Dental Hygiene Prescribing: What You Need to Know

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From the Winter 2016 Journal of the Colorado Dental Association

During last year’s 2014 state legislative session, the Colorado Dental Practice Act was reviewed and updated pursuant to HB 14-1227, the dental sunset review bill. Substantial changes were made to the Dental Practice Act that will impact dental practices in the months and years to come. One of the key changes in this bill was the addition of new provisions that allow dental hygienists to collaborate with a dentist and prescribe, administer or dispense a limited formulary of preventive agents like fluoride and nonsystemic topical antimicrobials.

Through the fall of 2014, the Colorado Dental Board met to develop the rules related to dental hygiene prescribing, among other sunset review topics. Rules were adopted in January and April 2015 and the current rule took effect June 30, 2015.
Dentists should be aware of the following highlights from the new dental hygiene prescribing rule:
• Before prescribing, administering or dispensing drugs, a dental hygienist must work with a dentist to develop an articulated plan for safe prescribing. The articulated plan must address mechanisms for consultation and referral, quality assurance measures, decision support tools, and emergency protocols. This plan must be reviewed and updated at least annually. Once the articulated plan is in place, a dental hygienist may prescribe from the dental hygiene formulary without needing the direct or indirect supervision of a dentist.
• Dental hygienists may prescribe, administer and dispense from a limited formulary of fluoride supplements, topical anti-caries treatments and topical anti-infectives. At the outset, the formulary is limited to only the specific drugs and dosages identified (see sidebar).
• Dental hygienists are prohibited from prescribing, administering or dispensing drugs whose primary effect is systemic (fluoride supplements are excepted) and controlled substances.
• Dental hygienists must keep clear documentation in the patient record of the drugs prescribed, administered or dispensed, including the rationale for prescribing the drug.
Note: This is a general summary of some highlights from Colorado’s dental hygiene prescribing rule as applicable to most dental and dental hygiene practices. It is not a comprehensive list of all requirements and exceptions. Please review the rule directly to ensure compliance with all requirements, as applicable to your practice.

