The purpose of these rules is to further clarify and define chapter 18.32 RCW, Dentistry.

The following general terms are defined within the context used in this chapter.

"Clinics" are locations situated away from the School of Dentistry on the University of Washington campus, as recommended by the dean in writing and approved by the DQAC.

"CITA" means Council of Interstate Testing Agencies, a regional dental testing agency that provides clinical dental testing services.

"CRDTS" means Central Regional Dental Testing Services, a regional testing agency that provides clinical dental testing services.

"Department" means the department of health.

"DQAC" means the dental quality assurance commission as established by RCW 18.32.0351.

"Facility" is defined as the building housing the School of Dentistry on the University of Washington campus, and other buildings, designated by the dean of the dental school and approved by the DQAC.

"NERB" means the Northeast Regional Board, a regional testing agency that provides clinical dental testing services.

"Secretary" means the secretary of the department of health or the secretary's designee.

"SRTA" means the Southern Regional Testing Agency, a regional testing agency that provides clinical dental testing services.

"WREB" means the Western Regional Examining Board, a national testing agency that provides clinical dental testing services.

The DQAC adopts the model procedural rules for adjudicative proceedings as adopted by the department of health and contained in chapter 246-11 WAC, including subsequent amendments.

The DQAC is granted the authority to issue the following types of dental licenses or permits:

(1) Licensure by examination standard. (RCW 18.32.040)

(2) Licensure without examination—Licensed in another state. (RCW 18.32.215)

(3) Faculty licensure. (RCW 18.32.195)

(4) Dental resident licensure. (RCW 18.32.195)

(5) Conscious sedation permits. (RCW 18.32.640)

(6) Anesthesia permits. (RCW 18.32.640)

(7) Temporary practice permits. (RCW 18.130.075)

To be eligible for Washington state dental licensure, the applicant must provide:

(1) A completed application and fee. The applicant must submit a signed application and required fee as defined in WAC 246-817-990;

(2) Proof of graduation from a dental school approved by the DQAC:

(a) DQAC recognizes only those applicants who are students or graduates of dental schools in the United States or Canada, approved, conditionally or provisionally, by the Commission on Dental Accreditation of the American Dental Association. The applicant must have received, or will receive, a Doctor of Dental Surgery (DDS) or Doctor of Dental Medicine (DMD) degree from that school;

(b) Other dental schools which apply for DQAC approval and which meet these adopted standards to the DQAC's satisfaction may be approved, but it is the responsibility of a school to apply for approval and of a student to ascertain whether or not a school has been approved;

(3) Proof of successful completion of the Integrated National Board Dental Examination, Parts I and II of the National Board Dental Examination, or the Canadian National Dental Examining Board Examination. An original scorecard or a certified copy of the scorecard shall be accepted. Exception: Dentists who obtained initial licensure in a state prior to that state's requirement for successful completion of the national boards, may be licensed in Washington, provided that the applicant provide proof that their original state of licensure did not require passage of the national boards at the time they were initially licensed. Applicants need to meet all other requirements for licensure;

(4) Proof of graduation from an approved dental school. The only acceptable proof is an official, posted transcript sent directly from such school, or in the case of recent graduates, a verified list of graduating students submitted directly from the dean of the dental school. Graduates of nonaccredited dental schools must also meet the requirements outlined in WAC 246-817-160;

(5) A complete listing of professional education and experience including college or university (predental), and a complete chronology of practice history from the date of dental school graduation to present, whether or not engaged in activities related to dentistry;

(6) Proof of malpractice insurance if available, including dates of coverage and any claims history;

(7) Written certification of any licenses held, submitted directly from another licensing entity, and including license number, issue date, expiration date and whether applicant has been the subject of final or pending disciplinary action;

(8) Proof of successful completion of:

(a) An approved practical/clinical examination under WAC 246-817-120; or

(b) A qualifying residency program under RCW 18.32.040 (3)(c);

(9) Proof of successful completion of an approved written jurisprudence examination;

(10) A recent 2" x 2" photograph, signed, dated, and attached to the application;

(11) Authorization for background inquiries to other sources may be conducted as determined by the DQAC including, but not limited to, the national practitioner data bank and drug enforcement agency. Applicants are responsible for any fees incurred in obtaining verification of requirements;

(12) Any other information for each license type as determined by the DQAC.

(1) An applicant seeking dentist licensure in Washington by examination, must successfully pass a written and practical examination approved by the Dental Quality Assurance Commission (commission).

The examination will consist of:

(a) A written examination. The Integrated National Board Dental Examination, Parts I and II of the National Board Dental Examination, or the Canadian National Dental Examining Board examination will be accepted, except as provided in subsection (4) of this section.

(b) A practical examination containing at least the following sections:

(i) Restorative;

(ii) Endodontic;

(iii) Periodontal;

(iv) Prosthodontic; and

(v) Comprehensive treatment planning or diagnostic skills.

(2)(a) The commission accepts the following practical examinations provided the testing agency offers at least the sections listed in subsection (1)(b) of this section:

(i) The Western Regional Examining Board's (WREB) clinical examination;

(ii) The Central Regional Dental Testing Services (CRDTS) clinical examination;

(iii) The Commission on Dental Competency Assessments (CDCA) formally known as Northeast Regional Board (NERB) clinical examination;

(iv) The Southern Regional Testing Agency (SRTA) clinical examination;

(v) The Council of Interstate Testing Agency's (CITA) clinical examination;

(vi) U.S. state or territory with an individual state board clinical examination;

(vii) The Joint Commission on National Dental Examinations dental licensure objective structured clinical examination (DLOSCE); or

(b) The commission will accept the complete National Dental Examining Board (NDEB) of Canada clinical examination as meeting its standards if the applicant is a graduate of an approved dental school defined in WAC 246-817-110 (2)(a).

(3) The applicant must pass all practical examination sections listed in subsection (1)(b) of this section with the following:

(a) The same testing agency; or

(b) A maximum of two testing agencies listed in subsection (2)(a) of this section administering all the practical examination sections in coordination with each other.

(4) The commission will only accept results of approved practical examinations taken within the preceding five years from the date of an application for licensure.

(5) The commission may, at its discretion, give or require an examination in any other subject under subsection (1)(a) and (b) of this section, whether in written or practical form or both written and practical.

For individuals holding a dentist credential in another U.S. state or territory, to be eligible for Washington state dental license without examination, the applicant must provide:

(1) A completed application on forms provided by the secretary;

(2) Applicable fees under WAC 246-817-990;

(3) A verification by a U.S. state or territory board of dentistry (or equivalent authority) of an active credential to practice dentistry, without restrictions, and whether the applicant has been the subject of final or pending disciplinary action;

(4) Proof of graduation from an approved dental school under WAC 246-817-110 (2)(a):

(a) The only acceptable proof is an official, posted transcript sent directly from such school;

(b) Graduates of nonapproved dental schools must meet the requirements under RCW 18.32.215 (1)(b).

(5) Proof that the applicant is currently engaged in the practice of dentistry:

(a) Dentists serving in the United States federal services as described in RCW 18.32.030(2) must provide documentation from their commanding officer regarding length of service, duties and responsibilities, and any adverse actions or restrictions;

(b) Dentists employed by a dental school approved under WAC 246-817-110 (2)(a) must provide documentation from the dean or appropriate administrator of the institution regarding the length and terms of employment, duties and responsibilities, and any adverse actions or restrictions;

(c) Dentists in a dental residency program must provide documentation from the director or appropriate administrator of the residency program regarding length of residency, duties and responsibilities, and any adverse actions or restrictions; or

(d) Dentists practicing dentistry for a minimum of twenty hours per week for the four consecutive years preceding application, in another U.S. state or territory must provide:

(i) Address of practice location(s);

(ii) Length of time at the location(s);

(iii) A letter from all malpractice insurance carrier(s) defining years when insured and any claims history;

(iv) Federal or state tax numbers; and

(v) DEA numbers if any.

(6) Proof of successful completion of a commission approved written jurisprudence examination;

(7) A recent 2" x 2" photograph, signed, dated, and attached to the application; and

(8) Authorization for background inquiries to other sources may include, but are not limited to, the national practitioner data bank and drug enforcement agency.

(1) The department shall provide an application for faculty licensure upon receipt of a written request from the dean of the school of dentistry of any institution of higher education in Washington state accredited by the commission on dental accreditation.

(2) Applicants for faculty licensure shall submit a signed application, including applicable fees, and other documentation as required by the DQAC.

(3) The dean of the school of dentistry of any higher education in Washington state accredited by the commission on dental accreditation, or their designee, shall notify the department of health of any changes in employment status of any person holding a faculty license.

(1) An applicant for Washington state dental licensure, who is a graduate of a dental school or college not accredited by the Commission on Dental Accreditation shall provide to the Dental Quality Assurance Commission (commission):

(a) Materials listed in WAC 246-817-110 (1), (3), (5) through (8), and (10) through (13);

(b) Official school transcript or diploma with dental degree listed transcribed to English if necessary;

(c) Evidence of successful completion of at least two additional predoctoral or postdoctoral academic years of dental education.

(i) Additional predoctoral or postdoctoral dental education completed prior to July 1, 2018, must be obtained at a dental school in the United States or Canada, approved, conditionally or provisionally, by the Commission on Dental Accreditation.

(ii) Additional predoctoral or postdoctoral dental education completed after July 1, 2018, must be obtained in a dental program in the United States or Canada, approved, conditionally or provisionally, by the Commission on Dental Accreditation and include clinical training; and

(d) An applicant for Washington state dental licensure must provide proof of successful completion of:

(i) An approved practical/clinical examination under WAC 246-817-120; or

(ii) A qualifying residency program under RCW 18.32.040 (3)(c).

(2) Upon completion of the requirements in subsection (1)(a) through (c) of this section, an applicant may be eligible to take the practical examination as approved in WAC 246-817-120 (2) through (4).

(a) The commission may issue examination approval up to six months before an applicant has completed the two additional predoctoral or postdoctoral academic years of dental education.

(b) An applicant must provide a letter from the school where the two additional predoctoral or postdoctoral academic years is being obtained indicating expected date of education completion.

Fingerprint-based national background checks may cause a delay in credentialing. Individuals who satisfy all other licensing requirements and qualifications may receive a temporary practice permit while the national background check is completed.

(1) A temporary practice permit, as defined in RCW 18.130.075, shall be issued at the written request of an applicant for dentists, expanded function dental auxiliaries, dental anesthesia assistants, and dental assistants. The applicant must be credentialed in another state, with credentialing standards substantially equivalent to Washington.

(2) The conditions of WAC 246-817-160 must be met for applicants who are graduates of dental schools or colleges not accredited by the American Dental Association Commission on Dental Accreditation.

(1) Unless there is a basis for denial of the credential or for issuance of a conditional credential, the applicant shall be issued a temporary practice permit when DQAC receives:

(a) A completed application form, all other documentation required to complete the credential application, completed fingerprint card, and fees for the credential;

(b) A written request for a temporary practice permit;

(c) Written verification of all credentials, whether active or not, attesting that the applicant has a credential in good standing and is not the subject of any disciplinary action for unprofessional conduct or impairment; and

(d) Results of disciplinary national practitioner data bank reports.

(2) The temporary practice permit shall expire when one of the following occurs:

(a) A full, unrestricted credential is granted;

(b) A notice of decision is mailed;

(c) One hundred eighty days after the temporary practice permit is issued.

(3) A temporary practice permit shall not be renewed, reissued or extended.

(4) A temporary practice permit grants the individual the full scope of practice for the profession.

A military spouse or state registered domestic partner of a military person may receive a temporary practice permit while completing any specific additional requirements that are not related to training or practice standards for the profession. This section applies to dentists licensed in chapter 18.32 RCW, expanded function dental auxiliaries licensed and dental assistants registered in chapter 18.260 RCW, and dental anesthesia assistants certified in chapter 18.350 RCW.

