N at i o n a l C o n f e r e n c e o f S tat e L e g i s l at u r e s
Improving Lifetime
Oral Health:
Policy Options
and Innovations
BY TAHRA JOHNSON AND KRISTINE GOODWIN
Many Americans lack access to basic, affordable oral health
speaking. Dental expenses for U.S. children ages 5 to 17 were
care. Tooth decay is the most preventable unmet health need
about $20 billion in 2009—almost 18 percent of all health care
in the United States, yet one-quarter of children have tooth
costs for this group.2
decay before they enter kindergarten and one-third of adults
report having it.1 Growing evidence links oral disease to chronic
In sum, tooth decay and unaddressed oral health problems
health conditions such as diabetes, heart and lung disease
add up to poor health outcomes and rising health care costs.
and potential pregnancy complications. Costly for families,
Emergency room (ER) visits for preventable dental conditions
communities and states, untreated tooth decay can lead to pain
cost $1.6 billion in 2012,3 and the cost of a procedure, such as a
and infection, missed school days, and problems with eating and
tooth extraction, can increase nearly 10 times when performed in
POLICYMAKERS CONVENE TO SHARE CHALLENGES
AND POLICY OPTIONS
More than 50 legislators, legislative staff, providers and others convened at NCSL’s Legislative Summit in August 2015
to discuss state options for improving oral health care and reducing costs for all populations. The session, “Smart Investments in Oral Health: State Policy Options for Improving Care and Reducing Costs,” featured national expert Andrew Snyder from the National Academy for State Health Policy. Snyder highlighted initiatives that address oral health coverage,
integration of oral health with primary care, innovations in oral health care delivery and public health strategies. According
to Snyder, oral health is an important issue for state policymakers for the following reasons:
•
Oral disease is preventable, but is highly prevalent and chronic.
•
Significant disparities exist among groups in the U.S., and there are long-standing, persistent barriers to low-income
people accessing care.
•
108 million Americans lack dental coverage.
•
Poor oral health has potential negative effects on development, nutrition, education, employability and quality of life.
•
Oral disease has been linked to avoidable emergency room visits and has connections to systemic conditions like cardiovascular disease, stroke, and diabetes.
IMPROVING ACCESS RESULTS
IN BETTER, LESS COSTLY CARE
Expand
access
Healthier
patients and
less-costly care
Increase
preventive care
Fewer ED vists
Source: Representative Susan Allen, “Missouri Oral Health Initiatives,”
NCSL Legislative Summit, August 2015.
Missouri Representative Susan Allen and Kentucky Representative Thomas Burch shared challenges and oral health
initiatives in their states. In Missouri, for example, Representative Allen pointed to provider shortages, especially in certain
geographic areas, and costly visits to the hospital emergency room for unaddressed oral health needs. In 2013, nearly
60,000 emergency department visits were due to tooth and jaw disorders and other dental problems. There, patients receive treatment that addresses the symptoms of pain, not the underlying causes, which could be better addressed in the
dentist’s office, Allen said. The trend is costly to the state: Dental emergency department (ED) visits cost about $300 per
visit and totaled $17.5 million in 2013. Expanding access to preventive services results in a positive return on investment,
she concluded. Other speakers and attendees shared policy options that address unmet needs and improve oral health
outcomes. Many of these examples are featured throughout this brief.
NATIONAL CONFERENCE OF STATE LEGISLATURES
2
an emergency room instead of a dental office.4
These factors are costly for states and affect the
quality of life for individuals and families.
Concerned about these cost and health status trends, policymakers have adopted myriad
strategies to improve oral health for children and
adults. This report highlights targeted state policy
options for improving oral health for children and
adults, as well as system-level reforms to improve care and reduce costs for all populations.
STATE OPTIONS FOR IMPROVING
CHILDREN’S ORAL HEALTH
Tooth decay is more prevalent among children
from lower-income families and children of certain
racial and ethnic groups, according to the Centers for Disease Control and Prevention (CDC).
Total U.S. dental expenditures for children up to
21 years old exceeded $25 billion5 in 2012, placing a significant financial burden on state budgets. According to a 2013 report from The Pew
Charitable Trusts, annual Medicaid spending for
dental services is expected to increase by 170
percent—from $8 billion in 2010 to $21 billion in
2020. State legislators have adopted numerous
strategies to improve oral health practices and
care for children.
Bright Futures offers pediatric care providers
Assess and Screen in
Primary Care Settings
and families tools for evidence-based care for
children from birth to age 21. For example, oral
health risk assessments are recommended at the
Pediatricians are often the first medical providers
to examine a baby or toddler’s mouth. By the age
6- and 9-month well-child visits with primary care
of 6 months, oral health screenings should be-
providers. A pediatrician can identify conditions
gin and continue as a routine part of every doc-
like plaque, cavities or inflammation of the gums,
tor’s visit, according to the American Academy of
and also refer a patient to a dental provider. