciously sedated and,
a defibrillator must be immediately available when ASA III and ASA IV status
patients are consciously sedated.
(c)
Parenteral deep sedation and/or general anesthesia. To
induce and maintain
parenteral
deep sedation/general anesthesia on
patients having dental/oral and maxillofacial surgical procedures in the State
of Texas, the following requirements must be met:
(1)
Professional Requirements:
[
(A)
Each dentist wishing to utilize either
of these techniques must be permitted by the State Board of Dental Examiners
(SBDE) to deliver parenteral deep sedation and/or general anesthesia after
having met the education requirements as detailed in rule 109.174 (g)(3) of
this title (relating to Sedation/Anesthesia Permit).
(B)
Parenteral deep sedation/general anesthesia
shall be induced and maintained by a dentist licensed by the State of Texas
and practicing in Texas, a physician anesthesiologist licensed by the Texas
State Board of Medical Examiners, or a Certified Registered Nurse Anesthetist
(CRNA) licensed in Texas.
(2)
Standard of care requirements. Each dentist
must maintain the minimum standard of care as detailed in rule 109.173 of
this title (relating to Minimum Standard of Care) and shall in addition:
[
(A)
adhere to the clinical requirements as detailed in
paragraph (3) of this subsection;
[
(B)
maintain a written parenteral deep sedation and/or
general anesthesia consent for each dental patient on whom each procedure
is performed, such consent shall specify that the risks related to the procedure
include cardiac arrest, brain injury and death:
[
(C)
maintain a time oriented, written anesthetic record
which shall record dosages of anesthetic agents utilized and shall include
physiologic vital sign monitoring during the course of the procedure;
[
(D)
maintain under continuous direct supervision
a minimum of two auxiliary personnel who shall be capable of reasonably assisting
in procedures, problems, and emergencies incident to the use of parenteral
deep sedation and/or general anesthesia;
(E)
maintain current certification in basic
cardiopulmonary resuscitation for the assistant staff by having them pass
a course sponsored by the American Heart Association or the American Red Cross;
(F)
not allow a parenteral deep sedation and/or
general anesthesia procedure to be performed in his/her office by a Certified
Registered Nurse Anesthetist (CRNA) unless the dentist holds a permit issued
by the State Board of Dental Examiners for the procedure being performed.
(3)
Clinical Requirements. Each dentist must
meet the following clinical requirements for utilization of parenteral deep
sedation and/or general anesthesia:
[
(A)
Patient Evaluation. Patients subjected to parenteral
deep sedation/general anesthesia must be suitably evaluated prior to the start
of any sedative/anesthetic procedure. In healthy or medically stable individuals
(ASA I, II) this may be simply a review of their current medical history and
medication use. However, with individuals who may not be medically stable
or who have a significant health disability (ASA III, IV), consultation with
their primary care physician or consulting medical specialist regarding potential
procedure risk or special monitoring should be considered.
[
(B)
Pre-Procedure preparation, informed consent:
[
(i)
the patient and/or guardian must be advised
of the procedure associated with the delivery of any sedative agents and the
appropriate informed consent should be obtained;
(ii)
if inhalation equipment is used in conjunction
with parenteral deep sedation and/or general anesthesia, the equipment must
be evaluated for proper operation and delivery of inhalation agents prior
to use on each patient;
(iii)
determination of adequate oxygen supply
must be completed prior to use with each patient;
(iv)
baseline vital signs should be obtained;
(v)
pre-treatment physical evaluation should
be performed as deemed appropriate;
(vi)
specific dietary restrictions must be
delineated based on technique used and patient's physical status;
(vii)
appropriate verbal or written instructions
regarding the procedure must be given to the patient and/or guardian;
(viii)
an intravenous line which is secured
throughout the procedure must be established, except as provided in subparagraph
(F) of this paragraph..
(C)
Personnel and Equipment Requirements:
[
(i)
a provider permitted to administer parenteral
deep sedation and/or general anesthesia shall be designated to be in charge
of the administration of anesthesia care;
(ii)
two additional individuals who are currently
certified in basic cardiopulmonary resuscitation or its equivalent, one of
whom is trained in patient monitoring shall be present for the delivery of
anesthesia care;
(iii)
when the same individual administering
the parenteral deep sedation and/or general anesthesia is performing the dental/oral
and maxillofacial procedure, one of the additional two individuals present
for the delivery of anesthesia care must monitor the patient and record required
information on the anesthesia record;
(iv)
equipment suitable to provide advanced
airway management and advanced life support should be on premises and available
for use.
(v)
any inhalation equipment utilized in conjunction
with parenteral deep sedation/general anesthesia must have a fail safe system
that is appropriately checked and calibrated.
(vi)
if nitrous oxide/oxygen delivery equipment
capable of delivering less than 25% oxygen is used, an in-line oxygen analyzer
must be utilized.
