This chapter covers the use of anesthesia and sedation by dentists in Maryland for the practice of dentistry. The use of local anesthesia by a dentist is not governed by this chapter. The administration of anesthesia and sedation by dentists in hospitals licensed in Maryland is not governed by this chapter. Dentists are increasingly administering anesthesia and sedation on an outpatient basis. It is in the best interests of the public and the dentists of Maryland to require dentists who administer anesthesia and sedation to meet certain minimal training and competency standards. Requiring a dentist to obtain a permit before the dentist may administer anesthesia, sedation, or both is the best method to ensure that such administration is performed by competent dentists trained in the use of such techniques. In this chapter, the following terms have the meanings indicated. Terms Defined. “Accredited facility” means a facility holding current certification from: The Accreditation Association for Ambulatory Health Care (AAAHC); The Joint Commission on Accreditation of Healthcare Organizations (JCAHO); The Joint Commission Ambulatory Health Care Accreditation (JCAHCA); The American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF); or Their successor organizations. “Administration evaluation” means an evaluation by the Board or its designee to determine if an applicant for a permit demonstrates knowledge of management of emergencies and anesthesia techniques to a level that meets the requirements of this chapter. “Advanced Cardiac Life Support (ACLS)” means a certification that an individual has successfully completed an advanced cardiac life support course offered by the American Heart Association or other entity approved by the Board. “Anesthesia” means an artificially induced insensibility to pain usually achieved by the administration of gases or the use of drugs. “Anesthesia and sedation” means: Moderate sedation; Deep sedation; and General anesthesia. Anxiolysis. “Anxiolysis” means a drug-induced state, with or without nitrous oxide/oxygen to decrease anxiety, in which patients respond normally to tactile stimulation and verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are maintained and require no assistance. “Anxiolysis” includes a single dose of one sedative, narcotic, class of drugs, or medication prescribed by the treating dentist and taken the evening before a procedure or the morning of a procedure, or both, provided that the dosage complies with the definition of anxiolysis under §B(6)(a) of this regulation. “Anxiolysis” does not include the administering, prescribing, or dispensing of any other sedative, narcotic, class of drugs, or medication for the purpose of anesthesia by a dentist to a patient to be used for anesthesia or sedation, to be taken the evening before a procedure or the morning of a procedure. “Board” means the State Board of Dental Examiners. “Certified registered nurse anesthetist” means a registered nurse who is currently certified to practice nurse anesthesia in Maryland. “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. Cardiovascular function is usually maintained. “Dentist” means an individual who holds a current license to practice dentistry in Maryland. “Facility” means any location in which anesthesia or sedation is administered for the practice of dentistry. “Facility evaluation” means an on-site inspection by the Board or its designee to determine if a facility where the applicant proposes to provide anesthesia and sedation is adequately supplied, equipped, staffed, and maintained in a condition to support the provision of anesthesia and sedation services in a manner that meets the requirements of this chapter. “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, drug-induced depression, or changes in neuromuscular function. Cardiovascular function may be impaired. “General anesthesia administration permit” means a permit that was issued by the Board before January 4, 2010, that authorized the dentist to whom the permit was issued to administer general anesthesia for the practice of dentistry. “General anesthesia facility permit” means a permit that was issued by the Board before January 4, 2010, that authorized the administration of general anesthesia for the practice of dentistry in the facility named in the permit. “Incident” means dental treatment performed on a patient under moderate sedation, deep sedation, or general anesthesia with unforeseen complications. “Moderate enteral sedation” means a drug-induced depression of consciousness through the gastrointestinal tract or oral mucosa 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. “Moderate parenteral sedation” means a drug-induced depression of consciousness that bypasses the gastrointestinal tract or oral mucosa 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. “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 maintained. “Parenteral” means a technique of administration in which the drug bypasses the gastrointestinal tract, that is, through an intramuscular, intravenous, intranasal, submucosal, subcutaneous, or intraosseous technique. “Parenteral sedation administration permit” means a permit that was issued by the Board before January 4, 2010, that authorized the dentist to whom the permit was issued to administer parenteral sedation for the practice of dentistry. “Parenteral sedation facility permit” means a permit that was issued by the Board before January 4, 2010, that authorized the administration of parenteral sedation for the practice of dentistry in the facility named in the permit. “Pediatric Advanced Life Support (PALS)” means a certification that an individual has successfully completed a pediatric advanced life support course offered by the American Heart Association or other entity approved by the Board. “Physician” means a physician, including a doctor of osteopathy, who holds a current license to practice medicine in Maryland. “Renewal evaluation” means an on-site inspection by the Board or its designee before the renewal of a permit to determine if a facility where the applicant proposes to provide anesthesia and sedation is adequately supplied, equipped, staffed, and maintained in a condition to support the provision of anesthesia and sedation services in a manner that meets the requirements of this chapter. “Sedation” means the reduction of stress or excitement by the administration of a drug that has a soothing, calming, or tranquilizing effect. A permit is not required for a dentist to administer anxiolysis. The administering, prescribing, or dispensing of more than one type of sedative, narcotic, class of drug, or medication for the purpose of anesthesia to be taken the evening before a procedure, or the morning of a procedure, is not anxiolysis and shall require the appropriate anesthesia or sedation permit. A dentist who intends to administer anxiolysis shall indicate the intent to administer anxiolysis in the patient's records. A dentist who administers anxiolysis may not administer a dose that is inappropriate for a patient's: Age; Weight; Medical condition; Infirmities; or Other propensities. Medications used to produce anxiolysis may not exceed current limits set by the manufacturer for unmonitored use by the individual. A dentist who administers anxiolysis shall maintain a margin of safety and a level of consciousness that does not approach moderate sedation and other deeper states of sedation and general anesthesia. The following permits shall be issued by the Board: Class I permit that authorizes a dentist to use a nonparenteral anesthetic technique to attain the level of moderate sedation; Class II permit that authorizes a dentist to use: A parenteral anesthetic technique to attain the level of moderate sedation; and Any procedure allowed with a Class I permit; Class III permit that authorizes a dentist to use: An anesthetic technique to attain the level of deep sedation or general anesthesia; and Any procedure allowed under either a Class I permit or a Class II permit; and Class III dental school facility permit issued to a dental school that allows a dentist who holds the appropriate Class I, Class II, or Class III permit to administer anesthesia or sedation in a dental school recognized by the Commission on Dental Accreditation or its successor organization. The following certificates shall be issued to qualified dentists by the Board: Certificate to allow a physician or another dentist to administer anesthesia and sedation, which allows a physician or another dentist to administer anesthesia and sedation to a patient at a specific practice location; Certificate to allow a dentist to treat a patient at a practice location other than their own at which anesthesia and sedation is administered, which allows a dentist to treat a patient at a practice location other than their own in which anesthesia and sedation is administered; and Certificate to allow a certified registered nurse anesthetist to administer anesthesia and sedation, which allows a certified registered nurse anesthetist to administer anesthesia and sedation to a patient at a specific practice location. After January 4, 2010, a dentist may not administer an anesthetic technique in order to attain a level beyond anxiolysis for the practice of dentistry unless the dentist holds an appropriate Class I, II, or III permit issued by the Board. On a form provided by the Board, a dentist shall advise the Board of the name and address of each location where the dentist wishes to administer anesthesia and sedation. A dentist may not administer anesthesia and sedation unless the dentist has obtained the appropriate permit for each location. On a form provided by the Board, a dentist shall advise the Board of each location at which the dentist has ceased to administer anesthesia and sedation. The Board shall keep a record of: Each location for which a dentist has been granted a permit to administer anesthesia and sedation; and Each location at which a dentist has ceased to administer anesthesia and sedation. Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Therefore, practitioners intending to produce a given level of sedation shall be able to recover patients whose level of sedation becomes deeper than initially intended. Individuals administering moderate enteral sedation or moderate parenteral sedation shall be able to recover patients who enter a state of deep sedation or general anesthesia, while those administering deep sedation shall be able to recover patients who enter a state of general anesthesia. Training and evaluation guidelines shall reflect this concern. In addition to the requirements outlined in this regulation, in order to obtain a permit, a dentist shall also meet the requirements outlined in Regulations .09—.11 of this chapter. A permit may be issued to a dentist authorizing the use of moderate sedation, deep sedation, or general anesthesia at a specific practice location. Class I: Moderate Enteral Sedation Permit. To qualify for a Class I permit, an applicant shall successfully complete: A Board-approved course of instruction that documents training of at least 24 hours of didactic education plus 20 clinically oriented experiences that provide competency in oral and combination inhalation-oral moderate sedation; or A postdoctoral training program accredited by the Commission on Dental Accreditation or its successor organization that affords comprehensive and appropriate training necessary to administer and manage moderate enteral sedation. Clinically oriented experiences referred to in §D(1) of this regulation may include: Supervised administration; Observations of videotaped patients undergoing oral or combination inhalation-oral moderate sedation; or Human simulation. In addition to the requirements outlined in §D of this regulation, an applicant for a Class I permit shall: Hold current certification in either ACLS or PALS, which the permit holder may not allow to expire, or successfully complete a course approved by the Board that provides instruction on medical emergencies and airway management; Receive a successful evaluation by the Board or the Board's designee; Provide an affidavit to the Board indicating whether the applicant has ever treated a patient under deep sedation or general anesthesia with an incident; and Submit any other pertinent documents or information requested by the Board. An affidavit provided to the Board under §F(3) of this regulation, which indicates that the applicant has treated a patient under deep sedation or general anesthesia with an incident, shall include at least the following: The date of the incident; The name, age, and address of the patient; The patient's original complete dental records; The name and license number of the licensee and the name and address of all other persons present during the incident; The address where the incident took place; The preoperative physical condition of the patient; The type of anesthesia and dosages of drugs administered to the patient; The techniques used in administering the drugs; Any adverse occurrence including: The patient's signs and symptoms; The treatments instituted in response to adverse occurrences; The patient's response to the treatment; and The patient's condition on termination of any procedures undertaken; and A narrative description of the incident including approximate times and evolution of symptoms. Class II: Moderate Parenteral Sedation Permit. To qualify for a Class II permit, an applicant shall successfully complete: A Board-approved course of instruction that documents training of at least 60 hours of didactic instruction plus management of at least 20 dental patients, who may be simulated, per participant in moderate parenteral sedation techniques; or A postdoctoral training program accredited by the Commission on Dental Accreditation or its successor organization that affords comprehensive and appropriate training necessary to administer and manage moderate parenteral sedation. In addition to the requirements outlined in §§H and I of this regulation, an applicant for a Class II permit shall: Hold current certification in either ACLS or PALS, which the permit holder may not allow to expire; Receive a successful evaluation by the Board or the Board's designee; Provide an affidavit to the Board indicating whether the applicant has ever treated a patient under deep sedation or general anesthesia with an incident; and Submit any other pertinent documents or information requested by the Board. An affidavit provided to the Board under §I(3) of this regulation, which indicates that the applicant has treated a patient under deep sedation or general anesthesia with an incident, shall include the information contained in §G of this regulation. Class III: Deep Sedation and General Anesthesia Permit. To qualify for a Class III permit, an applicant shall have successfully completed: An advanced training program in anesthesia and related subjects beyond the undergraduate dental curriculum that is approved by the Board; or A postdoctoral training program accredited by the Commission on Dental Accreditation or its successor organization that affords comprehensive and appropriate training necessary to administer and manage deep sedation and general anesthesia. In addition to the requirements outlined in §I of this regulation, an applicant for a Class III permit shall: Hold current certification in either ACLS or PALS, which the permit holder may not allow to expire; Receive a successful evaluation by the Board or its designee; Provide an affidavit to the Board indicating whether the applicant has ever treated a patient under deep sedation or general anesthesia with an incident; and Submit any other pertinent documents or information requested by the Board. An affidavit provided to the Board under §L(3) of this regulation, which indicates that the applicant has treated a patient under deep sedation or general anesthesia with an incident, shall include the information contained in §G of this regulation. Class I Permit. To qualify for a Class I permit, the dentist who will perform the administration shall pass: An office inspection evaluation; A clinical evaluation consistent with the age level of the patients treated by the dentist; An evaluation of the dentist to safely administer sedation techniques; and An evaluation of the ability of the dentist to effectively respond to sedation related emergencies. The clinical evaluation required in §A of this regulation shall require the participation of the office staff. The clinical evaluation required by §A(2) of this regulation shall include evaluating treatment of at least the following: Laryngospasm; Foreign body airway obstruction; Emergency airway management; Emesis and aspiration; Acute allergic reaction; Bronchospasm; Angina; Conditions requiring advanced cardiac life support, including: Bradycardia; Tachycardia; Ventricular fibrillation; and Cardiac arrest; Hypotension; Hypoglycemia; Hypertension; Seizure; and Syncope. Class II or Class III Permit. To qualify for a Class II or Class III permit, the dentist who will perform the administration shall pass an administration evaluation that consists of an office inspection and clinical evaluation. The clinical evaluation required by §D(1) of this regulation shall: Require the participation of the clinical office staff; and Evaluate the technical competency of the dentist to: Safely administer moderate parenteral sedation, deep sedation, or general anesthesia; and Effectively respond to anesthesia related emergencies. The clinical evaluation required by §D(1) of this regulation shall include evaluating the treatment of at least the following: Laryngospasm; Foreign body airway obstruction; Emergency airway management; Emesis and aspiration; Acute allergic reaction; Bronchospasm; Angina; Conditions requiring advanced cardiac life support, including: Bradycardia; Tachycardia; Ventricular