(1) A temporary practice permit may be issued to an applicant who is a military spouse or state registered domestic partner of a military person and:

(a) Is moving to Washington as a result of the military person's transfer to Washington;

(b) Left employment in another state to accompany the military person to Washington;

(c) Holds an unrestricted, active credential in another state that has substantially equivalent credentialing standards for the same profession to those in Washington; and

(d) Is not subject to any pending investigation, charges, or disciplinary action by the regulatory body of the other state or states.

(2) A temporary practice permit grants the individual the full scope of practice for the profession.

(3) A temporary practice permit expires when any one of the following occurs:

(a) The credential is granted;

(b) A notice of decision on the application is mailed to the applicant, unless the notice of decision on the application specifically extends the duration of the temporary practice permit; or

(c) One hundred eighty days after the temporary practice permit is issued.

(4) To receive a temporary practice permit, the applicant must:

(a) Submit the necessary application, fee(s), fingerprint card if required, and documentation for the credential;

(b) Attest on the application that the applicant left employment in another state to accompany the military person;

(c) Meet all requirements and qualifications for the credential that are specific to the training, education, and practice standards for the profession;

(d) Provide verification of having an active unrestricted credential in the same profession from another state that has substantially equivalent credentialing standards for the profession in Washington;

(e) Submit a copy of the military person's orders and a copy of:

(i) The military-issued identification card showing the military person's information and the applicant's relationship to the military person;

(ii) A marriage license; or

(iii) A state registered domestic partnership; and

(f) Submit a written request for a temporary practice permit.

(5) For the purposes of this section:

(a) "Military person" means a person serving in the United States armed forces, the United States public health service commissioned corps, or the merchant marine of the United States.

(b) "Military spouse" means the husband, wife, or registered domestic partner of a military person.

To be eligible for registration as a dental assistant you must:

(1) Provide a completed application on forms provided by the secretary;

(2) Pay applicable fees as defined in WAC 246-817-99005; and

(3) Provide any other information determined by the secretary.

To be eligible for licensure as an EFDA in Washington an applicant must:

(1) Provide a completed application on forms provided by the secretary;

(2) Pay applicable fees as defined in WAC 246-817-99005;

(3) Provide evidence of:

(a) Completion of a dental assisting education program accredited by the Commission on Dental Accreditation (CODA); or

(b) Obtain the Dental Assisting National Board (DANB) certified dental assistant credential, earned through pathway II, which includes:

(i) A minimum of three thousand five hundred hours of experience as a dental assistant within a continuous twenty-four through forty-eight month period;

(ii) Employer-verified knowledge in areas as specified by DANB;

(iii) Passage of DANB certified dental assistant examination; and

(iv) An additional dental assisting review course, which may be provided online, in person or through self-study; or

(c) A Washington limited license to practice dental hygiene; or

(d) A Washington full dental hygiene license and completion of a course in taking final impressions affiliated with or provided by a CODA accredited dental assisting program, dental hygiene school or dental school.

(4) Except for applicants qualified under subsection (3)(d) of this section, provide evidence of completing an EFDA education program approved by the commission where training includes:

(a) In a didactic, clinical and laboratory model to the clinically competent level required for close supervision:

(i) In placing and finishing composite restorations on a typodont and on clinical patients; and

(ii) In placing and finishing amalgam restorations on a typodont and on clinical patients; and

(iii) In taking final impressions on a typodont; and

(b) In a didactic, clinical and laboratory model to the clinically competent level required for general supervision:

(i) In performing coronal polish, fluoride treatment, and sealants on a typodont and on clinical patients; and

(ii) In providing patient oral health instructions; and

(iii) In placing, exposing, processing, and mounting dental radiographs; and

(c) The basic curriculum shall require didactic, laboratory, and clinical competency for the following:

(i) Tooth morphology and anatomy;

(ii) Health and safety (current knowledge in dental materials, infection control, ergonomics, mercury safety, handling);

(iii) Placement and completion of an acceptable quality reproduction of restored tooth surfaces—Laboratory and clinic only;

(iv) Radiographs (covered in path II)—Laboratory and clinic only;

(v) Ethics and professional knowledge of law as it pertains to dentistry, dental hygiene, dental assisting, and EFDA;

(vi) Current practices in infection control;

(vii) Health history alerts;

(viii) Final impression;

(ix) Matrix and wedge;

(x) Rubber dam;

(xi) Acid etch and bonding;

(xii) Occlusion and bite registration;

(xiii) Temporary restorations;

(xiv) Dental emergencies;

(xv) Risk management and charting;

(xvi) Intra-oral anatomy;

(xvii) Pharmacology; and

(xviii) Bases, cements, liners and sealers.

(5) Except for applicants qualified under subsection (3)(d) of this section, attain a passing score on:

(a) A written restorations examination approved by the commission; and

(b) A clinical restorations examination approved by the commission.

(6) Provide any other information determined by the secretary.

To be eligible for a license as an EFDA without examination you must:

(1) Provide a completed application on forms provided by the secretary;

(2) Pay applicable fees as defined in WAC 246-817-990;

(3) Provide evidence of:

(a) A current license in another state with substantially equivalent licensing standards as determined by the commission; or

(b) A Washington full dental hygiene license and completion of a course in taking final impressions affiliated with or provided by a CODA accredited dental assisting program, dental hygiene school or dental school; and

(4) Provide any other information determined by the secretary.

An applicant for certification as a dental anesthesia assistant must submit to the department:

(1) A completed application on forms provided by the secretary;

(2) Applicable fees as defined in WAC 246-817-99005;

(3) Evidence of:

(a) Completion of a commission approved dental anesthesia assistant education and training. Approved education and training includes:

(i) Completion of the "Dental Anesthesia Assistant National Certification Examination (DAANCE)" or predecessor program, provided by the American Association of Oral and Maxillofacial Surgeons (AAOMS); or

(ii) Completion of the "Oral and Maxillofacial Surgery Assistants Course" course provided by the California Association of Oral and Maxillofacial Surgeons (CALAOMS); or

(iii) Completion of substantially equivalent education and training approved by the commission.

(b) Completion of training in intravenous access or phlebotomy. Training must include:

(i) Eight hours of didactic training that must include:

(A) Intravenous access;

(B) Anatomy;

(C) Technique;

(D) Risks and complications; and

(ii) Hands on experience starting and maintaining intravenous lines with at least ten successful intravenous starts on a human or simulator/manikin; or

(iii) Completion of substantially equivalent education and training approved by the commission;

(c) A current and valid certification for health care provider basic life support (BLS), advanced cardiac life support (ACLS), or pediatric advanced life support (PALS);

(d) A valid Washington state general anesthesia permit of the oral and maxillofacial surgeon or dental anesthesiologist where the dental anesthesia assistant will be performing his or her services; and

(4) Any other information determined by the commission.

(1) If the credential has expired for three years or less, the practitioner must meet the requirements of chapter 246-12 WAC, Part 2.

(2) If the credential has expired for over three years, the practitioner must:

(a) Comply with the current statutory conditions;

(b) Meet the requirements of chapter 246-12 WAC, Part 2.

(1) A dentist may obtain an inactive license by meeting the requirements of WAC 246-12-090 and RCW 18.32.185.

(2) An inactive license must be renewed every year on or before the practitioner's birthday according to WAC 246-12-100 and 246-817-990.

(3) If a license is inactive for three years or less, to return to active status a dentist must meet the requirements of WAC 246-12-110, 246-817-440, and 246-817-990.

(4) If a license is inactive for more than three years, and the dentist has been actively practicing in another United States jurisdiction, to return to active status the dentist must:

(a) Provide certification of an active dentist license, submitted directly from another licensing entity. The certification shall include the license number, issue date, expiration date and whether the applicant has been the subject of final or pending disciplinary action;

(b) Provide verification of active practice in another United States jurisdiction within the last three years; and

(c) Meet the requirements of WAC 246-12-110, 246-817-440, and 246-817-990.

(5) If a license is inactive for more than three years, and the dentist has not been actively practicing in another United States jurisdiction, to return to active status the dentist must provide:

(a) A written request to change licensure status;

(b) The applicable fees according to WAC 246-817-990;

(c) Proof of successful completion of:

(i) An approved practical/practice examination under WAC 246-817-120; or

(ii) A qualifying residency program under RCW 18.32.040 (3)(c);

(d) Written certification of all dental or health care licenses held, submitted directly from the licensing entity. The certification shall include the license number, issue date, expiration date and whether the applicant has been the subject of final or pending disciplinary action;

(e) Written declaration that continuing education and competency requirements for the two most recent years have been met according to WAC 246-817-440;

(f) Proof of successful completion of an approved written jurisprudence examination within the past year; and

(g) Proof of malpractice insurance if available, including dates of coverage and any claims history.

(1) To obtain a retired active status license, a licensed dentist must comply with WAC 246-12-120, 246-12-130, and 246-12-140, excluding WAC 246-12-120 (2)(c) and (d).

(2) A licensed dentist with a retired active status license may practice under the following conditions:

(a) In emergent circumstances calling for immediate action; or

(b) In intermittent circumstances on a nonpermanent basis.

(3) A licensed dentist with a retired active license may not receive compensation for dental services.

(4) A licensed dentist with a retired active status license must renew every year on or before the practitioner's birthday according to WAC 246-12-130 and 246-817-990 and must complete 63 hours of continuing education as required in WAC 246-817-440 every three years.

The license of any dentist, dental hygienist or other individual licensed pursuant to the laws of Washington to engage in any activity being performed in the premises under the supervision or control of a licensed dentist shall be displayed in a place visible to individuals receiving services in the premises, and readily available for inspection by any designee of the DQAC.

The following definitions apply to WAC 246-817-304 through 246-817-315 unless the context requires otherwise:

(1) "Clinical record" is the portion of the record that contains information regarding the patient exam, diagnosis, treatment discussion, treatment performed, patient progress, progress notes, referrals, studies, tests, imaging of any type and any other information related to the diagnosis or treatment of the patient.

(2) "Financial record" is the portion of the record that contains information regarding the financial aspects of a patient's treatment including, but not limited to, billing, treatment plan costs, payment agreements, payments, insurance information or payment discussions held with a patient, insurance company or person responsible for account payments.

(3) "Notation" is a condensed or summarized written record/note.

(4) "Patient record" is the entire record of the patient maintained by a practitioner that includes all information related to the patient.

(1) A licensed dentist who treats patients shall maintain legible, complete, and accurate patient records.

(2) The patient record must contain the clinical records and the financial records.

(3) The clinical record must include at least the following information:

(a) For each clinical record entry note, the signature, initials, or electronic verification of the individual making the entry note;

(b) For each clinical record entry note, identify who provided treatment if treatment was provided;

(c) The date of each patient record entry, document, radiograph or model;

(d) The physical examination findings documented by subjective complaints, objective findings, an assessment or diagnosis of the patient's condition, and plan;

(e) A treatment plan based on the assessment or diagnosis of the patient's condition;

(f) Up-to-date dental and medical history that may affect dental treatment;

(g) Any diagnostic aid used including, but not limited to, images, radiographs, and test results. Retention of molds or study models is at the discretion of the practitioner, except for molds or study models for orthodontia or full mouth reconstruction which shall be retained as listed in WAC 246-817-310;

(h) A complete description of all treatment/procedures administered at each visit;

(i) An accurate record of any medication(s) administered, prescribed or dispensed including:

(i) The date prescribed or the date dispensed;

(ii) The name of the patient prescribed or dispensed to;

(iii) The name of the medication; and

(iv) The dosage and amount of the medication prescribed or dispensed, including refills.

(j) Referrals and any communication to and from any health care provider;

(k) Notation of communication to or from the patient or patient's parent or guardian, including:

(i) Notation of the informed consent discussion. This is a discussion of potential risk(s) and benefit(s) of proposed treatment, recommended tests, and alternatives to treatment, including no treatment or tests;

(ii) Notation of posttreatment instructions or reference to an instruction pamphlet given to the patient;

(iii) Notation regarding patient complaints or concerns associated with treatment, this includes complaints or concerns obtained in person, by phone call, email, mail, or text; and

(iv) Termination of doctor-patient relationship; and

(l) A copy of each laboratory referral retained for three years as required in RCW 18.32.655.