(vii)
the inhalation equipment must have an
appropriate nitrous oxide/oxygen scavenging system.
(viii)
regardless of the sedation/anesthesia
technique, the ability of the provider and/or the facility to deliver positive
pressure oxygen must be maintained.
(D)
Monitoring and Documentation. Maintain personal supervision
of the patient during the induction and maintenance of parenteral deep sedation
and/or general anesthesia and during maintenance of parenteral deep sedation
and/or general anesthesia for a period of time necessary to establish pharmacologic
and physiologic vital sign stability. When a Certified Registered Nurse Anesthetist
(CRNA) provides the anesthesia care, he/she shall be under the direct supervision
of the dentist in the dental office. Delegation of personal supervision may
occur if a second dentist or physician anesthesiologist is delivering the
anesthesia care.
[
(i)
Oxygenation. Color of mucosa, skin or blood
shall be continually evaluated. Oxygenation saturation shall be evaluated
continuously by pulse oximetry;
(ii)
Ventilation. Intubated patient - must
auscultate breath sounds and monitor of end-tidal CO2. Non-intubated patient
- auscultation of breath sounds, observation of chest excursions and/or monitoring
of end-tidal CO2;
(iii)
Circulation. Continuous EKG monitoring
of all patients throughout the procedure with electrocardioscopy shall occur.
Shall record blood pressure and pulse continually at least every five minutes;
(iv)
Temperature. A device capable of measuring
body temperature should be readily available, if needed, during the administration
of parenteral deep sedation/general anesthesia. When agents implicated in
precipitating malignant hyperthermia are utilized, continual monitoring of
body temperature must be performed;
(v)
Documentation. A written time-oriented
anesthetic record must be maintained. Individuals present during the administration
of parenteral deep sedation/general anesthesia shall be documented.
(E)
Recovery and Discharge:
[
(i)
oxygen and suction equipment must be immediately
available in the recovery area and/or operatory;
(ii)
continual monitoring of vital signs when
the anesthetic is no longer being administered, i.e., the patient must have
continuous supervision until oxygenation, ventilation, circulation and temperature,
as indicated, are stable and the patient is appropriately responsive for discharge
from the facility;
(iii)
the dentist must determine and document
that oxygenation, ventilation, circulation activity, skin color, level of
consciousness and temperature, as indicated, are stable prior to discharge;
(iv)
must provide explanation and documentation
of post-operative instructions to patient and/or a responsible adult at the
time of discharge.
(v)
the dentist must determine and provide
for documentation that the patient has met discharge criteria prior to leaving
the office.
(F)
Special situations include multiple/combination techniques
single dosage techniques (IN, IM and SC) and types of special patients:
[
(i)
In selected circumstances, parenteral deep
sedation/general anesthesia may be utilized without first establishing an
indwelling intravenous line. These circumstances include parenteral deep sedation/general
anesthesia for very brief procedures, or brief periods of time, which, for
example, may occur in some pediatric patients; or the establishment of intravenous
access after parenteral deep sedation/general anesthesia has been induced
due to poor patient cooperation. Vital sign monitoring and IV access during
special situations should in as far as possible adhere to generally accepted
standards of care. When these situations occur, the dentist responsible for
administering parenteral deep sedation/general anesthesia shall document the
reasons preventing the recommended preoperative of intraoperative management.
(ii)
Due to the fact that some dental patients
undergoing parenteral deep sedation/general anesthesia are mentally and/or
physically challenged, it is not always possible to suitably evaluate these
patients prior to administering care. When these situations occur, the dentist
responsible for administering the parenteral deep sedation/general anesthesia
shall document the reasons preventing the recommended preoperative management.
(G)
Emergency Management:
[
(i)
the anesthesia permit holder/provider is
responsible for the anesthetic management, adequacy of the facility and treatment
of emergencies associated with the administration of parenteral deep sedation
and/or general anesthesia including immediate access to pharmacologic antagonists
and equipment for establishing a patent airway and providing positive pressure
ventilation with oxygen;
(ii)
advanced airway equipment, resuscitation
medications and a defibrillator must also be immediately available;
(iii)
appropriate pharmacologic agents must
be immediately available if known triggering agents of malignant hyperthermia
are part of the anesthesia plan.
This agency hereby certifies that the proposal
has been reviewed by legal counsel and found to be within the agency's legal
authority to adopt.
Filed with the Office of the Secretary of State, on
April 5, 1999.
TRD-9902008
Douglas A. Beran, Ph.D.
Executive Director
State Board of Dental Examiners
Earliest possible date of adoption: May 16, 1999
For further information, please call: (512) 463-6400
22 TAC §109.500
The State Board of Dental Examiners proposes new Subchapter
T, Agreements with Non-Dentists, new §109.500, concerning management
service agreements.