fibrillation; and Cardiac arrest; Hypotension; Hypoglycemia; Hypertension; Seizure; Syncope; and Venipuncture complications. In addition to the requirements outlined in Regulation .09 of this chapter, for a dentist to obtain a Class I, Class II, or Class III permit, each facility in which the dentist wishes to administer an anesthesia technique shall pass a facility evaluation in order to attain: A level beyond anxiolysis; Moderate enteral sedation; Moderate parenteral sedation; or Deep sedation and general anesthesia. Except as otherwise provided in this regulation, to qualify for a permit, the facility and the applicant shall pass an evaluation of facility equipment, medications, and clinical records to include at least the following: Oxygen and gas delivery system, backup system fail-safe; Gas storage facility; Safety indexed gas system; Suction and backup system; Auxiliary lighting system; Suitability of operating room: Size; Lighting; Communications; and EMT accessibility; Recovery area, including oxygen, suction, and visual and electronic monitoring, which may include the operating room; Appropriate emergency drugs; Nonexpired drugs; Appropriate devices to maintain an airway with positive pressure ventilation; Preoperative medical history and physical evaluation form; Anesthesia records, including monitoring and discharge records; Monitoring equipment, including pulse oximeter and blood pressure monitoring; Anesthesia and monitoring equipment to ensure they are in proper working order; Defibrillator or automated external defibrillator (AED); For deep sedation or general anesthesia in pediatric patients: A precordial stethoscope; A pretracheal stethoscope; or A capnograph; and For Class II and Class III permits: An electrocardiogram (EKG); A capnograph measuring device; and Pulse oximeter. In addition to the requirements outlined in §A of this regulation, to qualify for a permit, the dentist who will perform the administration and the dentist's staff shall be present in the operatory during the evaluation. An applicant for a permit may not transport anesthesia or sedation equipment from one dental office to another for facility examination purposes. A Board evaluator shall hold a permit at the same or higher level as the permit sought by the applicant being evaluated. To the extent practicable, a Board evaluator shall provide the results of the evaluation to the Board in writing within 7 days of an applicant’s evaluation. Either the Board or the Board’s Anesthesia Committee shall: Review the results of the evaluation; and Notify the applicant of the results in a timely manner. If requested, an applicant shall be provided with a copy of the evaluation provided to the Board. An applicant who fails either an administration evaluation or a facility evaluation twice shall be required to pay a fee equal to the renewal fee for the permit sought by the applicant before either the third evaluation or any subsequent evaluations. A dentist who has passed an administration and facility evaluation for a Class I, Class II, or Class III permit may receive a like permit for another facility or facilities if: The dentist holds an active Class I, Class II, or Class III permit for which the dentist has passed an administration and facility evaluation; and Each facility for which the dentist seeks another permit has at least one dentist who has passed an administration and facility evaluation for a like permit at that location within 2 years of the date of application for the additional permit. Alternatively, a dentist who has passed an administration and facility evaluation for a Class I, Class II, or Class III permit may receive a like permit for another facility or facilities if: The dentist holds an active Class I, Class II, or Class III permit for which the dentist has passed an administration and facility evaluation; and The dentist seeking the additional permit: Is present during a facility evaluation at which the dentist and the dentist's staff pass a facility evaluation; and Passes an evaluation, appropriate for the permit level, that includes simulated management of emergencies with the participation of the clinical office staff trained to handle emergencies. In addition to the requirements of §§A and B of this regulation, the dentist seeking the additional permit or permits shall: Submit to the Board an application on a form provided by the Board; and Pay the appropriate fee. Administration of moderate enteral sedation, moderate parenteral sedation, deep sedation, or general anesthesia to a patient requires at least the following appropriately trained individuals: The treating dentist; An individual trained and competent in basic life support or its equivalent to assist the treating dentist; and Another individual trained and competent in basic life support or its equivalent in close proximity to assist if needed. A dentist administering moderate enteral sedation, moderate parenteral sedation, deep sedation, or general anesthesia to a patient: May not leave the site until the patient: Is conscious; Is spontaneously breathing; Has stable vital signs; Is ambulatory with assistance; and Is under the care of a responsible adult; and May not induce a second patient until the first patient: Is conscious; Is spontaneously breathing; Has stable vital signs; Is ambulatory with assistance; and Is under the care of a responsible adult. A treating dentist who allows a physician, another dentist, or certified registered nurse anesthetist to administer moderate enteral sedation, moderate parenteral sedation, deep sedation, or general anesthesia under Regulation .31, .32, or .33 of this chapter shall ensure that the physician, dentist, or certified registered nurse anesthetist does not leave the site until the patient: Is conscious; Is spontaneously breathing; Has stable vital signs; Is ambulatory with assistance; and Is under the care of a responsible adult. A treating dentist who allows a physician, another dentist, or certified registered nurse anesthetist to administer moderate sedation, deep sedation, or general anesthesia shall ensure that the physician, dentist, or certified registered nurse anesthetist does not induce a second patient until the first patient: Is conscious; Is spontaneously breathing; Has stable vital signs; Is ambulatory with assistance; and Is under the care of a responsible adult. A dentist who held a current general anesthesia administration permit on January 4, 2010, may continue to administer anesthesia and sedation under the general anesthesia administration permit until the expiration of the permit only as provided in this regulation. A dentist who held a current parenteral sedation administration permit on January 4, 2010, may continue to administer moderate parenteral sedation under the parenteral sedation administration permit until the expiration of the permit only as provided in this regulation. A dentist who held a current general anesthesia administration permit on January 4, 2010, may administer anesthesia and sedation under the general anesthesia administration permit, consistent with a Class III permit, only in a facility for which the dentist holds a current general anesthesia facility permit. A dentist who held a current general anesthesia administration permit on January 4, 2010, and who wishes to administer general anesthesia in a facility for which the dentist does not hold a general anesthesia facility permit shall apply for and be issued a Class III permit for that site in accordance with Regulations .07—.11 of this chapter. A dentist who held a current parenteral sedation administration permit on January 4, 2010, may administer parenteral sedation under the parenteral sedation administration permit consistent with a Class II permit, only in a facility for which the dentist holds a current parenteral sedation facility permit. A dentist who held a current parenteral sedation administration permit on January 4, 2010, and who wishes to administer parenteral sedation at a facility for which the dentist does not hold a parenteral sedation facility permit, shall apply for and be issued a Class II permit for that site in accordance with Regulations .07—.11 of this chapter. A dentist whose general anesthesia administration permit has expired may not administer general anesthesia unless the dentist holds a Class III permit issued by the Board. A dentist whose parenteral sedation administration permit has expired may not administer parenteral sedation unless the dentist holds a Class II permit issued by the Board. General anesthesia facility permits and parenteral sedation facility permits in existence on January 4, 2010, shall expire as provided in this regulation. A general anesthesia facility permit issued to a dentist who does not hold a general anesthesia administration permit shall expire on January 4, 2010. A parenteral sedation facility permit issued to a dentist who does not hold a parenteral sedation