/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/delegationpractice-protocols/,/clinical/cckm-tools/content/delegationpractice-protocols/ambulatory-delegation-protocols/,

/clinical/cckm-tools/content/delegationpractice-protocols/ambulatory-delegation-protocols/name-97352-en.cckm

201711331

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Delegation/Practice Protocols,Ambulatory Delegation Protocols

Fluoride Varnish in Primary Care - Pediatric - Ambulatory [91]

Fluoride Varnish in Primary Care - Pediatric - Ambulatory [91] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Ambulatory Delegation Protocols




Delegation Protocol Number: 91

Delegation Protocol Title:
Fluoride Varnish in Primary Care – Pediatric – Ambulatory

Delegation Protocol Applies To:
UW Health Primary Care Clinics

Target Patient Population:
Pediatric patients ages 6 months through 5 years not under the care of a dentist.

Delegation Protocol Champions:
Sandra Kamnetz, MD - Department of Family Medicine
Gail Allen, MD – Department of Pediatrics

Delegation Protocol Reviewers:
Sandy Jacobson - Director Primary Care Clinics – Pediatrics
Kymn Wenkman, MSN, RN – UW Health Clinical Staff Education
Diane Mikelsons, MS, RN – UW Health Clinical Staff Education

Responsible Department:
Department of Pediatrics
Department of Family Medicine

Purpose Statement:
To delegate authority from the patient’s primary care provider to Registered Nurses (RNs), Licensed Practical
Nurses (LPNs) or Medical Assistants (MAs) to verify patient status regarding the need for a fluoride treatment
and to create orders for in-office fluoride treatment which will be routed for provider (co)signature. These
orders may be carried out prior to being cosigned.

Who May Carry Out This Delegation Protocol:
RNs, LPNs, and MAs who have successfully completed the on-line training program posted in the Learning
Development system, and have completed a return demonstration.

Guidelines for Implementation:
1. This protocol is initiated at well child exams for eligible pediatric patients at risk for caries as outlined below.
Any patient, ages 6 months through 5 years beginning with the first erupted tooth and not under the care of
a dentist, are eligible for treatment under this delegation protocol.
2. If the patient meets the established age criterion, the family/legal guardian agrees to treatment, the staff
will enter an order for topical fluoride application. The order will be routed to the provider for cosignature,
but the staff may apply 5% sodium fluoride varnish prior to the order being cosigned.
3. Staff will ask the parent/guardian if the child has any oral problems today.
3.1. Provider will be consulted if parent/guardian indicates the child has oral problems.
4. Staff will select from the following smart phrases to document in the patient’s medical record
4.1. If topical fluoride applied, the staff will use both the documentation and the patient instruction smart
phrases
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

4.1.1. “.fluorideapply” - 5% Sodium Fluoride Varnish applied to teeth per delegation protocol #91 and
under the authority and supervision of the billing provider. Patient tolerated application well.
Parent(s)/guardian provided with instruction for home care.
4.1.2. “.fluorideinstruct” for AVS Patient Instruction for Fluoride:
4.2. If refused, staff will document using “.fluoriderefused” – topical Fluoride offered and refused
4.3. If declined because patient sees a dentist, staff will document using “.fluorideseedentist” - Fluoride
offered and declined; patient sees dentist.

Order Mode: Cosign Required – Protocol/Policy

References:
1. Smiles for Life. Fluoride varnish: Available at:
http://smilesforlifeoralhealth.org/buildcontent.aspx?tut=584&pagekey=64563&cbreceipt=0 Accessed
December 16, 2015.
2. U.S. Preventive Services Task Force. Recommendation Statement: Dental Caries in Children from Birth
Through 5 Years Screening. Accessed January 5, 2016. Available at:
http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatement
3. Dooley D, Moultrie NM, Heckman B, Gansky SA, Potter MB, Walsh MM. Oral Health Prevention and Toddler
Well-Child Care: Routine Integration in a Safety Net System. Pediatrics. 2015;137(1):1.
4. Topical fluoride for caries prevention. Weyant, Robert J. et al. The Journal of the American Dental
Association, Volume 144, Issue 11, 1279-1291.
5. American Dental Association Council on Scientific Affairs. Professionally applied topical fluoride: evidence-
based clinical recommendations. JADA 2006;137(8):1151-9. Available at: http://jada.ada.org/article/S0002-
8177(14)64961-8/abstract Accessed December 16, 2015.
6. American Dental Association Council on Scientific Affairs. Chairside guide: Topical fluoride. Available at:
http://ebd.ada.org/contentdocs/fluoride_chairside.pdf. Accessed October 24, 2013.


Collateral Documents/Tools:
Smart phrases: .fluorideapply, fluroideinstruct, fluoriderefused, fluorideseedentist
Smart Set: Topical Fluoride Application [4887]

Approved By:
UW Health Ambulatory Protocol Committee: November 2013: *March 2016
UW Health Clinical Knowledge Management Council: November 2013; *March 2016
UWHC Medical Board: November 2013; *March 2016
UW Health Chief Medical Officer: December 2013; * March 2016

Effective Date: March 2016

Scheduled For Review: April 2018
* Expedited Review Process
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org