Douglas A. Beran, Executive Director, State Board of Dental Examiners,
has determined that for the first five-year period the rule is in effect there
will be no fiscal implications for state or local government as a result of
enforcing the rule.
Mr. Beran has determined that for each year of the first five years the
rule is in effect the public benefit anticipated as a result of enforcing
the rule will be to clarify the activities that individuals or entities having
management service contracts or agreements with a dentist or an organization
providing dental services will result in the contract management practicing
dentistry in violation of the Dental Practice Act.
It is unknown if there will be any fiscal implications for small businesses.
Should such costs be incurred they will not be of such magnitude to impact
the economic viability of a small business. Therefore the SBDE has determined
that compliance with the proposed new rule will not have an adverse economic
impact on small businesses as the cost of compliance, if any, will be minimal.
Comments on the proposal may be submitted to Mei Ling Clendennen, Executive
Assistant, State Board of Dental Examiners, 333 Guadalupe, Tower 3, Suite
800, Austin, Texas 78701, 512-463-6400 To be considered all comments must
be received by the State Board of Dental Examiners on or before May 17, 1999.
The new rule is proposed under Texas Government Code, §2001.021
et. seq.; Texas Civil Statutes, Article 4543 §2 and 4551d which provide
the State Board of Dental Examiners with the authority to adopt and promulgate
rules consistent with the Dental Practice Act, and Article 4551a which defines
the practice of dentistry.
The proposed new rule does not affect other statutes, articles, or codes.
§109.500.Management Service Agreement.
(a)
For the purposes of this rule, the term dentist shall include
the following:
(1)
a dentist licensed by the State Board of Dental Examiners;
(2)
a professional corporation wholly owned by one or
more dentists;
(3)
other entities composed of wholly owned by, or controlled
by a dentist or dentists.
(b)
Any dentist entering into any contract, partnership or
other agreement which allows any person other than a dentist any one or more
of the following rights, powers or authorities shall be presumed to have violated
the provisions of the Dental Practice Act, Article 4551a regarding managing,
controlling, attempting to control, influencing, attempting to influence or
otherwise interfering with the exercise of a dentist's independent professional
judgment regarding the diagnosis or treatment of any dental disease, disorder
or physical condition:
(1)
controlling, owning or setting any conditions for access
to or the specific contents of dental records of patients of a dentist.
(2)
setting a maximum or other standardized time for the
performance of specific dental procedures.
(3)
placing any limitations or requirements on treatments,
referrals, or consultations except those based on the professional judgment
of the dentist.
(4)
limiting or imposing requirements concerning the type
or scope of dental treatment, procedures or services which may be recommended,
prescribed, directed or performed, except that a dentist may limit the dentist's
practice or the practice of a dentist employed by or contracting with the
dentist to certain procedures or the treatment of certain dental diseases.
(5)
limiting or imposing requirements concerning the supplies,
instruments or equipment deemed reasonably necessary by a dentist to provide
diagnoses and treatment of the patients of the dentist.
(6)
limiting or imposing requirements for the professional
training deemed necessary by the dentist to properly serve the patients of
the dentist.
(7)
directing or influencing the selection of specific
diagnostic examinations and treatment or practices regarding patients without
due regard to the recommended diagnostic examinations and treatment agreed
upon by the dentist and the patient, except that a dentist having the responsibility
for training or supervising another dentist may reasonably limit treatment
or practices as a part of the training or supervision of a dentist based upon
the training and competency of a dentist to perform certain treatment or practices.
(8)
limiting or determining the duties of professional,
clinical or other personnel employed to assist a dentist in the practice of
dentistry.
(9)
establishing professional standards, protocols or
practice guidelines which in the professional judgment of the dentist providing
dental service to the dentist's patient, conflict with generally accepted
standards within the dental profession.
(10)
entering into a dental practice management agreement
providing for a fee determined by a percentage of the revenue earned by a
dentist from the dentist's practice.
(11)
placing limitations or conditions upon communications
that are clinical in nature with the dentist's patients.
(12)
precluding or restricting a dentist's ability to
exercise independent professional judgment over all qualitative and quantitative
aspects of the delivery of dental care.
(13)
scheduling patients of the dentist in a manner that
may have the effect of discouraging new patients from coming into the dentist's
practice, or postponing future appointments or that give scheduling preference
to an individual, class or group.
(14)
penalizing a dentist for reporting violations of
a law regulating the practice of dentistry.
(15)
conditioning the payment of fees to a dentist or
the amount of management fees a dentist must pay, on the referral of patients
to other health care providers specified by a non-dentist, or collecting a
management fee that is not reasonably related to the fair market value of
services provided.