administration permit shall expire on January 4, 2010. At least 120 days before the expiration of a general anesthesia administration permit the Board shall mail an application to each individual who holds a general anesthesia administration permit to convert the general anesthesia administration permit to a Class III permit. At least 120 days before the expiration of a parenteral sedation administration permit the Board shall mail an application to each individual who holds a parenteral sedation administration permit to convert the parenteral sedation administration permit to a Class II permit. A dentist who held a current general anesthesia administration permit and a general anesthesia facility permit on January 4, 2010, and who wishes to receive a Class III permit for a location for which the dentist holds a current general anesthesia facility permit, may receive a Class III permit for the location for which the dentist held a general anesthesia facility permit if the applicant: Submits to the Board at least 90 days before the expiration of the permit an application on a form provided by the Board; Passes a renewal evaluation in each facility for which the applicant wishes to receive a Class III permit; Pays the renewal fee set by the Board in COMAR 10.44.20; Provides an affidavit to the Board indicating whether the applicant, since the issuance of the original general anesthesia administration permit, has treated a patient under deep sedation or general anesthesia with an incident; Provides evidence satisfactory to the Board that the applicant meets the continuing education requirements outlined in Regulation .29 of this chapter; and Submits any other pertinent documents or information requested by the Board. An affidavit provided to the Board under §C(4) of this regulation, which indicates that the applicant has treated a patient under deep sedation or general anesthesia with an incident, shall include the information contained in Regulation .08G of this chapter. The evaluation outlined in §C(2) of this regulation shall consist of an evaluation of: Anesthesia and monitoring equipment to ensure they are in proper working order; Simulated management of emergencies with the participation of the clinical office staff trained to handle emergencies; and Drugs in the office to ensure that the applicant: Maintains the appropriate drugs on the premises; and Only utilizes drugs on the premises the dates of which have not expired. If an applicant returns an application to the Board at least 90 days before the expiration of the permit, and the Board is unable to approve or deny the application before the expiration of the permit through no fault of the applicant, the permit shall remain in effect until the Board: Issues the permit; or Denies issuance of the permit. Failure to receive the Board's application does not relieve a permit holder from the requirement to submit an application to the Board at least 90 days before the expiration of a permit. The Board may issue a Class III permit to an applicant for a specific practice location after the Board's review of: The applicant's application and accompanying affidavit; The applicant's qualifications; The evaluation; and Any other pertinent documents or information, including, but not limited to, patient complaints that may affect the applicant's ability to safely and effectively administer anesthesia and sedation. This regulation does not preclude the Board from taking disciplinary action against a dentist who holds a: General anesthesia administration permit; or Class III permit. A dentist who held a current parenteral sedation administration permit and a parenteral sedation facility permit on January 4, 2010, and who wishes to receive a Class II permit for the location for which the dentist holds a current parenteral sedation facility permit, may receive a Class II permit for the location for which the dentist held a parenteral sedation facility permit or permits if the applicant: Submits to the Board at least 90 days before the expiration of the permit: An application on a form provided by the Board; Written verification of inspection of the applicant's anesthesia and monitoring equipment from a recognized service company; and Written verification from the applicant that: Since the issuance of the parenteral sedation administration permit, the applicant and the appropriate individuals in the applicant's staff have completed training in basic life support and the handling of medical emergencies; The applicant maintains the appropriate drugs on the premises; and The applicant only utilizes drugs on the premises the dates of which have not expired; Pays the renewal fee set by the Board in COMAR 10.44.20; Provides an affidavit to the Board indicating whether the applicant, since the issuance of the original parenteral sedation administration permit, has treated a patient under deep sedation or general anesthesia with an incident; Provides evidence satisfactory to the Board that the applicant meets the continuing education requirements outlined in Regulation .29 of this chapter; and Submits any other pertinent documents or information requested by the Board. An affidavit provided to the Board under §J(3) of this regulation, which indicates that the applicant has treated a patient under deep sedation or general anesthesia with an incident, shall include the information contained in Regulation .08G of this chapter. The training in basic life support and the handling of emergencies outlined in §J(1)(c)(i) of this regulation shall be completed before the submission of each application. If an applicant returns an application to the Board at least 90 days before the expiration of a permit, and the Board is unable to approve or deny the application before the expiration of the permit through no fault of the applicant, the permit shall remain in effect until the Board: Issues the permit; or Denies issuance of the permit. Failure to receive the Board's application does not relieve a permit holder from the requirement to submit an application to the Board at least 90 days before the expiration of a permit. The Board may issue a Class II permit to an applicant for a specific practice location after the Board's review of: The applicant's application and accompanying affidavit; The applicant's qualifications; and Any other pertinent documents or information, including, but not limited to, patient complaints that may affect the applicant's ability to safely and effectively administer sedation. This regulation does not preclude the Board from taking disciplinary action against a dentist who holds a: Parenteral sedation administration permit; or Class II permit. A dentist with a general anesthesia administration permit or a parenteral sedation administration permit in existence on January 4, 2010, shall comply with Regulations .14, .26, .27, .30, .31, .32, and .34 of this chapter. To apply to obtain a permit, an applicant shall: Submit to the Board an application on a form provided by the Board; Pay the fee set by the Board in COMAR 10.44.20; and Provide evidence satisfactory to the Board that the applicant meets the qualifications for a Class I, Class II, or Class III permit. The Board may issue a Class I, Class II, or Class III permit to an applicant for a specific practice location after the Board's review of: The applicant's application and accompanying affidavit; The applicant's qualifications; The applicant's administration evaluation; The applicant's facility evaluation; and Any other pertinent documents or information including, but not limited to, patient complaints that may affect the applicant's ability to safely and effectively administer anesthesia and sedation. A permit expires on April 1 of the 5th year following the effective date of the permit. The Board shall mail a renewal application to each individual holding a Class I or Class II permit at least 180 days before the expiration of the permit. Before a Class I or Class II permit expires, an applicant may apply to renew the permit for an additional 5-year term if the applicant: Submits to the Board at least 90 days before the expiration of the permit: A renewal application on a form provided by the Board; Written verification of inspection of the applicant's anesthesia and monitoring equipment from a recognized service company; and Written verification from the applicant that: Since the issuance of the permit or the previous renewal of the permit, the applicant and the appropriate individuals on the applicant's office staff have completed training in basic life support and the handling of medical emergencies; The applicant maintains the appropriate drugs on the premises; and The applicant only utilizes drugs on the premises the dates of which have not expired; Pays the renewal fee set by the Board in COMAR 10.44.20; Provides an affidavit to the Board indicating whether the applicant, since the issuance of the original permit or renewal, whichever is