(4) Clinical record entries must not be erased or deleted from the record.

(a) Mistaken handwritten entries must be corrected with a single line drawn through the incorrect information. New or corrected information must be initialed and dated.

(b) If the record is an electronic record then a record audit trail must be maintained with the record that includes a time and date history of deletions, edits and/or corrections to electronically signed records.

(1) A licensed dentist shall keep readily accessible patient records for at least six years from the date of the last treatment.

(2) A licensed dentist shall respond to a written request from a patient to examine or copy a patient's record within fifteen working days after receipt. A licensed dentist shall comply with chapter 70.02 RCW for all patient record requests.

(3) A licensed dentist shall comply with chapter 70.02 RCW and the Health Insurance Portability and Accountability Act, 45 C.F.R. destruction and privacy regulations.

If requested as part of an investigation authorized by the secretary, a licensed dentist who operates a dental practice in the state of Washington shall provide to the secretary:

(1) Documentation that the licensed dentist is:

(a) The owner, purchaser, or lessee of the dental equipment;

(b) The owner, purchaser, or lessee of the office the dentist occupies; and

(c) Associated with other persons in the practice of dentistry, whether or not the associate is licensed to practice dentistry.

(2) All contracts or agreements governing the dental practice business relationships with co-owners, partners, and associates.

All licensees engaged in the practice of dentistry shall submit a complete report of any patient mortality or other incident which results in temporary or permanent physical or mental injury requiring hospitalization of said patient during, or as a direct result of dental procedures or anesthesia related thereto. This report shall be submitted to the DQAC within thirty days of the occurrence.

Every dentist who operates a dental office in the state of Washington must write a valid prescription to the dental laboratory or dental technician with whom he/she intends to place an order for the making, repairing, altering or supplying of artificial restorations, substitutes or appliances to be worn in the human mouth. A separate prescription must be submitted to the dental laboratory or dental technician for each patient's requirements. To be valid, such prescriptions must be written in duplicate and contain the date, the name and address of the dental laboratory or the dental technician, the name and address of the patient, description of the basic work to be done, the signature of the dentist serving the patient for whom the work is being done and the dentist's license certificate number. The original prescription shall be referred to the dental laboratory or the dental technician and the carbon copy shall be retained for three years, by the dentist, in an orderly, accessible file and shall be readily available for inspection by the secretary or his/her authorized representative.

When Schedule II, III, IV or V drugs as described in chapter 69.50 RCW are stocked by the dental office for dispensing to patients, an inventory control record must be kept in such a manner to identify disposition of such medicines. Such records shall be available for inspection by the secretary or his/her authorized representative.

It shall be unprofessional conduct for any dentist to discriminate or to permit any employee or any person under the supervision and control of the dentist to discriminate against any person, in the practice of dentistry, on the basis of race, color, creed or national origin, or to violate any of the provisions of any state or federal antidiscrimination law.

The attending dentist, without reasonable cause, shall not neglect, ignore, abandon, or refuse to complete the current procedure for a patient. If the dentist chooses to withdraw responsibility for a patient of record, the dentist shall:

(1) Advise the patient that termination of treatment is contemplated and that another dentist should be sought to complete the current procedure and for future care; and

(2) Advise the patient that the dentist shall remain reasonably available under the circumstances for up to fifteen days from the date of such notice to render emergency care related to that current procedure.

Dentists shall not represent the care being rendered to their patients or the fees being charged for providing such care in a false or misleading manner, nor alter patient records, such as but not limited to, misrepresenting dates of service or treatment codes.

A dentist who is personally present, operating as a dentist or personally overseeing the operations being performed in a dental office, over fifty percent of the time that such office is being operated, shall identify himself/herself in any representation to the public associated with such office or practice and shall provide readily visible signs designating his/her name at such respective office entrances or office buildings. Any representation that omits such a listing of dentists is misleading, deceptive, or improper conduct. Dentists who are present or overseeing operations under this rule less than fifty percent of the time shall identify themselves to patients prior to services being initiated or rendered in any fashion. Every office shall have readily available a list of the names of dentists who are involved in such office less than fifty percent of the time.

It shall be misleading, deceptive or improper conduct for any dentist to represent that he/she is a member of any dental association, society, organization, or any component thereof where such membership in fact does not exist.

In order to protect the public from inherently misleading claims of specialty expertise by dentists who are not adequately trained and experienced, a licensed dentist must comply with the requirements in this section to avoid deception of the public with accurate advertising and representation.

(1) A licensed dentist has the legal authority to practice in all areas of dentistry as defined in RCW 18.32.020 and also the authority to confine their practice in areas within the scope of their education, training, and experience and in accordance with chapters 18.32 RCW and 246-817 WAC.

(2) A licensed dentist may advertise or represent themselves as a specialist if the dentist meets the standards listed in subsection (4) of this section.

(3) A licensed dentist who does not meet the standards listed in subsection (4) of this section is considered a general dentist. A general dentist is permitted to render specialty services but shall not advertise or represent themselves as a specialist in the areas listed in subsection (4) of this section.

(4) A licensed dentist must comply with one of the following requirements before advertising or representing themselves as a specialist in Washington:

(a) Successfully complete a Commission on Dental Accreditation postdoctoral education program at least two years in length, and is recognized by the National Commission on Recognition of Dental Specialties and Certifying Boards in one of the following specialty areas:

(i) Dental anesthesiology;

(ii) Dental public health;

(iii) Endodontics;

(iv) Oral and maxillofacial pathology;

(v) Oral and maxillofacial radiology;

(vi) Oral and maxillofacial surgery;

(vii) Oral medicine;

(viii) Orofacial pain;

(ix) Orthodontics and dentofacial orthopedics;

(x) Pediatric dentistry;

(xi) Periodontics; or

(xii) Prosthodontics.

(b) Successfully complete a Commission on Dental Accreditation advanced educational program or program of any other accreditors recognized by the United States Department of Education which is at least two years in length in a special interest area of dentistry not listed in (a) of this subsection.

(5) It is misleading, deceptive, or unprofessional conduct for a licensed dentist to advertise or represent themselves by adopting or using any title to the public as a dental specialist, expert, board certified, or diplomate practicing in an area when they have not successfully completed the requirements specified for the dental specialty listed in subsection (4) of this section.

(a) Effective July 1, 2022, a licensed dentist in a group practice that includes two or more dentists must be identified as a general dentist or a specialist as listed in subsection (4) of this section.

(b) A licensed dentist in a group practice who meets the standards listed in subsection (4) of this section shall include the area of their specialty.

(c) Qualifications of any licensed dentist must be made available to the public upon request.

To be exempt from the law prohibiting the practice of dentistry, dental technicians must comply with the provisions of RCW 18.32.030(6). The form of the required prescription is defined in WAC 246-817-330.

The goal of continuing education is to encourage the lifetime professional development of the licensed dentist, and to enhance the clinical and overall skills needed to protect the health and safety of all patients.

(1) A licensed dentist shall complete a minimum of 63 hours of continuing education every three years.

(a) The three-year continuing education reporting period for a dentist licensed in Washington before 2019 begins January 1, 2019, and verification of completion of continuing education hours will be due on the dentist's annual license renewal date in 2022, and every three years thereafter. The three-year continuing education reporting period for a dentist initially licensed in Washington in 2019 or later begins upon date of licensure.

(b) A licensed dentist shall attest to the completion of 63 hours of continuing education every three years as a part of their license renewal requirement.

(c) The dental quality assurance commission (commission) may randomly audit up to 25 percent of licensed dentists every three years for compliance after the license is renewed as allowed by WAC 246-12-170 through 246-12-240.

(d) A licensed dentist shall comply with the requirements of WAC 246-12-170 through 246-12-240.

(e) The commission will not authorize or approve specific continuing education courses.

(2) A licensed dentist shall complete the commission approved dental jurisprudence examination once every three years. One hour of continuing education will be granted toward the 63-hour requirement.

(3) A licensed dentist must complete a minimum of two hours of commission approved health equity training every three years. Two hours of continuing education will be granted towards the 63-hour requirement. An approved program providing health equity continuing education training must meet the requirements listed in WAC 246-12-830. For purposes of this rule, health equity has the same meaning as defined in WAC 246-12-810.

(4) Continuing education must contribute to the professional knowledge and development of the licensed dentist or enhance services provided to patients. Continuing education must be completed in one or more of the following subject categories:

(a) Education courses relating to the practice of dentistry;

(b) Emergency management, advanced cardiac life support (ACLS), and pediatric advanced life support (PALS);

(c) Health care provider basic life support (BLS). BLS certification is required in WAC 246-817-720. One hour of continuing education for each BLS certification course will be granted. A licensed dentist may not count more than three hours every three years in this category;

(d) Infection control, federal/state safety standards, and radiation protection;

(e) Pharmacology, prescribing practices, and pain management;

(f) Ethics;

(g) Patient care related education including risk management, methods of health delivery, multicultural, and suicide prevention education;

(h) Washington state dentistry law;

(i) Practice management and billing practices. A licensed dentist may not count more than 21 hours every three years in this category.

(5) Continuing education in subject categories identified in subsection (4) of this section may be completed using any of the following activities or methods:

(a) Attendance at local, state, national, or international continuing education courses, live interactive webinars, dental study clubs, postdoctoral education, and dental residencies;

(b) Self-study by various means, relevant to dentistry, without an instructor physically present.

(i) Self-study can be continuing education provided online or through the mail provided by a continuing education provider. Thirty minutes will count for every one hour completed for this activity, except for live or recorded interactive webinars;

(ii) Self-study can be reading a book that contributes to the professional knowledge and development of the licensed dentist, or enhance services provided to patients. A two-page synopsis of what was learned written by the licensed dentist is required. Two hours of continuing education for each book and synopsis will be granted. A licensed dentist may not count more than six hours every three years for this activity.

(c) Teaching, presenting, or lecturing in a course, only if the presentation or lecture is created or authored by the dentist claiming the continuing education hours. A licensed dentist may not count more than 21 hours every three years in this activity;

(d) Direct clinical supervision of dental students and dental residents. A licensed dentist may not count more than 21 hours every three years in this activity;

(e) Publishing a paper in a peer review journal. A licensed dentist may count 15 hours the year the paper is published and may not count more than a total of 30 hours every three years in this activity. A copy of the publication is required;

(f) Reading and critically evaluating any hypothesis-driven scientific journal article on a topic that has relevance to dentistry and is published in a peer-reviewed journal devoted to dentistry, medicine, or useful to dentistry. A licensed dentist may not count more than 21 hours every three years.

(i) Before completing this activity, the licensed dentist must complete at least four hours of education in evidence-based dentistry or medicine that includes journal article evaluation. The four-hour education may count toward the required 63-hour requirement. The four-hour education is a one-time requirement. A licensed dentist may not count more than four hours every three years.

(ii) A licensed dentist may count one hour for each article that the dentist completes a "Critical Evaluation of a Journal Article" questionnaire. The questionnaire may be obtained from the commission. The completed questionnaire is required;

(g) Volunteer dental patient care. A licensed dentist may not count more than 21 hours every three years; and

(h) The commission will accept a current certification or recertification from any specialty board approved and recognized by the American Dental Association (ADA), the American Board of Dental Specialties (ABDS), or other specialty board certification or recertification approved by the commission as 62 hours of continuing education. The commission will also accept the award of Fellow of the Academy of General Dentistry, Master of the Academy of General Dentistry, or the Lifelong Learning and Service Recognition Award as 62 hours of continuing education. The certification, recertification, or award must be obtained in the three-year reporting period.

(6) Proof of continuing education is a certificate of completion, letter, or other documentation verifying or confirming attendance or completion of continuing education hours. Documentation must be from the organization that provided the activity, except in subsection (5)(b)(ii), (e), and (f)(ii) of this section, and must contain at least the following:

(a) Date of attendance or completion;

(b) Hours earned; and

(c) Course title or subject.