(c)
The entry into one or more of the following agreements
by a dentist shall not be presumed to have violated the Texas Dental Practice
Act, Article 4551a, Section (8):
(1)
leases, mortgages, ownership agreements or other arrangements
regarding use of space for dental offices, based on a set, non percentage
fee reasonably related to the fair market value of the office space provided
at the time the lease or other arrangement is entered into.
(2)
agreements regarding the purchase, sale, financing
or lease of dental equipment, instruments and supplies so long as the dentist
maintains the complete care, custody, and control of the dental instruments
and supplies and the lease does not provide for a payment or fee based upon
a percentage of the revenue received by the dentist, or the dental practice.
(3)
agreements providing for accounting, bookkeeping,
investment or similar financial services.
(4)
the financing, lease, use or ownership of non-dentist
business equipment such as telephones, computers, software, and general office
equipment at reasonable, market related fees.
(5)
services regarding the pledge, collection or sale
of accounts receivable from patients.
(6)
agreements regarding billing and collection services.
(7)
advertising and marketing services so long as the
dentist remains solely responsible for the content of any advertising or marketing
services and for ensuring that such conform to all applicable legal requirements.
(8)
agreements regarding consulting, professional development,
business practices and other advisory agreements which do not limit the dentist's
ability to use the dentist's independent professional judgment regarding the
diagnosis or treatment of any dental disease, disorder or physical condition.
(9)
employment agreements which specify that the dentist
shall continue to have the right to use the dentist's independent professional
judgment regarding the diagnosis or treatment of any dental disease, disorder
or physical condition, provided that in practice the dentist is allowed to
use the dentist's professional judgment.
(d)
The provisions of subsection (c) of this section herein
may be rebutted and the entry into these agreements or other undertakings
may be found to be in violation of the Dental Practice Act if it can be shown
that the agreements or other undertakings result in the control, attempt to
control, influence, attempt to influence or otherwise interfere with the exercise
of a dentist's independent professional judgment regarding the diagnosis or
treatment of any dental disease, disorder or physical condition.
(e)
This rule shall not be applicable to dentists or others
covered by Article 4551b, entitled Exceptions, Article 4551m, regarding administration
of an estate and continuation of practice nor Article 4551n regarding employment
of dentists.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of the Secretary of State, on
April 5, 1999.
TRD-9902009
Douglas A. Beran, Ph.D.
Executive Director
State Board of Dental Examiners
Earliest possible date of adoption: May 16, 1999
For further information, please call: (512) 463-6400
22 TAC §115.20
The State Board of Dental Examiners proposes amendments to
§115.20, concerning the Dental Hygiene Advisory Committee its purpose
and composition.
Douglas A. Beran, Executive Director, State Board of Dental Examiners,
has determined that for the first five-year period the rule is in effect there
will be no fiscal implications for local government as a result of enforcing
the rule; however, for state government, there will be an annual fiscal implication
of approximately $720 compensatory per diem and $2,400 transportation expenses
for members of the Dental Hygiene Advisory Committee.
Mr. Beran has determined that for each year of the first five years the
rule is in effect the public benefit anticipated as a result of enforcing
the rule will be that the Dental Hygiene Advisory Committee may be continued
in existence for four years and that the committees performance will be reviewed
annually by the State Board of Dental Examiners. The Dental Hygiene Advisory
Committee will advise the State Board of Dental Examiners on matters relating
to dental hygiene and any rule proposed by the State Board of Dental Examiners
relating to the practice of dental hygiene will be reviewed and commented
upon by the Dental Hygiene Advisory Committee.
There will be no effect on small and large business and on persons who
are required to comply with the rule as proposed.
Comments on the proposal may be submitted to Mei Ling Clendennen, Executive
Assistant, State Board of Dental Examiners, 333 Guadalupe, Tower 3, Suite
800, Austin, Texas 78701, 512-463-6400. To be considered all comments must
be received by the State Board of Dental Examiners on or before May 17, 1999.
The amended rule is proposed under Texas Government Code, §2001.021
et. seq.; Texas Civil Statutes, Article 4543 §2 and 4551d which provide
the State Board of Dental Examiners with the authority to adopt and promulgate
rules consistent with the Dental Practice Act, and Article 4551e, §4A,
which establishes the Dental Hygiene Advisory Committee and specifies its
duties.
The proposed amended rule does not affect other statutes, articles, or
codes, except for Texas Government Code §2110 which addresses advisory
committees in general.
§115.20.Dental Hygiene Advisory Committee - Purpose and Composition.
(a)
The Dental Hygiene Advisory Committee is established pursuant
to Texas Civil Statutes, Article 4551e, §4A, for the purpose of advising
the Board on matters relating to dental hygiene. [
(b)
The Board shall annually evaluate the Committee's work,
its usefulness, and the costs related to the Committee's work to include agency
staff time in support of the Committee's activities. Reimbursement of costs
shall be determined as set out in the General Appropriations Act and under
Article 4551e, §4A, .