later, has treated a patient under deep sedation or general anesthesia with an incident requiring admission to a hospital either for a period greater than 24 hours, or for purposes other than observation. Provides evidence satisfactory to the Board that the applicant meets the continuing education requirements outlined in Regulation .29 of this chapter; and Submits any other pertinent documents or information requested by the Board. An affidavit provided to the Board under §B(3) of this regulation, which indicates that the applicant has treated a patient under deep sedation or general anesthesia with an incident, shall include the information contained in Regulation .08G of this chapter. The training in basic life support and the handling of medical emergencies outlined in §B(1)(c)(i) of this regulation shall be completed before the submission of each application for renewal. If an applicant for the renewal of a Class I or Class II permit returns a renewal application to the Board at least 90 days before the expiration of the permit, and the Board is unable to approve or deny the application before the expiration of the permit through no fault of the applicant, the permit shall remain in effect until the Board: Renews the permit; or Denies renewal of the permit. Failure to receive the Board's renewal application does not relieve the permit holder from the requirement to submit a renewal application to the Board at least 90 days before the expiration of the permit. The Board may issue a renewal of a Class I or Class II permit to an applicant for a specific practice location after the Board's review of: The applicant's renewal application and accompanying affidavit; The applicant's qualifications; and Any other pertinent documents or information, including, but not limited to, patient complaints that may affect the applicant's ability to safely and effectively administer anesthesia and sedation. The Board shall mail a renewal application to each individual holding a Class III permit at least 180 days before the expiration of the permit. Before a permit expires, an applicant may apply to renew the permit for an additional 5-year term if the applicant: Submits to the Board, at least 90 days before the expiration of the permit, a renewal application on a form provided by the Board; Passes a renewal evaluation in each facility for which the applicant wishes to renew a permit; Pays the renewal fee set by the Board in COMAR 10.44.20; Provides an affidavit to the Board indicating whether the applicant, since the issuance of the original permit or renewal, whichever is later, has treated a patient under deep sedation or general anesthesia with an incident requiring admission to a hospital either for a period greater than 24 hours, or for purposes other than observation; Provides evidence satisfactory to the Board that the applicant meets the continuing education requirements outlined in Regulation .29 of this chapter; and Submits any other pertinent documents or information requested by the Board. An affidavit provided to the Board under §B(4) of this regulation, which indicates that the applicant has treated a patient under deep sedation or general anesthesia with an incident, shall include the information contained in Regulation .08G of this chapter. The renewal evaluation outlined in §B(2) of this regulation shall consist of an evaluation of an administration evaluation that consists of an office inspection and clinical evaluation. The clinical evaluation required by §D of this regulation shall: Require the participation of the clinical office staff; and Evaluate the technical competency of the dentist to: Safely administer general anesthesia, deep sedation, and moderate parenteral sedation; and Effectively respond to simulated anesthesia related emergencies with the participation of the clinical office staff trained to handle emergencies. The clinical evaluation outlined in §E of this regulation shall include evaluating the treatment of at least the following: Laryngospasm; Foreign body airway obstruction; Emergency airway management; Emesis and aspiration; Acute allergic reaction; Asthmatic attack; Bronchospasm; Angina; Conditions requiring advanced cardiac life support, including: Bradycardia; Tachycardia; Ventricular fibrillation; and Cardiac arrest; Hypotension; Hypoglycemia; Hypertension; Seizure; and Syncope. In addition to the requirements of §D of this regulation, a dentist who wishes to renew a Class III permit shall pass a facility evaluation of facility equipment, medications, and clinical records to include at least the following: Oxygen and gas delivery system, backup system, back-up system fail-safe; Gas storage facility; Safety indexed gas system; Suction and backup system; Auxiliary lighting system; Suitability of operating room: Size; Lighting; Communications; and EMT accessibility; Recovery area, including oxygen, suction, and visual and electronic monitoring, which may include the operating room; Appropriate emergency drugs; Nonexpired drugs; Appropriate devices to maintain an airway with positive pressure ventilation; Preoperative medical history and physical evaluation form; Anesthesia records, including monitoring and discharge records; Monitoring equipment, including pulse oximeter and blood pressure monitoring; Electrocardiogram (EKG); Anesthesia and monitoring equipment to ensure that they are in proper working order; Defibrillator or automated external defibrillator (AED); Capnograph measuring device; and In addition to the requirements of this section, for deep sedation or general anesthesia in pediatric patients a dentist shall have a pulse oximeter and either a: Precordial stethoscope; or Pretracheal stethoscope. The applicant and the applicant’s staff shall be present in the operatory during the evaluation. If an applicant for the renewal of a Class III permit returns a renewal application to the Board at least 90 days before the expiration of the permit, and the Board is unable to approve or deny the application before the expiration of the permit through no fault of the applicant, the permit shall remain in effect until the Board: Renews the permit; or Denies renewal of the permit. Failure to receive the Board's renewal application does not relieve the permit holder from the requirement to submit a renewal application to the Board at least 90 days before the expiration of the permit. The Board may issue a renewal of a Class III permit to an applicant for a specific practice location after the Board's review of: The applicant's renewal application and accompanying affidavit; The applicant's qualifications; The renewal evaluation; and Any other pertinent documents or information, including, but not limited to, patient complaints that may affect the applicant's ability to safely and effectively administer anesthesia and sedation. After January 4, 2010, a dentist may not administer anesthesia or sedation for the practice of dentistry in a dental school recognized by the Commission on Dental Accreditation or its successor organization unless the dental school holds a Class III dental school facility permit. A dental school that applies for a Class III dental school facility permit shall pass an on-site facility evaluation by the Board or its designee as specified in Regulation .11 of this chapter. To obtain a dental school Class III facility permit a dental school recognized by the Commission on Dental Accreditation or its successor organization shall: Submit to the Board an application on a form provided by the Board; Pay the fee set by the Board in COMAR 10.44.20; and Provide evidence satisfactory to the Board that the dental school meets the qualifications for a Class III dental school facility permit. A Class III dental school facility permit shall expire on April 1 of the 5th year following the effective date of the permit. The Board shall mail a renewal application to each dental school holding a Class III dental school facility permit at least 180 days before the expiration of the permit. Before a Class III dental school facility permit expires, the dental school may renew the permit for an additional 5-year term if the dental school: Submits to the Board, at least 90 days before the expiration of the permit, a renewal application on a form provided by the Board; Passes a renewal facility evaluation in each facility for which the dental school wishes to renew a permit; and Pays the renewal fee set by the Board in COMAR 10.44.20. The renewal evaluation outlined in §B(2) of this regulation shall consist of an evaluation of: Anesthesia and monitoring equipment to ensure they are in proper working order; and Drugs in the facility to ensure that the dental school: Maintains the appropriate drugs on the premises; and Only utilizes drugs on the premises the dates of which have not expired. If a dental school returns a renewal application for a Class III dental school facility permit to the Board at least 90 days before the