Effective August 1, 2020, a licensed dentist must complete a commission-approved one-time training that is at least three hours in length for suicide assessment that includes screening, referral, and imminent harm via lethal means elements.

(1) This training must be completed by the end of the first full continuing education reporting period after August 1, 2020, or during the first full continuing education reporting period after initial licensure, whichever is later.

(2) Training accepted by the commission must be on the department's model list as authorized in chapter 246-12 WAC, Part 14.

(3) A licensed dentist who has successfully completed the suicide assessment, treatment, and management curriculum in RCW 43.70.447, by the school of dentistry at the University of Washington prior to licensure is exempt from the training requirement in this section.

(4) Training completed between July 23, 2017, and August 1, 2020, that meets the requirements of subsection (2) or (3) of this section, is accepted as meeting the one-time training requirement of this section.

(5) The hours spent completing the training in suicide assessment under this section count toward meeting applicable continuing education requirements for dentist license renewal.

(1) To renew a certification a certified dental anesthesia assistant must complete a minimum of 14 hours of continuing education every three years and follow the requirements of WAC 246-12-170 through 246-12-240.

(2) A certified dental anesthesia assistant must complete a minimum of two hours of approved health equity training every three years. Two hours of continuing education will be granted towards the 14-hour requirement. An approved program providing health equity continuing education training must meet the requirements listed in WAC 246-12-830. For purposes of this rule, health equity has the same meaning as defined in WAC 246-12-810.

(3) Continuing education must involve direct application of dental anesthesia assistant knowledge and skills in one or more of the following categories:

(a) General anesthesia;

(b) Moderate sedation;

(c) Physical evaluation;

(d) Medical emergencies;

(e) Health care provider basic life support (BLS), advanced cardiac life support (ACLS), or pediatric advanced life support (PALS);

(f) Monitoring and use of monitoring equipment;

(g) Pharmacology of drugs; and agents used in sedation and anesthesia.

(4) Continuing education is defined as any of the following activities:

(a) Attendance at local, state, national, or international continuing education courses;

(b) Health care provider basic life support (BLS), advanced cardiac life support (ACLS), or pediatric advanced life support (PALS), or emergency related classes;

(c) Self-study through the use of multimedia devices or the study of books, research materials, or other publications.

(i) Multimedia devices. The required documentation for this activity is a letter or other documentation from the organization. A maximum of two hours is allowed per reporting period.

(ii) Books, research materials, or other publications. The required documentation for this activity is a two-page synopsis of what was learned written by the credential holder. A maximum of two hours is allowed per reporting period.

(d) Distance learning. Distance learning includes, but is not limited to, correspondence course, webinar, print, audio/video broadcasting, audio/video teleconferencing, computer aided instruction, e-learning/on-line-learning, or computer broadcasting/webcasting. A maximum of four hours of distance learning is allowed per reporting period.

The definitions in this section apply throughout this section and WAC 246-817-460 unless the context requires otherwise.

(1) "Health care provider" means an individual applying for a credential or credentialed specifically as defined in chapters 18.32, 18.260, and 18.350 RCW.

(2) "Health care information" means any information, whether oral or recorded in any form or medium that identifies or can readily be associated with the identity of, and relates to the health care of, a patient.

(3) "Key party" means a person legally authorized to make health care decisions for the patient.

(4) "Legitimate health care purpose" means activities for examination, diagnosis, treatment, and personal care of patients, including palliative care, as consistent with community standards of practice for the dental profession. The activity must be within the scope of practice of the health care provider.

(5) "Patient" means an individual who receives health care services from a health care provider. The determination of when a person is a patient is made on a case-by-case basis with consideration given to a number of factors, including the nature, extent and context of the professional relationship between the health care provider and the person. The fact that a person is not receiving treatment or professional services is not the sole determining factor.

(1) A health care provider shall not engage, or attempt to engage, in sexual misconduct with a current patient, or key party, inside or outside the health care setting. Sexual misconduct shall constitute grounds for disciplinary action. Sexual misconduct includes, but is not limited to:

(a) Sexual intercourse;

(b) Touching the breasts, genitals, anus or any sexualized body part except as consistent with accepted community standards of practice for examination, diagnosis and treatment and within the health care provider's scope of practice;

(c) Rubbing against a patient or key party for sexual gratification;

(d) Kissing;

(e) Hugging, touching, fondling or caressing of a romantic or sexual nature;

(f) Examination of or touching genitals without using gloves;

(g) Not allowing a patient privacy to dress or undress except as may be necessary in emergencies or custodial situations;

(h) Not providing the patient a gown or draping except as may be necessary in emergencies;

(i) Dressing or undressing in the presence of the patient or key party;

(j) Removing patient's clothing or gown or draping without consent, emergent medical necessity or being in a custodial setting;

(k) Encouraging masturbation or other sex act in the presence of the health care provider;

(l) Masturbation or other sex act by the health care provider in the presence of the patient or key party;

(m) Soliciting a date with a patient or key party;

(n) Discussing the sexual history, preferences or fantasies of the health care provider;

(o) Any behavior, gestures, or expressions that can reasonably be interpreted as seductive or sexual;

(p) Sexually demeaning behavior including any verbal or physical contact which can reasonably be interpreted as demeaning, humiliating, embarrassing, threatening or harming a patient or key party;

(q) Photographing or filming the body or any body part or pose of a patient or key party, other than for legitimate health care purposes; or for the educational or marketing purposes with the consent of the patient; and

(r) Showing a patient or key party sexually explicit photographs, other than for legitimate health care purposes.

(2) Sexual misconduct also includes sexual contact with any person involving force, intimidation, or lack of consent; or a conviction of a sex offense as defined in RCW 9.94A.030.

(3) A health care provider shall not:

(a) Offer to provide health care services in exchange for sexual favors;

(b) Use health care information to contact the patient or key party for the purpose of engaging in sexual misconduct;

(c) Use health care information or access to health care information to meet or attempt to meet the health care provider's sexual needs.

(4) A health care provider shall not engage in the activities listed in subsection (1) of this section with a former patient or key party if the health care provider:

(a) Uses or exploits the trust, knowledge, influence or emotions derived from the professional relationship; or

(b) Uses or exploits privileged information or access to privileged information to meet the health care provider's personal or sexual needs.

(5) When evaluating whether a health care provider has engaged or has attempted to engage in sexual misconduct, the commission will consider factors including, but not limited to:

(a) Documentation of a formal termination;

(b) Transfer of care to another health care provider;

(c) Duration of the health care provider-patient relationship;

(d) Amount of time that has passed since the last dental health care services to the patient;

(e) Communication between the health care provider and the patient between the last dental health care services rendered and commencement of the personal relationship;

(f) Extent to which the patient's personal or private information was shared with the health care provider;

(g) Nature of the patient's health condition during and since the professional relationship; and

(h) The patient's emotional dependence and vulnerability.

(6) Patient or key party initiation or consent does not excuse or negate the health care provider's responsibility.

(7) These rules do not prohibit:

(a) Providing health care services in case of emergency where the services cannot or will not be provided by another health care provider;

(b) Contact that is necessary for a legitimate health care purpose and that meets the standard of care appropriate to the dental profession; or

(c) Providing dental services for a legitimate health care purpose to a person who is in a preexisting, established personal relationship with the health care provider where there is no evidence of, or potential for, exploiting the patient.

The purpose of WAC 246-817-501 through 246-817-570 is to establish guidelines on delegation of duties to persons who are not licensed to practice dentistry. The dental laws of Washington state authorized the delegation of certain duties to nondentist personnel and prohibit the delegation of certain other duties. By statute, the duties that may be delegated to a person not licensed to practice dentistry may be performed only under the supervision of a licensed dentist. The degree of supervision required to assure that treatment is appropriate and does not jeopardize the systemic or oral health of the patient varies with, among other considerations, the nature of the procedure and the qualifications of the person to whom the duty is delegated. The dentist is ultimately responsible for the services performed in his/her office and this responsibility cannot be delegated. In order to protect the health and well-being of the people of this state, the DQAC finds it necessary to adopt the following definitions and regulations.

The definitions in this section apply throughout WAC 246-817-501 through 246-817-570 unless the context clearly requires otherwise.

(1) "Close supervision" means that a supervising dentist whose patient is being treated has personally diagnosed the condition to be treated and has personally authorized the procedures to be performed. The supervising dentist is continuously on-site and physically present in the treatment facility while the procedures are performed by the assistive personnel and capable of responding immediately in the event of an emergency. Close supervision does not require a supervising dentist to be physically present in the operatory.

(2) "Coronal polishing" means a procedure limited to the removal of plaque and stain from exposed tooth surfaces, using an appropriate instrument and polishing agent.

This procedure is not intended or interpreted to be an oral prophylaxis as defined in subsection (8) of this section a procedure specifically reserved to be performed by a licensed dentist or dental hygienist. Coronal polishing may, however, be a portion of the oral prophylaxis procedure.

(3) "Debridement at the periodontal surgical site" means curettage or root planing after reflection of a flap by the supervising dentist. This does not include cutting of osseous tissues.

(4) "Elevating soft tissues" means part of a surgical procedure involving the use of the periosteal elevator to raise flaps of soft tissues. Elevating soft tissue is not a separate and distinct procedure in and of itself.

(5) "General supervision" means that a supervising dentist has examined and diagnosed the patient and provided subsequent instructions to be performed by the assistive personnel, but does not require that the dentist be physically present in the treatment facility.

(6) "Incising" means part of the surgical procedure of which the end result is removal of oral tissue. Incising, or the making of an incision, is not a separate and distinct procedure in and of itself.

(7) "Luxation" means an integral part of the surgical procedure of which the end result is extraction of a tooth. It is the dislocation or displacement of a tooth or of the temporomandibular articulation.

(8) "Oral prophylaxis" means the preventive dental procedure of scaling and polishing which includes complete removal of calculus, soft deposits, plaque, stains and the smoothing of unattached tooth surfaces. The objective of this treatment is to create an environment in which hard and soft tissues can be maintained in good health by the patient.

(9) "Periodontal soft tissue curettage" means the closed removal of tissue lining the periodontal pocket, not involving the reflection of a flap.

(10) "Root planing" means the process of instrumentation by which the unattached surfaces of the root are made smooth by the removal of calculus or deposits.

(11) "Supportive services" means services that are related to clinical functions in direct relationship to treating a patient.

(12) "Suturing" is defined as the readaption of soft tissue by use of stitches as a phase of an oral surgery procedure.

(13) "Treatment facility" means a dental office or connecting suite of offices, dental clinic, room or area with equipment to provide dental treatment, or the immediately adjacent rooms or areas. A treatment facility does not extend to any other area of a building in which the treatment facility is located.

(14) "Volunteer dental assistant" means an individual who, without compensation, provides the supportive services under WAC 246-817-520 in a charitable dental clinic.

(1) A supervising dentist may delegate the supportive services in subsection (4) of this section under the dentist's close supervision, provided the registered dental assistant has demonstrated skills necessary to perform each task competently.

(2) Delegation of supportive services not in subsection (4) of this section may be subject to disciplinary action.

(3) In addition to supportive services in subsection (4) of this section, registered dental assistants may perform nonclinical tasks.

(4) Supportive services allowed under close supervision:

(a) Oral inspection, with no diagnosis.

(b) Take and record blood pressure and vital signs.

(c) Place, expose, and process radiographs.

(d) Take intra-oral and extra-oral photographs.

(e) Perform coronal polish. A licensed dentist shall determine the teeth are free of calculus or other extraneous material prior to dismissing the patient.

(f) Give fluoride treatments.

(g) Give patient education in oral hygiene.

(h) Give preoperative and postoperative instructions.

(i) Deliver an oral sedative drug to patient.

(j) Assist in the administration of inhalation minimal sedation (nitrous oxide) analgesia, including starting and stopping the flow as directed by the supervising dentist.

(k) Place topical anesthetics.

(l) Place and remove the rubber dam.