(c)
The Committee shall elect from among its members a presiding
officer who shall
serve for one year and who shall
report to the
Board on Committee activities as may be required, but no less often than annually
[
(d)
The Committee is abolished on
September 1, 2003,
[
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of the Secretary of State, on
April 5, 1999.
TRD-9902010
Douglas A. Beran, Ph.D.
Executive Director
State Board of Dental Examiners
Earliest possible date of adoption: May 16, 1999
For further information, please call: (512) 463-6400
Chapter 153.
Provisions of the Texas Appraiser Licensing and Certification Act
22 TAC §153.18
The Texas Appraiser Licensing and Certification Board proposes
an amendment to §153.18, relating to continuing education required for
the renewal of an appraiser trainee authorization. The amendment will clarify
and resolve confusion as to the number of classroom hours required to be devoted
to the Uniform Standards of Professional Appraisal Practice (USPAP) required
for the third, fifth, seventh, etc. renewals, and increase that amount to
15 hours.
Renil C. Liner, Commissioner, Texas Appraiser Licensing and Certification
Board, has determined that for the first five-year period the section is in
effect there will be no fiscal implications for state or local government
as a result of enforcing or administering the rule.
Mr. Liner also has determined that for each year of the first five years
the section is in effect the public benefit anticipated as a result of enforcing
the section will be for appraiser trainees to be better educated in the Uniform
Standards of Professional Appraisal Practice (USPAP)which will result in more
competent and knowledgeable appraisals which in tern will protect financial
institutions and the public. There will be no effect on small businesses.
There is no anticipated economic cost to persons who are required to comply
with the section as proposed.
Comments on the proposal may be submitted Renil C. Liner, Commissioner,
Texas Appraiser Licensing and Certification Board, P.O. Box 12188 Austin,
Texas 78711-2188.
The amendment is proposed under the Powers and Duties of the
Board, Texas Appraiser Licensing and Certification Act, §5 (Texas Civil
Statutes, Article 6573a.2), which provides the board with authority to adopt
rules. Section 14, Certificate and License Renewal, and Section 17, Appraiser
Trainees, will be affected by the proposal.
§153.18.Appraiser Continuing Education.
(a)
(No change.)
(b)
Renewing an Appraiser Trainee Authorization. As a condition
for renewing an appraiser trainee authorization, a trainee must successfully
complete educational courses during the one-year period preceding the expiration
of the appraiser trainee authorization being renewed. The courses must comply
with the fundamental education requirements for application for licensing
and certification set out is §153.13 (e)-(n) of this title (relating
to Educational Requirements):
(1)-(2)
(No change.)
(3)
Beginning with the third annual renewal, every other
annual renewal (third, fifth, seventh, etc.) must include a minimum of
15
[
(c)-(d)
(No change.)
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of the Secretary of State, on
April 1, 1999.
TRD-9901962
Renil C. Liner
Commissioner
Texas Appraiser Licensing and Certification Board
Proposed date of adoption: May 16, 1999
For further information, please call: (512) 465-3950
22 TAC §153.22
The Texas Appraiser Licensing and Certification Board proposes
new §153.22, License Holder's Responsibility to the Board. New §153.22
is being added to clarify that all licensees are subject to all provisions
of the Act, and to provide that all licensees and those applying for renewals,
must respond to inquiries of the Board within 20 days and comply with final
actions and orders of the board or be subject to disciplinary action.
Renil C. Liner, Commissioner, Texas Appraiser Licensing and Certification
Board, has determined that for the first five-year period the section is in
effect there will be no fiscal implications for state or local government
as a result of enforcing or administering the rule.
Mr. Liner also has determined that for each year of the first five years
the section is in effect the public benefit anticipated as a result of enforcing
the section will be for the board to more efficiently and effectively carry
out, respond to and resolve complaints and its other licensing and regulatory
duties, and to assure adherence to decisions and final orders of the board.
There will be no effect on small businesses. There is no anticipated economic
cost to persons who are required to comply with the section as proposed.
Comments on the proposal may be submitted to Renil C. Liner, Commissioner,
Texas Appraiser Licensing and Certification Board, P.O. Box 12188 Austin,
Texas 78711-2188.
The new section is proposed under the Powers and Duties of the
Board, Texas Appraiser Licensing and Certification Act, §5 (Texas Civil
Statutes, Article 6573a.2), which provides the board with authority to adopt
rules. Section 12, Enforcement Proceedings; Section 12A, Contested Case Proceedings;
and Section 14, Certificate and License Renewal, may be affected by the proposal.
§153.22.License Holder's Responsibility to the Board.