Below is a complete copy of the Colorado Dental Board Rule for Dental Hygienist Limited Prescriptive Authority 
Rule XIII. Limited Prescriptive Authority for Dental Hygienists
A. Pursuant to section 12-35-124(1)(g)(I), C.R.S., a dental hygienist without supervision of a dentist may prescribe, administer, and dispense fluoride, fluoride varnish, antimicrobial solutions for mouth rinsing, and other nonsystemic antimicrobial agents in collaboration with a licensed dentist and, if applicable, when issued a National Provider Identifier (NPI) number by the Centers for Medicare & Medicaid Services (CMS) under the U.S. Department of Health and Human Services.
1. Collaboration with a dentist requires the dental hygienist to develop an articulated plan for safe prescribing which documents how the dental hygienist intends to maintain ongoing collaboration with a dentist in connection with the dental hygienist’s practice of prescribing as allowed in section 12-35-124(1)(g), C.R.S., and section C of this rule.
2. The articulated plan shall guide the dental hygienist’s prescriptive practice and shall include at least the following:
a. A mechanism for consultation and referral to a dentist when the dental hygienist detects a condition that requires care beyond the scope of practicing unsupervised dental hygiene;
b. A quality assurance plan;
c. Decision support tools; and
i. A decision support tool is an assistive tool commonly recognized by healthcare professionals as a valid resource for information on pharmaceutical agents or to aid the dental hygienist in making appropriate judgments regarding safe prescribing.
ii. Such tools may include, but are not limited to, electronic prescribing databases, evidence-based guidelines, antimicrobial reference guides, and professional journals and textbooks.
d. Emergency protocols and standing orders, including use of emergency drugs.
3. The dental hygienist shall:
a. Retain the written articulated plan with the collaborating dentist’s signature on file;
b. Review the plan annually; and
c. Update the plan as necessary.
4. The articulated plan is subject to Board review and the dental hygienist shall provide the plan to the Board upon request.
B. A dental hygienist shall not prescribe, administer, or dispense the following:
1. Drugs whose primary effect is systemic, with the exception of fluoride supplements permitted under section 12-35-124(1)(g)(III)(A), C.R.S., and section C.1 of this rule below; and
2. Dangerous drugs or controlled substances.
C. A dental hygienist may prescribe the following:
1. Fluoride supplements as follows (all using sodium fluoride):
a. Tablets: 0.5 mg, 1.1 mg, or 2.2 mg;
b. Lozenges: 2.21 mg; and
c. Drops: 1.1 mL.
2. Topical anti-caries treatments as follows (all using sodium fluoride unless otherwise indicated):
a. Toothpastes: 1.1% or less (or stannous fluoride 0.4%);
b. Topical gels: 1.1% or less (or stannous fluoride 0.4%);
c. Oral rinses: 0.05%, 0.2%, 0.44%, or 0.5%;
d. Oral rinse concentrate used in periodontal disease: 0.63% stannous fluoride;
e. Fluoride varnish: 5%; and
f. Prophy pastes containing approximately 1.23% sodium fluoride and used for polishing procedures as part of professional dental prophylaxis treatment; and
3. Topical anti-infectives as follows:
a. Chlorhexidine gluconate rinses: 0.12%;
b. Chlorhexidine gluconate periodontal chips for insertion into the periodontal pocket;
c. Tetracycline impregnated fibers, inserted subgingivally into the periodontal sulcus (pocket);
d. Doxycycline hyclate periodontal gel, inserted subgingivally into the periodontal sulcus (pocket); and
e. Minocycline hydrochlorided periodontal paste, inserted subgingivally into the periodontal sulcus (pocket).
D. A dental hygienist shall maintain clear documentation in the patient record of the:
1. Agent prescribed, administered, or dispensed, including dose, amount, and refills;
2. Date of the action; and
3. Rationale for prescribing, administering, or dispensing the agent.
E. A prescriptive order shall include:
1. Name of the patient,
2. Date of action,
3. Agent prescribed including dose, amount and refills, and
4. Rationale for prescribing the agent.
F. If a dental hygienist prescribes, administers, or dispenses without supervision of a dentist but fails to develop the required articulated plan, or fails to maintain clear documentation in the patient record; or prescribes, administers, or dispenses outside of what is allowed pursuant to section 12-35-124(1)(g), C.R.S., or in this rule, then such conduct constitutes grounds for discipline pursuant to section 12-35-129(1)(i), C.R.S.
G. Any dental hygienist placing therapeutic agents or prescribing as allowed in this rule shall have proof of current Basic Life Support (BLS) for healthcare providers.
H. The placement and removal of therapeutic agents in periodontal pockets and limited prescriptive authority may not be delegated or assigned to a dental assistant.
I. Pursuant to section 12-35-128(3)(b)(II), C.R.S., a dental assistant under the indirect supervision of a dentist may deliver topical fluoride.

Drugs Dental Hygienists May Prescribe
1. Fluoride supplements as follows (all using sodium fluoride):
a. Tablets: 0.5 mg, 1.1 mg, or 2.2 mg;
b. Lozenges: 2.21 mg; and
c. Drops: 1.1 mL.
2. Topical anti-caries treatments as follows (all using sodium fluoride unless otherwise indicated):
a. Toothpastes: 1.1% or less (or stannous fluoride 0.4%);
b. Topical gels: 1.1% or less (or stannous fluoride 0.4%);
c. Oral rinses: 0.05%, 0.2%, 0.44%, or 0.5%;
d. Oral rinse concentrate used in periodontal disease: 0.63% stannous fluoride;
e. Fluoride varnish: 5%; and
f. Prophy pastes containing approximately 1.23% sodium fluoride and used for polishing procedures as part of professional dental prophylaxis treatment; and
3. Topical anti-infectives as follows:
a. Chlorhexidine gluconate rinses: 0.12%;
b. Chlorhexidine gluconate periodontal chips for insertion into the periodontal pocket;
c. Tetracycline impregnated fibers, inserted subgingivally into the periodontal sulcus (pocket);
d. Doxycycline hyclate periodontal gel, inserted subgingivally into the periodontal sulcus (pocket); and
e. Minocycline hydrochlorided periodontal paste, inserted subgingivally into the periodontal sulcus (pocket).