I hereby certify, under penalty of law, that all in<strong>for</strong>mation contained in this application is true andcorrect. I also certify I have read <strong>Ohio</strong> <strong>State</strong> <strong>Dental</strong> Board Rule 4715-5-05 (Use of <strong>General</strong><strong>Anes<strong>the</strong>sia</strong> and Deep Sedation) and understand its contents.Print NameSignedApplicantDateTHIS SPACE TO BE COMPLETED BY THE OHIO STATE DENTAL BOARDACTION BY BOARD ON APPLICATIONCertified that applicant meets training, educational, and facility requirements.Training, education and/or facility of applicant fail to meet requirements.Reasons:Page 7
4715-5-05 Use of general anes<strong>the</strong>sia and deep sedation.(A)(B)No dentist shall administer general anes<strong>the</strong>sia or deep sedation in <strong>the</strong> state of <strong>Ohio</strong> unlesssuch dentist possesses a permit of authorization issued by <strong>the</strong> <strong>Ohio</strong> state dental board or hasmade application <strong>for</strong> such permit and, based on a credentials review, is notified that a <strong>for</strong>malevaluation as outlined in paragraph (C) of this rule is pending. The dentist holding suchpermit shall be subject to review and such permit must be renewed biennially.In order to receive such permit, <strong>the</strong> dentist must apply on a prescribed application <strong>for</strong>m to<strong>the</strong> <strong>Ohio</strong> state dental board, submit <strong>the</strong> application fee, and produce evidence showing tha<strong>the</strong> or she:(1) Has completed an approved, accredited post-doctoral training program whichaf<strong>for</strong>ds appropriate training necessary to administer deep sedation andgeneral anes<strong>the</strong>sia; and/or(2) Has completed an approved Accreditation council <strong>for</strong> graduate medicaleducation (ACGME) accredited post-doctoral training program inanes<strong>the</strong>siology which af<strong>for</strong>ds appropriate training necessary to administerdeep sedation and general anes<strong>the</strong>sia; and/or(3) Has completed a minimum of one year advanced clinical training inanes<strong>the</strong>siology from a Joint commission on accreditation of healthcareorganization (JCAHO) accredited institution that meets <strong>the</strong> objectives set<strong>for</strong>th in Part Two of <strong>the</strong> American dental association’s “Guidelines <strong>for</strong>Teaching <strong>the</strong> Comprehensive Control of Anxiety and Pain in Dentistry”; and(4) Has a properly equipped facility(s), whe<strong>the</strong>r fixed, mobile, or portable, <strong>for</strong><strong>the</strong> administration of general anes<strong>the</strong>sia or deep sedation in which <strong>the</strong> permitholder agrees to have available and utilize adequate monitoring, personnel,emergency equipment and drugs as recommended in <strong>the</strong> American dentalassociation’s “Guidelines <strong>for</strong> <strong>the</strong> Use of Conscious Sedation, Deep Sedationand <strong>General</strong> <strong>Anes<strong>the</strong>sia</strong> <strong>for</strong> Dentists” and/or <strong>the</strong> American association of oraland maxillofacial surgeon’s “Office <strong>Anes<strong>the</strong>sia</strong> Evaluation Manual”; and(5) At <strong>the</strong> time of application maintains successful completion of an advancedcardiac life support course, or its age appropriate equivalent; and(6) Maintains a permanent address within <strong>the</strong> state of <strong>Ohio</strong> in which he or sheconducts business pursuant to his or her <strong>Ohio</strong> dental license.(C)Prior to <strong>the</strong> issuance of such permit, <strong>the</strong> <strong>Ohio</strong> state dental board shall require an on-siteevaluation of <strong>the</strong> facility(s), equipment, personnel, anes<strong>the</strong>tic techniques, and relateddocument(s) to determine if <strong>the</strong> a<strong>for</strong>ementioned requirements have been met. Thisevaluation shall be conducted by a qualified consultant appointed by <strong>the</strong> <strong>Ohio</strong> state dentalboard and will follow <strong>the</strong> American dental association’s “Guidelines <strong>for</strong> <strong>the</strong> Use ofConscious Sedation, Deep Sedation and <strong>General</strong> <strong>Anes<strong>the</strong>sia</strong> <strong>for</strong> Dentists” and/or <strong>the</strong>American association of oral and maxillofacial surgeon’s “Office <strong>Anes<strong>the</strong>sia</strong> EvaluationPage 8
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