(a)
A certified or licensed appraiser or appraiser trainee
or applicant for renewal is subject to all provisions of the Act and board
rules and shall, within 20 days of notice to said individual's address of
record, unless granted a written extension by the board, answer all inquiries
concerning matters under the jurisdiction of the board, and shall fully comply
with final decisions and orders of the board.
(b)
Failure to comply with this section constitutes a separate
violation of §152.20(a)(2) of this title (relating to Guidelines for
Revocation, Suspension or Denial of Licensure or Certification).
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of the Secretary of State, on
April 1, 1999.
TRD-9901961
Renil C. Liner
Commissioner
Texas Appraiser Licensing and Certification Board
Proposed date of adoption: May 16, 1999
For further information, please call: (512) 465-3950
The effective date
of these sections shall be July 1, 1988.
]
this chapter
], shall have the following
meanings, unless the context clearly indicates otherwise.
or production of increased tolerance to pain in the conscious
patient
].
(8)
] [
Parenteral
]
Conscious Sedation - a minimally depressed level of consciousness that retains
the patient's ability to independently and continuously maintain an airway
and respond appropriately to physical stimulation and verbal command,
and that is
produced by a pharmacologic or non-pharmacologic method,
or a combination thereof.
In accord with this particular definition,
the drugs and/or techniques used should carry a margin of safety wide enough
to render unintended loss of consciousness unlikely. Further, patients whose
only response is reflex withdrawal from repeated painful stimuli would not
be considered to be in a state of conscious sedation.
(9)
] [
Parenteral
]
Deep Sedation -
an induced
[
A Controlled
] state of depressed
consciousness accompanied by partial loss of protective reflexes, including
the
inability to
continually maintain an airway independently and/or
respond purposefully to verbal command,
and is
produced by
a pharmacological or non-pharmacological method, or a combination thereof.
(2)
] Direct supervision - the
dentist responsible for the sedation/anesthesia procedure shall be physically
present in the office and shall be continuously aware of the patient's physical
status and well being.
(3)
] General anesthesia -
an induced
[
A controlled
] state of unconsciousness accompanied
by partial or complete loss of protective reflexes, including inability to
independently maintain an airway and respond purposefully
to physical
stimulation or
[
to
] verbal command,
and is
produced
by a pharmacological or non-pharmacological method or a combination thereof.
(4)
] Local anesthesia - the
elimination of sensations, especially pain, in one part of the body by the
[
topical application or
] regional injection of a drug.
(5)
] May [
or could
]
- indicates freedom or liberty to follow a
reasonable
[
suggested
] alternative.
(6)
] Must or shall - indicates
an imperative need and/or duty; an essential or indispensable item; mandatory.
(7)
] Nitrous Oxide/oxygen
inhalation conscious sedation - the administration by inhalation of a combination
of nitrous oxide and oxygen producing an altered level of consciousness that
retains the patient's ability to independently and continuously maintain an
airway and respond appropriately to physical stimulation and/or verbal command.
(10)
] Personal supervision
- the
provider
[
dentist
] responsible for the sedation/
anesthesia procedure shall be physically present in the room with the patient
at all times during the induction and maintenance of the procedure.
(11)
] Should - indicates the
recommended manner to obtain the standard; highly desirable.
Texas
] State Board of Dental
Examiners and practicing in Texas shall conduct
his/her
[
their
] practice in a manner consistent with that of a reasonable and
prudent dentist under the same or similar circumstances. Further, each dentist:
shall
] include, but shall not necessarily be limited to, blood
pressure and pulse/heart rate as may be indicated for each patient.
every two
years
] offered by either the American Heart Association or the American
Red Cross.
Shall obtain an informed consent in all situations where required by law.
]
Texas
] State Board of Dental Examiners
shall appoint advisory consultants for advice and recommendations to the Board
on permit requirements, applicant and facility approval.
From the effective date of these sections, each
]
A
dentist licensed by the [
Texas
] State Board of Dental Examiners
and practicing in Texas, who desires to utilize nitrous oxide/oxygen inhalation
conscious sedation, parenteral conscious sedation, and/or parenteral deep
sedation and general anesthesia, must obtain a permit [
of authorization
] from the [
Texas
] State Board of Dental Examiners for the
requested procedure.
Texas
] State Board
of Dental Examiners under previous rules prior to the effective date of this
section for the utilization of nitrous oxide/oxygen inhalation conscious sedation,
parenteral conscious sedation,
or parenteral deep sedation/general anesthesia,
except as described in subsection (d) of this section, shall remain permitted
provided that the appropriate fees have been paid and that the dentist has
a current license.
[
or general anesthesia may qualify for a new
permit.
]
Each holder of an existing
permit shall be required to complete and submit a new application for the
procedure(s) desired within one year from the effective date of these sections
to the Texas State Board of Dental Examiners. If the new permit application
is not received within this designated period, the prior permit shall be canceled.