(m) Apply tooth separators as for placement for Class III gold foil.

(n) Apply sealants.

(o) Place a matrix and wedge for a direct restorative material after the dentist has prepared the cavity.

(p) Place cavity liners and bases.

(q) Perform acid etch and apply bonding agents.

(r) Polish restorations but may not intra-orally adjust or finish permanent restorations.

(s) Sterilize equipment and disinfect operatories.

(t) Place retraction cord.

(u) Hold in place and remove impression materials after the dentist has placed them.

(v) Take impressions, bite registrations, or digital scans of the teeth and jaws for:

(i) Diagnostic and opposing models;

(ii) Fixed and removable orthodontic appliances, occlusal guards, bleaching trays, and fluoride trays; and

(iii) Temporary indirect restorations such as temporary crowns.

(w) Take digital scans of prepared teeth for fabrication of permanent indirect restorations.

(x) Take a facebow transfer for mounting study casts.

(y) Fabricate and deliver bleaching and fluoride trays.

(z) Fabricate, cement, and remove temporary crowns or temporary bridges.

(aa) Remove the excess cement after the dentist has placed a permanent or temporary inlay, crown, bridge or appliance, or around orthodontic bands.

(bb) Place a temporary filling (as zinc oxide-eugenol (ZOE)) after diagnosis and examination by the dentist.

(cc) Pack and medicate extraction areas.

(dd) Place periodontal packs.

(ee) Remove periodontal packs or sutures.

(ff) Select denture shade and mold.

(gg) Place and remove orthodontic separators.

(hh) Select and fit orthodontic bands, try in fixed or removable orthodontic appliances prior to the dentist cementing or checking the appliance.

(ii) Prepare teeth for the bonding of orthodontic appliances.

(jj) Bond attachments for clear removable orthodontic aligners.

(kk) Remove and replace archwires and orthodontic wires.

(ll) Fit and adjust headgear.

(mm) Remove fixed orthodontic appliances, orthodontic cement, and orthodontic bonded resin material.

(1) A supervising dentist may delegate the supportive services in subsection (5) of this section under the dentist's close supervision, provided the EFDA has demonstrated skills necessary to perform each task competently.

(2) A dentist may delegate the supportive services in subsection (6) of this section under the dentist's general supervision, provided the EFDA has demonstrated skills necessary to perform each task.

(3) Delegation of supportive services not in subsection (5) or (6) of this section may be subject to disciplinary action.

(4) In addition to supportive services in subsections (5) and (6) of this section, licensed EFDAs may perform nonclinical tasks.

(5) Supportive services allowed under close supervision:

(a) Supportive services under WAC 246-817-520(4), except for supportive services in subsection (6) of this section.

(b) Place, carve, finish, and polish direct restorations.

(c) Take preliminary and final impressions and bite registrations, to include computer assisted design and computer assisted manufacture applications.

(6) Supportive services allowed under general supervision are:

(a) Perform coronal polishing.

(b) Give fluoride treatments.

(c) Apply sealants.

(d) Place, expose, and process radiographs.

(e) Give patient oral health instructions.

Unlicensed persons may select shade for crowns or fixed prostheses with the use of a technique which does not contact the oral cavity to avoid contamination with blood or saliva. The procedure shall be performed pursuant to the written instructions and order of a licensed dentist.

This list is not all inclusive. Delegation of procedures not in subsections (1) through (22) of this section should not be assumed to be allowed. Supportive services approved for delegation to registered dental assistants are under WAC 246-817-520. A dentist may not allow registered dental assistants who are in his or her employ or are acting under his or her supervision or direction to perform any of the following procedures:

(1) Any removal of or addition to the hard or soft natural tissue of the oral cavity.

(2) Any placing of permanent restorations in natural teeth.

(3) Any diagnosis of or prescription for treatment of disease, pain, deformity, deficiency, injury, or physical condition of the human teeth or jaws, or adjacent structure.

(4) Any administration of general or local anesthetic, including intravenous sedation.

(5) Any oral prophylaxis, except coronal polishing as a part of oral prophylaxis as defined under WAC 246-817-510 and 246-817-520 (4)(e).

(6) Any scaling procedure.

(7) The taking of any impressions of the teeth or jaws, or the relationships of the teeth or jaws, for the purpose of fabricating any intra-oral restoration, appliances, or prosthesis, other than impressions allowed as a delegated task under WAC 246-817-520.

(8) Intra-orally adjust and finish permanent restorations.

(9) Cement or recement any permanent restoration or stainless steel crown.

(10) Incise gingiva or other soft tissue.

(11) Elevate soft tissue flap.

(12) Luxate teeth.

(13) Curette to sever epithelial attachment.

(14) Suture.

(15) Establish occlusal vertical dimension for dentures.

(16) Try-in of dentures set in wax.

(17) Insertion and post-insertion adjustments of dentures.

(18) Endodontic treatment - Open, extirpate pulp, ream and file canals, establish length of tooth, and fill root canal.

(19) Use of any light or electronic device for invasive procedures.

(20) Intra-oral air abrasion or mechanical etching devices.

(21) Place direct pulp caps.

(22) Fit and adjust occlusal guards.

This list is not all inclusive. Delegation of procedures not in subsections (1) through (20) of this section should not be assumed to be allowed. Supportive services approved for delegation to licensed expanded function dental auxiliaries are under WAC 246-817-525. A dentist may not allow EFDAs who are in his or her employ or are acting under his or her supervision or direction to perform any of the following procedures:

(1) Any removal of or addition to the hard or soft natural tissue of the oral cavity except for placing and carving direct restorations.

(2) Any diagnosis of or prescription for treatment of disease, pain, deformity, deficiency, injury, or physical condition of the human teeth or jaws, or adjacent structure.

(3) Any administration of general or local anesthetic, including intravenous sedation.

(4) Any oral prophylaxis, except coronal polishing as a part of oral prophylaxis as defined under WAC 246-817-510 and 246-817-520 (4)(e).

(5) Any scaling procedure.

(6) Intra-orally adjust and finish permanent inlays, crowns, and bridges.

(7) Cement or recement any permanent restoration or stainless steel crown.

(8) Incise gingiva or other soft tissue.

(9) Elevate soft tissue flap.

(10) Luxate teeth.

(11) Curette to sever epithelial attachment.

(12) Suture.

(13) Establish occlusal vertical dimension for dentures.

(14) Try-in of dentures set in wax.

(15) Insertion and postinsertion adjustments of dentures.

(16) Endodontic treatment - Open, extirpate pulp, ream and file canals, establish length of tooth, and fill root canal.

(17) Use of any light or electronic device for invasive procedures.

(18) Intra-oral air abrasion or mechanical etching devices.

(19) Place direct pulp caps.

(20) Fit and adjust occlusal guards.

A dentist may allow a dental hygienist licensed under chapter 18.29 RCW to perform the following acts under the dentist's general supervision:

(1) Head and neck examination.

(2) Oral inspection and measuring of periodontal pockets, with no diagnosis.

(3) Record health histories.

(4) Take and record blood pressure and vital signs.

(5) Take intraoral and extraoral radiographs.

(6) Take intraoral and extraoral photographs.

(7) Patient education in oral hygiene.

(8) Give preoperative and postoperative instructions.

(9) Oral prophylaxis and removal of deposits and stains from the surfaces of the teeth.

(10) Give fluoride treatments.

(11) Apply topical anesthetic agents.

(12) Deliver oral antibiotic prophylaxis as prescribed by a dentist.

(13) Place and remove the rubber dam.

(14) Apply topical preventive or prophylactic agents.

(15) Administer local anesthetic agents and adjunctive procedures if all conditions in (a) through (d) of this subsection are met. Adjunctive procedures include local anesthetic reversal agents and buffered anesthetic.

(a) The patient is at least eighteen years of age;

(b) The patient has been examined by the delegating dentist within the previous twelve months;

(c) There has been no change in the patient's medical history since the last examination. If there has been a change in the patient's medical history within that time, the dental hygienist must consult with the dentist before administering local anesthetics;

(d) The delegating dentist who performed the examination has approved the patient for the administration of local anesthetics by a dental hygienist under general supervision and documented this approval in the patient's record;

(e) If any of the conditions in (a) through (d) of this subsection are not met, then close supervision is required.

(16) Perform subgingival and supragingival scaling.

(17) Perform root planing.

(18) Apply sealants.

(19) Polish and smooth restorations.

(20) Sterilize equipment and disinfect operatories.

(21) Place retraction cord.

(22) Take impressions, bite registration, or digital scans of the teeth and jaws for:

(a) Diagnostic and opposing models;

(b) Fixed and removable orthodontic appliances, occlusal guards, bleaching trays, and fluoride trays; and

(c) Temporary indirect restorations such as temporary crowns.

(23) Take a facebow transfer for mounting study casts.

(24) Fabricate and deliver bleaching and fluoride trays.

(25) Fabricate, cement, and remove temporary crowns or temporary bridges.

(26) Place a temporary filling such as zinc oxide-eugenol or ZOE after diagnosis and examination by the dentist.

(27) Remove excess cement after the dentist has placed a permanent or temporary inlay, crown, bridge or appliance, or around orthodontic bands.

(28) Pack and medicate extraction areas.

(29) Place periodontal packs.

(30) Remove periodontal packs or sutures.

(31) Select denture shade and mold.

(32) Place and remove orthodontic separators.

(33) Select and fit orthodontic bands, try in fixed or removable orthodontic appliances prior to the dentist cementing or checking the appliance.

In addition to the acts allowed in WAC 246-817-520 and 246-817-550, a dentist may allow a dental hygienist licensed under chapter 18.29 RCW to perform the following acts under the dentist's close supervision:

(1) Perform soft-tissue curettage.

(2) Administer local anesthetic agents and adjunctive procedures.

(a) General supervision is allowed if all conditions in WAC 246-817-550 (6)(a) through (d) are met.

(b) Adjunctive procedures include local anesthetic reversal agents and buffered anesthetic.

(3) Place restorations into the cavity prepared by the dentist, and thereafter could carve, contour, and adjust contacts and occlusion of the restoration.

(4) Administer nitrous oxide analgesia.

(5) Place antimicrobials.

No dentist shall allow a dental hygienist duly licensed under the provisions of chapter 18.29 RCW who is in his/her employ or is acting under his/her supervision or direction to perform any of the following procedures:

(1) Any surgical removal of tissue of the oral cavity, except for soft-tissue curettage, as defined in WAC 246-817-510.

(2) Any prescription of drugs or medications requiring the written order or prescription of a licensed dentist or physician.

(3) Any diagnosis for treatment or treatment planning.

(4) The taking of any impression of the teeth or jaw, or the relationship of the teeth or jaw, for the purpose of fabricating any intra-oral restoration, appliances, or prosthesis. Not prohibited are the taking of impressions solely for diagnostic and opposing models or taking wax bites solely for study casts.

(5) Intra-orally adjust occlusal of inlays, crowns, and bridges.

(6) Intra-orally finish margins of inlays, crowns, and bridges.

(7) Cement or recement, permanently, any cast restorations or stainless steel crowns.

(8) Incise gingiva or other soft tissue.

(9) Elevate soft tissue flap.

(10) Luxate teeth.

(11) Curette to sever epithelial attachment.

(12) Suture.

(13) Establish occlusal vertical dimension for dentures.

(14) Try-in of dentures set in wax.

(15) Insertion and post-insertion adjustments of dentures.

(16) Endodontic treatment—Open, extirpate pulp, ream and file canals, establish length of tooth, and fill root canal.

(1) A supervising dentist may delegate the administration of a test for screening of novel coronavirus disease 2019 to a registered dental assistant and licensed expanded function dental auxiliary under the dentist's close supervision, provided the registered dental assistant and licensed expanded function dental auxiliary have demonstrated skills necessary to perform the task competently.

(2) A supervising dentist may delegate the administration of a test for screening of novel coronavirus disease 2019 to a licensed dental hygienist under the dentist's general supervision, provided the licensed dental hygienist has demonstrated skills necessary to perform the task competently.