expiration of the permit, and the Board is unable to approve or deny the application before the expiration of the permit through no fault of the dental school, the permit shall remain in effect until the Board: Renews the permit; or Denies renewal of the permit. Failure to receive the Board's renewal application does not relieve the dental school from the requirement to submit a renewal application to the Board at least 90 days before the expiration of the permit. A dental school that holds a Class III Dental School Facility Permit shall advise the Board of any additional locations it has opened since the issuance or the renewal of its original permit. The notice required under §A of this regulation shall be provided to the Board in writing not later than 30 days before the opening of the additional location. A dentist may not administer anesthesia or sedation for the practice of dentistry in an additional location unless the school holds a Class III dental school facility permit for the additional location. A dental school that applies for a Class III dental school facility permit for an additional location shall pass an on-site facility evaluation by the Board or its designee as contained in Regulation .11 of this chapter. All facilities including a dental school that holds a Class III dental school facility permit shall maintain for 5 years for inspection by the Board: The name of each dentist who has administered anesthesia or sedation; and The license number of each dentist who has administered anesthesia or sedation. During reasonable business hours, the Board or its designee may conduct unannounced inspection visits of any dental office or facility if the Board has: Received a complaint or has initiated a complaint; and Reason to believe that anesthesia or sedation has been administered: Without an appropriate permit; or In violation of this chapter. Dentists and all associated personnel shall cooperate with the inspectors. Within 30 days of the conclusion of the inspection, the inspectors shall make reasonable efforts to submit a written report of the inspection to: The Board; and Each dentist and individual who was the subject of the inspection. The owner or operator of a facility may not permit an individual to administer anesthesia or sedation unless the individual is qualified to do so under this chapter. The owner or operator of a facility shall ensure that the facility: Remains properly equipped in accordance with Regulation .11A of this chapter; and Remains properly staffed in accordance with Regulation .14 of this chapter. In addition to the requirements contained in §B of this regulation, the owner or operator of a facility shall ensure that the facility has: Appropriate nonexpired emergency drugs; and Appropriate nonexpired drugs. After an opportunity for a hearing, the Board may take disciplinary action against a dentist under Health Occupations Article, §4-315(a) or (b), Annotated Code of Maryland, if the Board finds that: The dentist violates any provisions of this chapter; or The facility is inadequate under the provisions of this chapter. Failure to comply with this chapter constitutes unprofessional conduct and may constitute other violations of law. Renewal of a Class I, Class II, or Class III Permit. Beginning in 2016 and thereafter, an applicant who seeks renewal of a Class I, Class II, or Class III permit shall: Complete not less than 24 hours of clinical continuing education related to sedation or anesthesia in a classroom setting during the 5-year term of the permit; and Maintain cardiopulmonary resuscitation certification from one of the following programs: The American Heart Association's Basic Life Support for Healthcare Providers; The American Red Cross's Cardiopulmonary Resuscitation for Professional Rescuers; The American Safety & Health Institute; or An equivalent program approved by the Board. Additional Requirements for Renewal of a Class I Permit. In addition to the requirements outlined in §A of this regulation, an applicant for the renewal of a Class I permit shall: Complete a Board-approved course of at least 4 hours that provides instruction on medical emergencies and airway management; Maintain Advanced Cardiac Life Support (ACLS) certification; or Maintain Pediatric Advanced Life support certification (PALS). The following courses may count toward the required hours of continuing education: Advanced Cardiac Life Support (ACLS) course; Pediatric Advanced Life Support (PALS) course; or A Board-approved course in medical emergency and airway management. Additional Requirements for Renewal of a Class II or Class III Permit. In addition to the requirements outlined in §A of this regulation, an applicant for the renewal of a Class II or Class III permit shall: Complete a Board-approved course of at least 4 hours that provides instruction on medical emergencies and airway management; Maintain Advanced Cardiac Life Support (ACLS) certification; or Maintain Pediatric Advanced Life Support (PALS) certification. The following courses may count toward the required hours of continuing education: Advanced Cardiac Life Support (ACLS) course; Pediatric Advanced Life Support (PALS) course; or A Board-approved course in medical emergency and airway management. A Class I, Class II, or Class III permit may not be transferred to another person or location. A treating dentist who wishes to allow a physician or another dentist to administer anesthesia and sedation to a patient at a specific practice location shall receive a certificate from the Board before allowing a physician or another dentist to administer anesthesia and sedation at that location. To apply for a certificate to allow a physician or another dentist to administer anesthesia and sedation: A treating dentist shall: Apply to the Board on a form approved by the Board; Possess either a Class I, Class II, or Class III permit; Provide an affidavit to the Board indicating whether the applicant has ever treated a patient under deep sedation or general anesthesia with an incident; Submit any other pertinent documents or information requested by the Board; and Pay a nonrefundable fee to the Board as set forth in COMAR 10.44.20; or A treating dentist shall: Apply to the Board on a form approved by the Board; Provide documentation to the Board that the treating dentist has completed a Board-approved training program where the treating dentist received competent training in treating patients under: Moderate enteral sedation and airway management; Moderate parenteral sedation and airway management; Deep sedation and airway management; or General anesthesia and airway management; Provide an affidavit to the Board indicating whether the applicant has ever treated a patient under deep sedation or general anesthesia with an incident; Submit any other pertinent documents or information requested by the Board; and Pay a nonrefundable fee to the Board as set forth in COMAR 10.44.20. An affidavit provided to the Board under §B(1)(c) or (2)(c) of this regulation, which indicates that the applicant has treated a patient under deep sedation or general anesthesia with an incident, shall include the information contained in Regulation .08G of this chapter. In addition to the requirements contained in §§A—C of this regulation, a treating dentist who applies for a certificate to allow a physician or another dentist to administer anesthesia and sedation to a patient shall: Maintain either a Class I, Class II, or Class III permit for the administration site; and Maintain facility equipment in the facility consistent with a Class III permit as outlined in Regulation .11A of this chapter. The Board may issue a certificate to a dentist to allow a physician or another dentist to administer anesthesia and sedation after the Board's review of: The applicant's application and accompanying affidavit; The applicant's qualifications; The applicant's patient records; and Any other pertinent documents or information including, but not limited to, patient complaints which may affect the applicant's ability to safely and effectively treat patients under anesthesia and sedation. A certificate issued to a treating dentist to allow a physician or another dentist to administer anesthesia and sedation at a specific location shall expire on April 1 of the 5th year following the effective date of the certificate. A dentist who administers anesthesia or sedation pursuant to §A of this regulation shall maintain the appropriate permit for the administration site. A dentist who holds a certificate to allow a physician or another dentist to administer anesthesia or sedation shall be present in the operatory during the administration of the anesthesia or sedation. Renewal. The Board shall mail a renewal application to each treating dentist who has received a certificate from the Board to allow a physician or another dentist to administer anesthesia and sedation at least 180 days before the expiration of the