Each new application shall be reviewed to determine if the permit holder meets
the "standard of care" requirements for the permit requested. If the requirements
are met, a new permit shall be issued. If the requirements are not met, the
permit applicant shall be notified and provided an appropriate period, at
the discretion of the Board, to correct the deficiency.
]
For new applicants who are otherwise properly qualified,
a temporary provisional permit may be issued for one year by the Board, based
solely upon the credentials contained in the application.
]
Prior to or after
the issuance of any permit, the Texas State Board of Dental Examiners may,
at its discretion, require an on-site office evaluation to determine if all
standards of these sections are being met.
]
Once a permit is issued, the Texas State Board of Dental
Examiners shall automatically renew the permit annually unless the holder
of said permit is informed by the Board that an evaluation of the permit is
required. Prior to an evaluation of an existing permit, the Board shall consider
factors to include patient complaints, morbidity, mortality, and advisory
consultant recommendations.
]
(h)
Annual dental license renewal certificates
shall include the annual permit renewal, except as provided for in (g) above,
and shall be assessed an annual renewal fee of $5.00 payable with the license
renewal beginning March 1 and thereafter. New permit issuances will be charged
a $25.00 fee, payable with the application for permit, beginning March 1,
1992.
]
Each dentist wishing to utilize this technique must produce
satisfactory evidence of completion of a didactic and clinical course of instruction
in this technique. Such courses of instruction shall:
]
(i)
be directed by qualified instructors with
advanced education in comprehensive pain control and with broad clinical experience
in this technique;
]
(ii)
include a minimum of four hours of didactic
work in pharmacodynamics of nitrous oxide/oxygen inhalation conscious sedation;
]
(iii)
include a minimum of six hours of clinical
experience under personal supervision.
]
Each dentist must produce satisfactory
evidence of completion of a continuing education course in the nitrous oxide
oxygen inhalation/ conscious sedation which includes the prevention and management
of emergencies in the dental office; or,
]
(C)
Each dentist must have successfully completed
qualifications governing the use of parenteral conscious sedation as noted
in subsection (b) of this section or deep sedation/general anesthesia as noted
in subsection (c) of this section.
]
Each dentist must maintain the
minimum standard of care as noted in 109.173 of this title (relating to Minimum
Standard of Care).
]
Each dentist shall induce, monitor, and provide continuous
personal supervision of the inhalation conscious sedation procedure, or the
dentist shall induce and may delegate under direct supervision, as defined
in Rule 109.172, the monitoring of the nitrous oxide inhalation conscious
sedation procedure to a dental auxiliary who has been certified by the Board.
Certification is obtained by successful completion of a written examination
offered by the Board on said subject.
]
parenteral
conscious sedation shall be induced and maintained by a dentist licensed by
the State of Texas and practicing in Texas, a physician anesthesiologist licensed
by the Texas State Board of Medical Examiners, or a Certified Registered Nurse
Anesthetist licensed in Texas (see paragraph (3) (G) of this subsection).
]
Professional requirements are as follows:
]
has satisfactorily completed
an intensive course that meets the "Guidelines for Teaching the Comprehensive
Control of Pain and Anxiety in Dentistry" published by the American Dental
Association Council on Dental Education for the parenteral conscious sedation
technique requested; or
]
has satisfactorily completed an
approved graduate program by the Commission on Dental Accreditation of the
American Dental Association where training to competency in parenteral conscious
sedation is a minimum standard required in the training guidelines (oral and
maxillofacial surgery, pediatric dentistry, periodontics, and some general
practice residencies); or
]
has satisfactorily completed qualifications governing the use of general anesthesia.
]
Standard of care requirements. Each dentist shall utilize
the following standard of care in addition to the minimum standards noted
in section 109.173 of this title (relating to Minimum Standard of Care) for
each parenteral conscious sedation procedure:
]
maintain an informed
conscious sedation consent by each dental patient on whom each procedure is
performed, which consent shall specify that the risks related to the procedure
include brain damage and death;
]
maintain an adequate written sedation record which shall include physiologic
vital sign monitoring during the course of the procedure;
]
maintain continuous direct supervision of the sedation procedure and patient
vital sign monitoring during the course of the procedure;
]
maintain current certification in basic cardiopulmonary resuscitation for
the assistant staff by having them pass a course sponsored by the American
Heart Association or the American Red Cross;
]
in utilizing parenteral
conscious sedation via an intravenous (IV) route of administration, the dentist
shall:
]
maintain personal supervision of the patient during the induction of conscious
sedation and for a period of time necessary to establish pharmacologic and
physiologic vital sign stability. When a certified registered nurse anesthetist
(CRNA) provides the conscious sedation care, he/she shall be under the direct
supervision of the dentist. Delegation of personal supervision may occur if
a second dentist or anesthesiologist is delivering the anesthesia care; and
]
utilize
visual and mechanical methods for vital sign monitoring which shall include,
but shall not necessarily be limited to, pulse rate, patient color texture,
blood pressure, respiration, blood and tissue oxygenation. Mechanical monitoring
shall include a minimum of pulse oximetry;
]
maintain direct supervision of auxiliary
personnel who shall be capable of reasonably assisting in procedures, problems,
and emergencies incident to the use of parenteral conscious sedation; and
]
not allow a parenteral
conscious sedation procedure to be performed in his/her office by a certified
registered nurse anesthetist (CRNA) unless the dentist holds a permit for
the procedure being performed issued by the Texas State Board of Dental Examiners.