(1) A supervising dentist may delegate the administration of a vaccination of novel coronavirus disease 2019 to a licensed dental hygienist under the dentist's close supervision, provided the licensed dental hygienist has demonstrated skills necessary to perform the task competently.

(2) For the purpose of administering vaccination for the novel coronavirus disease 2019, a dentist's approval of the vaccination protocol and screening meets the dentist's requirement to diagnose the condition to be treated and personal authorization of the procedure as required by close supervision under WAC 246-817-510(1).

The purpose of WAC 246-817-601 through 246-817-660 is to establish requirements for infection control where dentistry is provided in the state of Washington to protect the health and well-being of the people. The Centers for Disease Control and Prevention Guidelines for Infection Control in Dental Health-Care Settings 2003, MMWR Vol. 52, No. RR-17, and the Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care, March 2016, are the basis for these rules. Case reports and public health events regarding the transmission of diseases from patient to patient, practitioner to patient, and patient to practitioner have been published that demonstrate risks that were either unrecognized in the past or new. This includes people accompanying patients and visitors. A strong educational component for practitioners is necessary to prevent disease transmission from patient to practitioner, practitioner to patient, and patient to patient.

The following definitions apply throughout WAC 246-817-601 through 246-817-660 unless the context clearly requires otherwise.

(1) "Hand hygiene" means the use of soap and water when hands are visibly soiled; or use of an alcohol-based hand rub.

(2) "Practitioner" means a licensed dentist under chapter 18.32 RCW, licensed dental hygienist under chapter 18.29 RCW, a licensed expanded function dental auxiliary under chapter 18.260 RCW, a certified dental anesthesia assistant, or a registered dental assistant under chapter 18.260 RCW.

(3) "The Centers for Disease Control and Prevention" or "CDC" means a federal agency that conducts and supports health promotion, prevention and preparedness activities in the United States.

(1) A licensed dentist shall develop and maintain written infection prevention policies and procedures appropriate for the dental services provided by the facility.

(2) A licensed dentist shall review with all practitioners the current office infection prevention policies and procedures annually. A licensed dentist shall maintain documentation of the annual review with all practitioners for five years.

(3) A practitioner shall complete one hour of current infection prevention standards education annually provided by a qualified individual or organization.

(4) Infection prevention standards education must include:

(a) Standard precautions and prevention of disease transmission;

(b) Prevention of cross-contamination;

(c) Practitioner safety and personal protection equipment;

(d) Hand hygiene;

(e) Respiratory hygiene and cough etiquette;

(f) Sharps safety and safe injection practices;

(g) Sterilization and disinfection of patient care items and devices;

(h) Environmental infection prevention and control;

(i) Dental unit water quality; and

(j) The requirements in WAC 246-817-601 through 246-817-660.

(5) A practitioner shall maintain their personal documentation of infection control prevention standards education for a period of five years.

(6) For the purposes of this section, a qualified individual or organization means a person or entity that has verifiable training, expertise, or experience in all aspects of infection control.

A practitioner shall comply with the applicable requirements of the Washington Industrial Safety and Health Act under chapter 49.17 RCW.

A practitioner shall perform hand hygiene as defined in WAC 246-817-610 in any of these situations:

(1) When hands are visibly soiled;

(2) In the event of barehanded touching of instruments, equipment, materials, and other objects likely to be contaminated by blood, saliva, or respiratory secretions; or

(3) Before and after treating each patient.

(1) A practitioner shall wear gloves whenever there is a potential for contact with blood, body fluids, mucous membranes, nonintact skin, or contaminated equipment.

(a) New gloves are required for each patient.

(b) Gloves must not be washed or reused.

(c) Gloves selection must be based on the performance characteristics of the glove in relation to the task to be performed as applicable in WAC 296-800-16065 and 296-823-15010.

(2) A practitioner shall wear mouth, nose, and eye protection during procedures that are likely to generate aerosols or splashes or splattering of blood or other body fluids.

(3) A practitioner shall comply with Washington state occupational exposure to bloodborne pathogens WAC 296-823-150.

(1) A licensed dentist shall post signs in a place visible to individuals receiving services in the premises with instructions to patients with symptoms of respiratory infection to:

(a) Cover their mouth/nose when coughing or sneezing;

(b) Use and dispose of tissues;

(c) Perform hand hygiene after hands have been in contact with respiratory secretions.

(2) A licensed dentist shall provide tissues and no-touch receptacles for disposal of tissues in the dental office.

(3) A licensed dentist shall offer masks to coughing patients and accompanying individuals in the dental office.

(1) A practitioner shall follow the CDC Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care, March 2016, guidelines for safe injection practices in dental settings.

(2) A practitioner shall use either a one-handed scoop technique or mechanical device designed for holding the needle cap when recapping needles. A practitioner shall not recap used needles by using both hands or any other technique that involves directing the point of a needle toward any part of the body.

(3) A practitioner shall place used disposable syringes and needles, scalpel blades, and other sharp items in appropriate puncture-resistant containers in each operatory.

A practitioner shall:

(1) Follow the CDC Guidelines for Infection Control in Dental Health-Care Settings 2003, MMWR Vol. 52, No. RR-17, Appendix C for Methods for Sterilizing and Disinfecting Patient-Care Items and Environmental Surfaces, including:

(a) Clean and reprocess through disinfection or sterilization reusable critical, semicritical, and noncritical dental equipment and devices according to manufacturer instructions before use on another patient.

(i) Effective August 31, 2022, sterilization of low-speed hand piece motors after use on a patient is required.

(ii) Sterilization is not required for those sections of a battery operated hand piece system that cannot be sterilized according to manufacturer's instructions. However, battery operated hand piece systems that have specific engineering controls to isolate the sections that cannot be sterilized, render those sections "noncritical," must be used if commercially available; those sections that cannot be sterilized must be processed according to manufacturer's instructions between patient uses.

(b) Clean and reprocess through disinfection or sterilization reusable critical, semicritical, and noncritical dental equipment and devices according to manufacturer instructions.

(c) Clean and reprocess reusable dental equipment according to the manufacturer instructions.

(d) All disposable and single-use items, as labeled by the United State Food and Drug Administration, must be discarded after use on a single patient.

(i) Single-use items that need to be tested for size are not considered used unless cemented in the mouth. Single-use items can be cleaned or reprocessed (disinfected or sterilized) when following manufacturer's instructions.

(ii) If a single-use item is not used, but is contaminated or exposed to aerosols during the appointment by being placed on a surface ready to use, it may only be sterilized if the process of doing so does not compromise the efficacy of the item including, but not limited to, anesthetic carpules.

(2) Bag or wrap contaminated instruments in packages, containers, or cassettes in preparation for sterilization.

(a) Store sterile instruments and supplies in a covered or closed area.

(b) Wrapped packages, containers, or cassettes of sterilized instruments must be inspected before opening and use to ensure the packaging material has not been compromised.

(c) Wrapped packages, containers, or cassettes of sterilized instruments must be opened as close to the time of the procedure as possible. Opening in the presence of the patient is preferred.

(d) Instruments sterilized for immediate use do not mandate the use of a bag or a wrap. If the instrument is not used immediately, it must be bagged or wrapped.

(3) Use all mechanical, chemical, and biological monitors according to manufacturer instructions to ensure the effectiveness of the sterilization process.

(4) Test sterilizers by biological spore test method as recommended by the manufacturer on at least a weekly basis when scheduled patients are treated.

(a) In the event of a positive biological spore test, the licensed dentist shall take immediate remedial action as recommended by the manufacturer.

(b) A licensed dentist shall record biological spore tests and results either in the form of a log reflecting dates and person or persons conducting the testing or copies of reports from an independent testing entity. A licensed dentist shall maintain this documentation for a period of five years.

(5) Thoroughly rinse items such as impressions contaminated with blood or saliva. Place and transport items such as impressions to a dental laboratory off-site in a case containment device that is sealed and labeled.

(6) Disinfect all work surfaces after each patient.

(7) Disinfect using an intermediate-level disinfectant having, but not limited to, a tuberculocidal claim, when a surface is visibly contaminated with blood.

(8) Use only United States Environmental Protection Agency registered disinfectants or detergents/disinfectants with label claims for use in health care setting, following the manufacturer's instructions.

(9) Use high volume evacuation (HVE) whenever possible in all clinical situations expected to produce aerosol or spatter, such as, but not limited to, ultrasonics, high-speed hand pieces and air polishing devices. HVE equipment must be installed and maintained to manufacturer's specifications to ensure proper evacuation at the treatment site. HVE devices must be used as intended for HVE. A saliva ejector does not qualify as an HVE device.

(10) The following definitions apply to WAC 246-817-655.

(a) "Critical," "semicritical," and "noncritical" means categories given to patient care items including, but not limited to, dental instruments, devices, and equipment depending on the potential risk of infection associated with intended use.

(i) "Critical items" means those items used to penetrate soft tissue, contact bone, enter into or contact the bloodstream or other normally sterile tissue. Critical items must be sterilized by heat.

(ii) "Noncritical items" means those items used to contact intact skin. Noncritical items must be disinfected with United States Environmental Protection Agency registered hospital disinfectant or detergent.

(iii) "Semicritical items" means those items used to contact mucous membranes or nonintact skin. Semicritical items must be sterilized by heat if heat-tolerant, or by high-level disinfection if a semicritical item is heat-sensitive.

(b) "Disinfect" or "disinfection" means use of a chemical agent on inanimate objects, such as floors, walls, or sinks, to destroy virtually all recognized pathogenic microorganisms, but not necessarily all microbial forms such as bacterial endospores.

(c) "High-level disinfection" means disinfection that inactivates vegetative bacteria, mycobacteria, fungi, and viruses but not necessarily high numbers of bacterial spores.

(d) "High volume evacuation" or "HVE" means the equipment used to remove debris, aerosols, and liquids.

(e) "Remedial action" means manufacturer recommended action necessary to obtain a negative spore test result.

(f) "Sterilize" or "sterilization" means the use of heat, chemical, or other nonchemical procedure to destroy all microorganisms.

(1) A licensed dentist shall use water for nonsurgical procedures that meets United States Environmental Protection Agency regulatory standards for drinking water of five hundred or less colony-forming units or CFUs/mL.

(2) A licensed dentist shall follow dental equipment manufacturer's instructions when testing the water delivery system for acceptable water quality. If manufacturer's instructions are unavailable, a licensed dentist shall test the water delivery system for acceptable water quality quarterly. A licensed dentist shall test the water delivery system five to ten days after repair or changes in the plumbing system and again at twenty-one to twenty-eight days later.

(a) Effective December 1, 2021, all water lines must be tested.

(i) All water lines for each operatory or dental unit can be pooled as one single sample.

(A) A pooled sample must use an equal amount of water from each water line.

(B) A pooled sample can have up to ten water lines included.

(C) The number of water lines pooled into one sample must be documented.

(ii) All water lines for each operatory or dental unit can be tested individually.

(b) In the event of an unacceptable level of colony-forming units or CFUs, a licensed dentist shall take immediate remedial action. For the purposes of this section, remedial action means any action necessary to reduce the CFUs to five hundred or a lesser number currently recognized by the United States Environmental Protection Agency as acceptable for drinking water.

(c) A licensed dentist shall record the water delivery system testing and maintenance either in the form of a log reflecting dates and person or persons conducting the test or maintenance or copies of reports from an independent testing entity. A licensed dentist shall maintain this documentation for a period of five years.

The purpose of WAC 246-817-701 through 246-817-790 is to govern the administration of anesthetic, sedation, and general anesthesia by dentists licensed in the state of Washington in settings other than hospitals as defined in WAC 246-320-010 and ambulatory surgical facilities as defined in WAC 246-310-010, pursuant to the DQAC authority in RCW 18.32.640.

(1) The DQAC has determined that sedation and anesthesia permitting should be based on the level of sedation or anesthesia because sedation or anesthesia is a continuum, and the route of administration and drug combinations are both capable of producing a deeper level of sedation or anesthesia than is initially intended. Practitioners intending to produce a given level of sedation should be able to rescue patients who enter a state deeper than initially intended.