certificate. Before the certificate expires, an applicant may apply to renew the certificate for an additional 5-year term if the applicant submits to the Board at least 90 days before the expiration of the certificate: A renewal application on a form provided by the Board; An affidavit indicating whether the applicant, since the issuance of the original certificate or renewal, whichever is later, has treated a patient under deep sedation or general anesthesia with an incident; A nonrefundable fee as set forth in COMAR 10.44.20; and Any other pertinent documents or information requested by the Board. An affidavit provided to the Board under §J(2) of this regulation, which indicates that the applicant has treated a patient under deep sedation or general anesthesia with an incident, shall include the information contained in Regulation .08G of this chapter. The Board may issue a renewal certificate to a dentist to allow a physician or another dentist to administer anesthesia and sedation after the Board's review of: The applicant's application and accompanying affidavit; The applicant's qualifications; and Any other pertinent documents or information including but not limited to patient complaints which may affect the applicant's ability to safely and effectively treat patients under anesthesia and sedation. If an applicant for the renewal of a certificate to allow a physician or another dentist to administer anesthesia and sedation returns a renewal application to the Board at least 90 days before the expiration of the certificate, and the Board is unable to approve or deny the application before the expiration of the certificate through no fault of the applicant, the certificate shall remain in effect until the Board: Renews the certificate; or Denies renewal of the certificate. Failure to receive the Board's renewal application does not relieve the certificate holder from the requirement to submit a renewal application to the Board at least 90 days before the expiration of the certificate. A treating dentist who treats a patient at a practice location other than the dentist's own location, at which anesthesia and sedation are administered to the patient, shall receive a certificate from the Board before treating the patient. To apply for a certificate to treat a patient at a practice location other than the dentist's own location, at which anesthesia and sedation are administered to the patient: A treating dentist shall: Apply to the Board on a form approved by the Board; Possess a Class I, Class II, or Class III permit; Provide an affidavit to the Board indicating whether the applicant has ever treated a patient under deep sedation or general anesthesia with an incident; Submit any other pertinent documents or information requested by the Board; and Pay a nonrefundable fee to the Board as set forth in COMAR 10.44.20; or A treating dentist shall: Apply to the Board on a form approved by the Board; Provide documentation to the Board that the treating dentist has completed a Board-approved training program where the treating dentist received competent training in treating patients under: Moderate enteral sedation and airway management; Moderate parenteral sedation and airway management; Deep sedation and airway management; or General anesthesia and airway management; Provide an affidavit to the Board indicating whether the applicant has ever treated a patient under deep sedation or general anesthesia with an incident; Submit any other pertinent documents or information requested by the Board; and Pay a nonrefundable fee to the Board as set forth in COMAR 10.44.20. An affidavit provided to the Board under §B(1)(c) or (2)(c) of this regulation, which indicates that the applicant has treated a patient under deep sedation or general anesthesia with an incident, shall include the information contained in Regulation .08G of this chapter. In addition to the requirements contained in §§A—C of this regulation, a treating dentist who applies for a certificate shall maintain a Class I, Class II, or Class III permit for an administration site in the State. The Board may issue a certificate after the Board's review of: The applicant's application and accompanying affidavit; The applicant's qualifications; The applicant's patient records; and Any other pertinent documents or information, including, but not limited to, patient complaints which may affect the applicant's ability to safely and effectively treat patients under anesthesia and sedation. A certificate issued under this regulation is not specific to a particular practice location. A certificate expires on April 1 of the 5th year following the effective date of the certificate. A dentist who administers anesthesia or sedation pursuant to this regulation shall maintain the appropriate permit for the administration site. A treating dentist who holds a certificate to treat a patient at a practice location other than the dentist’s own location, at which anesthesia or sedation are administered to the patient, shall be present in the operatory during the administration of the anesthesia or sedation. Renewal. The Board shall mail a renewal application to each treating dentist who has received a certificate from the Board at least 180 days before the expiration of the certificate. Before the certificate expires, an applicant may apply to renew the certificate for an additional 5-year term if the applicant submits to the Board at least 90 days before the expiration of the certificate: A renewal application on a form provided by the Board; An affidavit indicating whether the applicant, since the issuance of the original certificate or renewal, whichever is later, has treated a patient under deep sedation or general anesthesia with an incident; A nonrefundable fee as set forth in COMAR 10.44.20; and Any other pertinent documents or information requested by the Board. An affidavit provided to the Board under §K(2) of this regulation, which indicates that the applicant has treated a patient under deep sedation or general anesthesia with an incident, shall include the information contained in Regulation .08G of this chapter. The Board may issue a renewal certificate to a dentist after the Board's review of: The applicant's application and accompanying affidavit; The applicant's qualifications; and Any other pertinent documents or information, including, but not limited to, patient complaints which may affect the applicant's ability to safely and effectively treat patients under anesthesia and sedation. If an applicant for the renewal of a certificate returns a renewal application to the Board at least 90 days before the expiration of the certificate, and the Board is unable to approve or deny the application before the expiration of the certificate through no fault of the applicant, the certificate shall remain in effect until the Board: Renews the certificate; or Denies renewal of the certificate. Failure to receive the Board's renewal application does not relieve the certificate holder from the requirement to submit a renewal application to the Board at least 90 days before the expiration of the certificate. A treating dentist who wishes to allow a certified registered nurse anesthetist to administer anesthesia and sedation to a patient at a specific practice location shall receive a certificate from the Board before allowing a certified registered nurse anesthetist to administer anesthesia and sedation at that location. To apply for a certificate to allow a certified registered nurse anesthetist to administer anesthesia and sedation, a treating dentist shall: Apply to the Board on a form approved by the Board; Provide an affidavit to the Board indicating whether the treating dentist has ever treated a patient under deep sedation or general anesthesia with an incident; Submit any other pertinent documents or information requested by the Board; and Pay a nonrefundable fee to the Board as set forth in COMAR 10.44.20. An affidavit provided to the Board under §B(2) of this regulation, which indicates that the applicant has treated a patient under deep sedation or general anesthesia with an incident, shall include the information contained in Regulation .08G of this chapter. In addition to the requirements in §§A—C of this regulation, a treating dentist who applies for a certificate to allow a certified registered nurse anesthetist to administer anesthesia and sedation to a patient shall maintain permits as follows: A treating dentist who allows a certified registered nurse anesthetist to administer moderate enteral sedation to a patient shall maintain a Class I permit for the administration site; A treating dentist who allows a certified registered nurse anesthetist to administer moderate parenteral sedation to a patient shall maintain a Class II permit for the administration site; and A treating dentist who allows a certified registered nurse anesthetist to administer deep sedation or general anesthesia to a patient shall