]
Deep sedation/general
anesthesia shall be induced and maintained by a dentist licensed by the State
of Texas and practicing in Texas, a physician anesthesiologist licensed by
the Texas State Board of Medical Examiners, or a certified registered nurse
anesthetist licensed in Texas. (see paragraph (3) (G) of this subsection).
]
professional requirements are as follows:
]
has completed a minimum of one
year of advanced training in anesthesia and related academic subjects beyond
the undergraduate dental school level in a training program as described in
Part II of the "Guidelines for Teaching the Comprehensive Control of Pain
and Anxiety in Dentistry" of the American Dental Association Council on Dental
Education; or
]
has completed an
approved graduate program by the Commission on Dental Accreditation of the
American Dental Association where training to competency in general anesthesia
is a minimum standard in the training guidelines and maintains an equivalency
to one year of anesthesia training (oral and maxillofacial surgery); or
]
has completed the requirements for admission to and has passed the fellowship
exam in the American Dental Society of Anesthesiology.
]
Standard of care requirements.
Each dentist shall utilize the following standard of care in addition to the
minimum standards noted in 109.173 of this title (relating to Minimum Standard
of Care):
]
maintain
an informed deep sedation/general anesthesia consent by each dental patient
on whom this technique is performed, which consent shall specify that the
risks related to the procedure include brain damage and death;
]
maintain an adequate written anesthesia record which shall include, but shall
not necessarily be limited to, physiologic vital signs and all medications
administered during the course of the procedure;
]
maintain personal supervision of the patient during the induction and maintenance
of the anesthesia. When a certified registered nurse anesthetist (CRNA) provides
the deep sedation/anesthesia care, he/she shall be under the direct supervision
of the dentist. Delegation of personal supervision may occur if a second dentist
or anesthesiologist is delivering the deep sedation/anesthesia care. Vital
sign monitoring shall utilize visual and mechanical methods which shall include,
but shall not necessarily be limited to, pulse rate, patient color/texture,
blood pressure, respiration, blood and tissue oxygenation, and heart rhythm.
Mechanical monitoring shall include a minimum of pulse oximetry and an electrocardioscope.
]
maintain original certification in advanced cardiac
life support from a course sponsored by the American Heart Association. The
dentist shall require his/her assistant staff to maintain current certification
in basic life support as obtained by courses offered by the American Heart
Association or the American Red Cross;
]
maintain the necessary
emergency equipment and medications to perform advanced cardiac life support
under the guidelines of the American Heart Association (airway equipment,
required intravenous equipment and medication, defibrillator, electrocardioscope,
etc.
]
maintain a minimum of two auxiliary personnel who shall be capable of reasonably
assisting in procedures, problems, and emergencies incident to the use of
deep sedation/general anesthesia; and
]
not allow a deep
sedation/general anesthesia procedure to be performed on a dental patient
in his/her office by a certified registered nurse anesthetist (CRNA) unless
the dentist maintains a permit for deep sedation/general anesthesia issued
by the Texas State Board of Dental Examiners
]
Subchapter T. Agreements with Non-dentists
Chapter 115.
Extension of Duties of Auxiliary Personnel Dental Hygiene
The Committee shall
be comprised of a balanced representation between members of the dental hygiene
profession and consumers of services provided by the profession, pursuant
to Article 6252-33, V.T.C.S. This balance shall be achieved through voluntary
action of current members or through Board action in order to achieve the
required representation.
]
at or following the May schedule for Committee evaluation and review.
This report shall coincide with the Board's annual evaluation of the Committee's
work
].
May 1 of the third year following adoption of these rules
] unless
the Board affirmatively votes prior to that date to continue the existence
of the Committee.
Part VIII.
Texas Appraiser Licensing and Certification Board
7
] classroom hours devoted to the USPAP
, which
shall include the successful completion of an examination, in addition to
[
as part of the
] 30 classroom hours
of fundamental
real estate appraisal courses specifically approved by the board
;
Chapter 155.
Rules Relating to Standards of Practice