(2) All anesthesia providers must provide 24-hour, on-call availability following an anesthesia procedure.

(a) A licensed dentist that only administers local anesthesia shall provide timely telephonic or electronic communication with the patient or their representative by the provider or a designated provider.

(b) In the event a licensed dentist will be unavailable for timely assistance, the licensed dentist shall have a prearranged agreement with another provider that is available to provide timely care to a patient.

(3) The dental assistant and expanded function dental auxiliary may not administer any general or local anesthetic, including intravenous sedation.

The definitions in this section apply throughout WAC 246-817-701 through 246-817-790 unless the context clearly requires otherwise.

(1) "Advanced cardiac life support" or "ACLS" means a set of clinical interventions for the urgent treatment of cardiac arrest, stroke, and other life-threatening medical emergencies, as well as the knowledge and skills to deploy those interventions.

(2) "American Society of Anesthesiologists patient classification I" means a normal healthy patient.

(3) "American Society of Anesthesiologists patient classification II" means a patient with mild systemic disease.

(4) "American Society of Anesthesiologists patient classification III" means a patient with severe systemic disease.

(5) "American Society of Anesthesiologists patient classification IV" means a patient with severe systemic disease that is a constant threat to life.

(6) "Analgesia" means the diminution of pain in the conscious patient.

(7) "Anesthesia" means the loss of feeling or sensation, especially loss of sensation of pain.

(8) "Anesthesia monitor" means a credentialed health care provider specifically trained in monitoring patients under sedation and capable of assisting with procedures, problems and emergency incidents that may occur as a result of the sedation or secondary to an unexpected medical complication.

(9) "Anesthesia provider" means a dentist, physician anesthesiologist, dental hygienist, or certified registered nurse anesthetist (CRNA) licensed, authorized, competent, and qualified to perform anesthesia within the state of Washington.

(10) "Automated external defibrillator" or "AED" means a portable electronic device that automatically diagnoses the life-threatening cardiac arrhythmias of ventricular fibrillation and pulseless ventricular tachycardia, and is able to treat through defibrillation.

(11) "Basic life support" or "BLS" means a type of care health care providers and public safety professionals provide to anyone who is experiencing cardiac arrest, respiratory distress, or an obstructed airway.

(12) "Carbon dioxide" or "CO2" means a gas consisting of one part carbon and two parts oxygen.

(13) "Close supervision" means that a supervising dentist whose patient is being treated has personally diagnosed the condition to be treated and has personally authorized the procedures to be performed. The supervising dentist is continuously on-site and physically present in the treatment facility while the procedures are performed by the assistive personnel and capable of responding immediately in the event of an emergency. Close supervision does not require a supervising dentist to be physically present in the operatory.

(14) "Commission on Dental Accreditation" or "CODA" means a national organization that develops and implements accreditation standards that promote and monitor the continuous quality and improvement of dental education programs.

(15) "Deep sedation" means a drug induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

(16) "Dental anesthesia assistant" means a health care provider certified under chapter 18.350 RCW and specifically trained to perform the functions authorized in RCW 18.350.040 under supervision of an oral and maxillofacial surgeon or dental anesthesiologist.

(17) "Enteral" means any technique of administration in which an agent is absorbed through the gastrointestinal tract.

(18) "General anesthesia" means a drug induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain an airway and respond purposefully to physical stimulation or verbal command, produced by a pharmacologic or nonpharmacologic method, or combination thereof may be impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.

(19) "Minimal sedation" means a minimally depressed level of consciousness, produced by a pharmacological method, that retains the patient's ability to independently and continuously maintain an airway and respond normally to tactile stimulation and verbal commands. Although cognitive function and coordination may be modestly impaired, ventilatory and cardiovascular functions are unaffected.

(20) "Moderate sedation" means a drug induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Moderate sedation can include both enteral and parenteral routes of administration.

(21) "Nothing by mouth" or "NPO" means the time before an examination or procedure during which a patient cannot eat or drink.

(22) "Parenteral" means a technique of administration in which the drug bypasses the gastrointestinal (GI) tract including, but not limited to, intramuscular, intravenous, intranasal, submuscosal, subcutaneous, and intraosseous.

(23) "Pediatric" means a child 12 years of age or younger.

(24) "Pediatric advanced life support" or "PALS" means a type of care that focuses on providing advanced airway and life support skills in immediate emergency care to children.

(1) Dental staff providing direct patient care in an in-office or out-patient setting must hold a current and valid health care provider BLS certification. Initial and renewal certification must include both didactic and hands-on components.

(2) Health care provider BLS certification must be obtained from an individual, organization, or training center who holds a current and valid BLS instructor certification and teaches the current International Liaison Committee on Resuscitation or ILCOR standard including, but not limited to, American Heart Association or American Red Cross.

(3) Health care provider BLS instruction must include online or in-person didactic instruction with a written assessment, in-person skills assessment on high quality chest compressions, rescue breathing using the bag valve mask, correct use of AED or defibrillator for adults, children, and infants, feedback to students, and a valid health care provider BLS certification card upon completion.

(4) Dental staff providing direct patient care include: Licensed dentists, licensed dental hygienists, licensed expanded function dental auxiliaries, certified dental anesthesia assistants, and registered dental assistants.

(5) Newly hired office staff providing direct patient care are required to obtain the required certification within 45 days from the date hired.

When anesthetic agents of any kind are administered, the dentist and staff must have access to an AED or defibrillator. The AED or defibrillator must be available and in reach within 60 seconds.

When anesthetic agents of any kind are administered, the dentist must comply with the requirements in this section.

(1) The anesthesia provider or anesthesia monitor shall record the patient's condition. The record must include documentation of all medications administered with dosages, regular and consistent time intervals, and route of administration. The provider administering the sedation may determine time intervals.

(2) All patients receiving any anesthetic agent including local anesthesia or minimal sedation with nitrous oxide, vital signs including, but not limited to, blood pressure and heart rate must be recorded, unless the cooperation of the patient or circumstances of the case will not allow it. If pretreatment vitals cannot be obtained, the reason or reasons why must be recorded. Obtaining vital signs on ASA 1 age 13 and under will be at the dentist's discretion.

(3) The following equipment must be available and include:

(a) Suction equipment capable of aspirating gastric contents from the mouth and pharynx;

(b) Portable oxygen delivery system including full face masks and a bag-valve-mask combination with appropriate connectors capable of delivering positive pressure, oxygen enriched ventilation to the patient;

(c) Blood pressure cuffor sphygmomanometer of appropriate size;

(d) Stethoscope or equivalent monitoring device.

(4) The following emergency drugs must be available and maintained:

(a) Bronchodilator including, but not limited to, albuterol;

(b) Sugar or glucose;

(c) Aspirin;

(d) Antihistaminic including, but not limited to, diphenhydramine;

(e) Coronary artery vasodilator including, but not limited to, nitroglycerin;

(f) Anti-anaphylactic agent including, but not limited to, epinephrine.

(5) A licensed dentist shall develop and maintain written emergency protocols and ensure:

(a) All staff are trained in the protocols wherever anesthetic agents of any kind are administered.

(b) The emergency preparedness written protocols include training requirements and procedures specific to the licensed dentist's equipment and drugs for responding to emergency situations involving sedation or anesthesia, including information specific to respiratory emergencies.

(c) The protocols are reviewed annually, updated as necessary, and the review is documented.

(d) The protocols include basic life support protocols, advanced cardiac life support protocols, or pediatric advanced life support protocols based on the level of anesthetics being administered.

(6) Equipment used for monitoring patients must be calibrated or performance verified according to manufacturer's instructions.

Local anesthesia must only be administered by a provider qualified under this chapter and dental hygienists as provided in chapter 18.29 RCW.

(1) "Local anesthesia" means the elimination of sensations, especially pain, in one part of the body by the topical application or regional injection of a drug.

(2) A licensed dentist administering local anesthetic agents shall comply with recordkeeping, equipment, and emergency medication requirements in WAC 246-817-724.

(3) A permit of authorization is not required.

(1) To administer minimal sedation with nitrous oxide, a licensed dentist shall successfully complete a minimum of 14 hours of education and training in one of the following:

(a) Minimal sedation with nitrous oxide;

(b) Moderate sedation with nitrous oxide;

(c) Advanced education program accredited by the CODA that meets comprehensive and appropriate training necessary to administer and manage minimal sedation with nitrous oxide; or

(d) Education and training must be consistent with ADA Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students, adopted by ADA House of Delegates October 2016 or prior adopted version in effect at the time training was completed.

(2) A licensed dentist shall ensure:

(a) Delegation of administration for minimal sedation with nitrous oxide is under the close supervision of an anesthesia provider qualified under this chapter.

(b) A second individual is in the office and able to immediately respond to any request from the licensed dentist or anesthesia provider.

(c) The patient must be continuously observed while minimal sedation with nitrous oxide is administered.

(3) A licensed dentist shall comply with recordkeeping, equipment, and emergency medication requirements in WAC 246-817-724.

(4) Dental records must contain documentation in the chart of nitrous oxide, and oxygen administered or dispensed.

(a) In the case of nitrous oxide sedation only, the record must include the maximum nitrous oxide concentration used and the times started and stopped or total time of administration.

(b) Other inhalation agents require a dose record noting the time each concentration or agent was administered or dispensed.

(5) A licensed dentist who administers minimal sedation with nitrous oxide shall complete seven hours of continuing education every five years as required in WAC 246-817-773.

(6) A licensed dentist who administers minimal sedation with nitrous oxide must hold a current and valid BLS certification.

(7) A permit of authorization is not required.

(1) To administer minimal sedation which is limited to a single dose of a single oral agent with or without nitrous oxide, a licensed dentist shall successfully complete a minimum of 16 hours of education and training in one of the following:

(a) Minimal sedation; or

(b) Moderate sedation; or

(c) Advanced education program accredited by the CODA that meets comprehensive and appropriate training necessary to administer and manage minimal sedation; or

(d) Education and training must be consistent with ADA Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students, adopted by ADA House of Delegates October 2016 or prior adopted version in effect at the time training was completed.

(2) A licensed dentist shall:

(a) Evaluate patient considered for minimal sedation prior to the administration of any sedative procedure.

(i) Review of the patient's current medical history and medication use is required for healthy or medically stable individuals with American Society of Anesthesiologists patient classification of I or II.

(ii) Consultation with the patient's primary care physician or consulting medical specialist is required for patients with significant medical considerations whom have American Society of Anesthesiologists patient classification III or IV. If the licensed dentist is unsuccessful in contacting or consulting with the patient's physician or physicians, the licensed dentist shall document the attempt or document the patient has no physician to contact.

(b) Administer oral sedative agents in the treatment setting or prescribe for patient dosage prior to the appointment. Single oral agents must be in a dose that is not to exceed the manufacturer's maximum recommended for home use.

(c) Ensure a second individual is in the office and able to immediately respond to any request from the anesthesia provider administering minimal sedation.

(d) Ensure the patient is continuously observed while in the office under the influence of minimal sedation.

(e) Comply with the recordkeeping, equipment, and emergency medication requirements in WAC 246-817-724.

(f) Ensure any adverse reactions are documented in the patient record.

(g) If a patient unintentionally enters into a moderate level of sedation, ensure the patient is returned to a level of minimal sedation as quickly as possible. While returning the patient to the minimal sedation level, periodic monitoring of pulse, respiration, and blood pressure must be maintained. In such cases, these same parameters must be taken and recorded at appropriate intervals throughout the procedure and vital signs and level of consciousness must be recorded during the sedation and prior to dismissal of the patient.

(3) A licensed dentist shall document in the patient record all agents administered, time administered, and dosage for minimal sedation.

(4) A licensed dentist who administers minimal sedation shall complete seven hours of continuing education every five years as required in WAC 246-817-773.

(5) A licensed dentist who administers minimal sedation must hold a current and valid BLS certification.

(6) A permit of authorization is not required.