maintain a Class III permit for the administration site. In addition to the requirements of this regulation, a dentist who allows a certified registered nurse anesthetist to administer anesthesia and sedation shall maintain facility equipment in the facility consistent with a Class III permit as outlined in Regulation .11A of this chapter. A treating dentist who holds a certificate to allow a certified registered nurse anesthetist to administer anesthesia or sedation shall be present in the operatory during the administration of the anesthesia or sedation. The Board may issue a certificate to a dentist to allow a certified registered nurse anesthetist to administer anesthesia and sedation after the Board's review of: The applicant's application and accompanying affidavit; The applicant's qualifications; The applicant's patient records; and Any other pertinent documents or information, including, but not limited to, patient complaints which may affect the applicant's ability to safely and effectively treat patients under anesthesia and sedation. A certificate issued to a treating dentist to allow a certified registered nurse anesthetist to administer anesthesia and sedation at a specific location expires on April 1 of the 5th year following the effective date of the certificate. Renewal. The Board shall mail a renewal application to each treating dentist who has received a certificate from the Board to allow a certified registered nurse anesthetist to administer anesthesia and sedation at least 180 days before the expiration of the certificate. Before the certificate expires, an applicant may apply to renew the certificate for an additional 5-year term if the applicant submits to the Board at least 90 days before the expiration of the certificate: A renewal application on a form provided by the Board; An affidavit indicating whether the applicant, since the issuance of the original certificate or renewal, whichever is later, has treated a patient under deep sedation or general anesthesia with an incident; A nonrefundable fee as set forth in COMAR 10.44.20; and Any other pertinent documents or information requested by the Board. An affidavit provided to the Board under §J(2) of this regulation, which indicates that the applicant has treated a patient under deep sedation or general anesthesia with an incident, shall include the information contained in Regulation .08G of this chapter. The Board may issue a renewal certificate to a dentist to allow a certified registered nurse anesthetist to administer anesthesia and sedation after the Board's review of: The applicant's application and accompanying affidavit; The applicant's qualifications; and Any other pertinent documents or information, including, but not limited to, patient complaints which may affect the applicant's ability to safely and effectively treat patients under anesthesia and sedation. If an applicant for the renewal of a certificate to allow a certified registered nurse anesthetist to administer anesthesia and sedation returns a renewal application to the Board at least 90 days before the expiration of the certificate, and the Board is unable to approve or deny the application before the expiration of the certificate through no fault of the applicant, the certificate shall remain in effect until the Board: Renews the certificate; or Denies renewal of the certificate. Failure to receive the Board's renewal application does not relieve the certificate holder from the requirement to submit a renewal application to the Board at least 90 days before the expiration of the certificate. A dentist who holds a Class I, Class II, or Class III permit shall maintain their wallet certificate in their possession for inspection at the administration site. A dentist who holds a general anesthesia facility permit or a parenteral sedation facility permit shall display the permit and any current renewal certificates in the facility. A dentist who treats a patient at an accredited facility as defined in Regulation .03 of this chapter where anesthesia or sedation is being administered to the patient by either another dentist, physician, or certified registered nurse anesthetist is not required to hold: A Class I, Class II, or Class III permit; or A certification to allow another dentist, physician, or certified registered nurse anesthetist to administer anesthesia or sedation. A dentist shall report to the Board, in writing, any death caused by or resulting from the dentist's administration of anxiolysis, moderate sedation, deep sedation, or general anesthesia within 7 days after its occurrence. A dentist shall report to the Board, in writing, any complication or disabling incident requiring admission to a hospital either for a period greater than 24 hours, or for purposes other than observation, as a result of the dentist’s administration of anxiolysis, moderate sedation, deep sedation, or general anesthesia within 15 days after its occurrence. The written report to the Board required in §§A and B of this regulation shall include: The date of the incident; The name, age, and address of the patient; The patient's original complete dental records; The name and license number of the licensee and the name and address of all other persons present during the incident; The address where the incident took place; The preoperative physical condition of the patient; The type of anesthesia and dosages of drugs administered to the patient; The techniques used in administering the drugs; Any adverse occurrence including: The patient's signs and symptoms; The treatment instituted in response to adverse occurrences; The patient's response to the treatment; and The patient's condition on termination of any procedures undertaken; and A narrative description of the incident including approximate times and evolution of symptoms. The duties outlined in §§A—C of this regulation apply to every dentist whether or not the dentist holds a permit. The Board may initiate a complaint based upon the contents of a morbidity or mortality report. A Board initiated complaint under §E of this regulation shall be independent of and may not prejudice the filing of a complaint by a third party. After an opportunity for a hearing, the Board may revoke or suspend a Class I, Class II, or Class III permit or take disciplinary action under Health Occupations Article, §4-315(a) or (b), Annotated Code of Maryland, if the Board finds that: The holder of the permit violates any provision of this chapter; or The facility is inadequate under the provisions of this chapter. Failure to comply with this chapter constitutes unprofessional conduct and may constitute other violations of law. After an opportunity for a hearing, the Board may revoke or suspend a general anesthesia administration permit or a parenteral sedation administration permit or take disciplinary action under Health Occupations Article, §4-315(a) or (b), Annotated Code of Maryland, if the Board finds that: The holder of the permit violates Regulation .13, .14, .26, .31, .32, .33, or .36 of this chapter; or The facility is inadequate under the provisions of this chapter. Failure to comply with the applicable provisions of this chapter constitutes unprofessional conduct and may constitute other violations of law. The Board may order the summary suspension of a permit if the Board: Finds that the public health, safety, or welfare imperatively requires emergency action; and Promptly gives the licensee: Written notice of the suspension, the finding, and the reasons that support the finding; and An opportunity to be heard. Service of the notice of the suspension, the finding, the reasons that support the finding, and the notice of the opportunity to be heard may be effected upon the holder of a permit by: Personal service; or Written notice sent by certified mail and regular mail to the permit holder's address on file with the Board. Service made pursuant to §B(2) of this regulation shall be effective upon mailing. The methods of service provided in this regulation are in addition to and not exclusive of any other means of service that are reasonably calculated to provide notice. Health Occupations Article, §4-205, Annotated Code of Maryland Effective date: February 11, 1985 (12:3 Md. 245) Regulation .04 amended effective March 8, 1999 (26:5 Md. R. 392) Regulation .07B, C amended effective September 23, 1996 (23:19 Md. R. 1376) Regulation .09 amended effective February 19, 1990 (17:3 Md. R. 300); March 8, 1999 (26:5 Md. R. 392) Regulation .10C amended effective September 23, 1996 (23:19 Md. R. 1376); March 8, 1999 (26:5 Md. R. 392) Regulations .01—.13 under General Anesthesia, repealed, and new Regulations .01—.37 under Anesthesia and Sedation, adopted effective January 4, 2010 (36:18 Md. R. 1380) Chapter revised effective May 11, 2015 (42:9 Md. R. 648) Regulation .11A amended effective December 30, 2019 (46:26 Md. R. 1165) Regulation .21G amended effective December 30, 2019 (46:26 Md. R. 1165)