(1) A licensed dentist is required to hold a permit of authorization to administer moderate sedation with enteral agents.

(2) To obtain a moderate sedation with enteral agents permit, a licensed dentist shall:

(a) Comply with the permitting and renewal requirements in WAC 246-817-774; and

(b) Successfully complete:

(i) A minimum of 16 hours of education and training in minimal sedation as required in WAC 246-817-745(1); and

(ii) A minimum of 21 hours of education and training in moderate sedation.

(iii) Moderate sedation education and training must:

(A) Meet ADA Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students, adopted by ADA House of Delegates October 2016 or prior adopted version in effect at the time training was completed; and

(B) Include medical emergency management, not limited to airway management, conducted in-person with hands-on skills.

(3) A licensed dentist shall:

(a) Ensure the patient is evaluated for moderate sedation with enteral agents prior to the administration of any sedative.

(i) Review at an appropriate time the patient's medical history and medication use and NPO or nothing by mouth status.

(ii) Consult with the patient's primary care physician or consulting medical specialist for a patient with significant medical considerations whom have American Society of Anesthesiologists patient classification of III or IV. If the anesthesia provider is unsuccessful in contacting or consulting with the patient's physician or physicians, document the attempt or document the patient has no physician to contact.

(iii) Patients body mass index must be assessed as part of a preprocedural workup.

(b) Administer oral sedative agents in the treatment setting or prescribe for patient dosage prior to the appointment.

(c) Ensure a second individual is in the office who can immediately respond to any request from the anesthesia provider.

(d) Ensure the patient is continuously observed while in the office.

(e) Record any adverse reactions in the patient record.

(f) Ensure the patient is returned to a level of moderate sedation as quickly as possible, if a patient unintentionally enters a deeper level of sedation. While returning the patient to the moderate level of sedation, periodic monitoring of pulse, respiration, and blood pressure and pulse oximetry must be maintained. In such cases, these same parameters must be taken and recorded at appropriate intervals throughout the procedure and vital signs and level of consciousness must be recorded during the sedation and prior to dismissal of the patient.

(g) Ensure a patient receiving moderate sedation with enteral agents is accompanied by a responsible adult upon departure from the treatment facility.

(4) A licensed dentist shall comply with the recordkeeping, equipment, and emergency medication requirements in WAC 246-817-724.

(a) When a sedative drug is used that has a reversal agent, the reversal agent must be in the office emergency kit and the equipment to administer the reversal agent must be stored with the delivery device.

(b) Pulse oximetry equipment or equivalent respiratory monitoring equipment must be available in the office.

(5) A licensed dentist who holds a valid moderate sedation with enteral agents permit shall complete seven hours of continuing education every three years as required in WAC 246-817-773.

(6) A licensed dentist who holds a valid moderate sedation with enteral agents permit must hold a current and valid BLS certification.

(1) A licensed dentist is required to hold a permit of authorization to administer moderate sedation with parenteral agents. A moderate sedation with parenteral agents permit allows the holder to deliver moderate sedation with enteral agents without obtaining a separate permit.

(2) To obtain a moderate sedation with parenteral agents permit, a licensed dentist shall:

(a) Comply with the permitting and renewal requirements in WAC 246-817-774;

(b) Successfully complete a postdoctoral course or courses of 60 clock hours or more which includes:

(i) Basic moderate sedation;

(ii) Physical evaluation;

(iii) Venipuncture and intravenous drug administration, training is a hands-on skill and must be completed in-person;

(iv) Technical administration;

(v) Recognition and management of complications and emergencies, training is a hands-on skill and must be completed in-person;

(vi) Monitoring; and

(vii) Supervised experience in providing moderate sedation with parenteral agents to 20 or more patients.

(c) Training in adult sedation, if treating an adult; and

(d) Training in pediatric sedation, if treating a pediatric patient.

(3) In addition to meeting the criteria in subsection (2) of this section, the licensed dentist shall hold and maintain a current certification in ACLS or PALS.

(a) If treating an adult, the dentist must have ACLS certification.

(b) If treating a pediatric patient, the dentist must have PALS certification.

(4) The use of any drugs classified under the Food and Drug Administration as general anesthetic agents including, but not limited to, Propofol, Ketamine, Sevoflurane, Halothane, and Isoflurane are considered outside the scope of a moderate sedation with parenteral agents permit.

(5) The drugs, drug amounts, and techniques used must carry a margin of safety wide enough to render unintended loss of consciousness highly unlikely.

(6) A licensed dentist shall:

(a) Ensure a patient receiving moderate sedation with parenteral agents receives the sedation from an anesthesia provider qualified under this chapter.

(b) Ensure the patient is evaluated for moderate sedation with parenteral agents prior to the administration of any sedative.

(i) Review, at an appropriate time, the patient's medical history and medication use and NPO or nothing by mouth status.

(ii) Consult with the patient's primary care physician or consulting medical specialist for a patient with significant medical considerations whom have American Society of Anesthesiologists patient classification of III or IV.

(iii) Patient's body mass index must be assessed as part of a preprocedural workup.

(iv) A focused physical examination to include vital signs, evaluation of the airway, and auscultation of the heart and lungs is required before administration of any sedative or anesthesia agent.

(c) Ensure a patient is not left alone in a room and is continually monitored by an anesthesia provider or trained anesthesia monitor as defined in WAC 246-817-772.

(d) Ensure an intravenous infusion is maintained during the administration of a parenteral agent. Two exceptions for intravenous infusion may occur, but reasons why intravenous infusion was not used must be documented for:

(i) Pediatric sedation cases using agents for brief procedures; and

(ii) When the pediatric patient is uncooperative or the emotional condition is such that intravenous access is not possible.

(e) Ensure when the operative dentist is also the provider administering the moderate sedation with parenteral agents, the operative dentist is continuously assisted by a trained anesthesia monitor as defined in WAC 246-817-772. The trained anesthesia monitor may function as the dental or surgical assistant.

(i) If treating an adult, the additional individual must have experience or training in adult sedation.

(ii) If treating a pediatric patient, the additional individual must have experience or training in pediatric sedation.

(f) Ensure a patient is visually and tactilely monitored either by themselves or an individual trained in monitoring sedated patients. Patient monitoring must include:

(i) Heart rate;

(ii) Blood pressure;

(iii) Respiratory rate;

(iv) Oxygen saturation;

(v) Continuous electrocardiographic monitoring when the patient has clinically significant cardiovascular disease.

(A) Clinically significant cardiovascular disease can be classified, but not limited to, coronary artery disease, arrhythmias, congenital heart defects, heart valve disease, disease of the heart muscle, and heart infection.

(B) Electrocardiographic monitoring of a pediatric patient is not required when the pediatric patient is uncooperative, the emotional condition is such that monitoring is not possible, or who does not tolerate the monitor pads or wiring. Reasons why electrocardiographic monitoring was not used must be documented.

(vi) End-tidal CO2. Monitoring is not required when:

(A) A pediatric sedation case uses agents for a brief procedure; or

(B) A pediatric patient is uncooperative or the emotional condition is such that end-tidal CO2 monitoring is not possible.

(C) Reasons why end-tidal CO2 monitoring was not performed must be documented.

(g) Comply with requirements of immobilization devices for pediatric patients.

(i) Immobilization devices, such as, papoose boards, must be applied in such a way as to avoid airway obstruction or chest restriction.

(ii) The pediatric patient head position and respiratory excursions must be checked frequently to ensure airway patency.

(iii) If an immobilization device is used, a hand or foot must be kept exposed.

(h) Ensure the patient's blood pressure, heart rate, pulse oximetry, and respiration rate is recorded every five minutes.

(i) Ensure the patient's level of consciousness is recorded prior to the dismissal of the patient.

(j) Ensure patient is accompanied by a responsible adult upon departure from the treatment facility.

(k) Ensure the patient is returned to a level of moderate sedation as quickly as possible, if the patient unintentionally enters a deeper level of sedation. While returning the patient to the moderate level of sedation, periodic monitoring of pulse, respiration, blood pressure and continuous monitoring of oxygen saturation must be maintained. In such cases, these same parameters must be taken and recorded at appropriate intervals throughout the procedure and vital signs and level of consciousness must be recorded during the sedation and prior to dismissal of the patient.

(7) A licensed dentist shall document in the patient record appropriate medical history and patient evaluation. Sedation records must be recorded during the procedure in a timely manner and must include:

(a) Blood pressure;

(b) Heart rate;

(c) Respiration;

(d) Pulse oximetry;

(e) End-tidal CO2. Monitoring is not required when:

(i) Pediatric sedation case uses agents for brief procedure; or

(ii) A pediatric patient is uncooperative or the emotional condition is such that end-tidal CO2 monitoring is not possible.

(iii) Reasons why end-tidal CO2 monitoring was not performed must be documented.

(f) Drugs administered including amounts and time administered;

(g) Length of procedure; and

(h) Any complications of sedation.

(8) A licensed dentist shall comply with the following recordkeeping, equipment, and emergency medication requirements:

(a) Equipment used for monitoring patients must be calibrated or performance verified according to manufacturer's instructions.

(b) An operating theater must be large enough to adequately accommodate the patient on a table or in an operating chair and permit an operating team consisting of at least two individuals to freely move about the patient;

(c) An operating table or chair must permit the patient to be positioned so the operating team can maintain the airway, quickly alter patient position in an emergency, and provide a firm platform for the administration of basic life support;

(d) A lighting system must be adequate to permit evaluation of the patient's skin and mucosal color and a backup lighting system of sufficient intensity to permit conclusion of any procedure underway at the time of general power failure;

(e) Suction equipment capable of aspirating gastric contents from the mouth and pharyngeal cavities. A backup suction device must be available;

(f) An oxygen delivery system with adequate full face masks and appropriate connectors that is capable of delivering high flow oxygen to the patient under positive pressure, together with an adequate portable backup system;

(i) If treating an adult, the equipment must be appropriate for adult sedation;

(ii) If treating a pediatric patient, the equipment must be appropriate for pediatric sedation;

(iii) Appropriate sized laryngeal mask airway must be ready for emergency use;

(g) A blood pressure cuff or sphygmomanometer of appropriate size and stethoscope; or equivalent monitoring devices;

(h) End-tidal CO2 monitor;

(i) Pulse oximetry; and

(j) An emergency drug kit with minimum contents of:

(i) Sterile needles, syringes, and tourniquet;

(ii) Narcotic antagonist;

(iii) Alpha and beta adrenergic stimulant;

(iv) Vasopressor;

(v) Coronary vasodilator including, but not limited to, nitroglycerin;

(vi) Antihistamine including, but not limited to, diphenhydramine;

(vii) Parasympatholytic;

(viii) Intravenous fluids, tubing, and infusion set;

(ix) Sedative antagonists for drugs used, if available;

(x) Bronchodilator agent including, but not limited to, albuterol;

(xi) ACLS or PALS emergency drugs; and

(xii) Anti-hypoglycemic agent.

(9) A licensed dentist who holds a valid moderate sedation with parenteral agents permit and administers moderate sedation with parenteral agents in another licensed dentist office, must have a contract in place that contains the provisions described in WAC 246-817-778 (1)(a) through (c).

(10) A licensed dentist who holds a valid moderate sedation with parental agents permit shall complete 14 hours of continuing education every three years as required in WAC 246-817-773.

(11) A licensed dentist who holds a valid moderate sedation with parenteral agents permit must hold a current and valid ACLS certification.

[Statutory Authority: RCW 18.32.0365 and 18.32.640. WSR 24-01-033, § 246-817-760, filed 12/11/23, effective 1/11/24; WSR 17-07-037, § 246-817-760, filed 3/8/17, effective 4/8/17; WSR 16-06-106, § 246-817-760, filed 3/1/16, effective 4/1/16; WSR 09-04-042, § 246-817-760, filed 1/30/09, effective 3/2/09. Statutory Authority: RCW 18.32.035. WSR 95-21-041, § 246-817-760, filed 10/10/95, effective 11/10/95.]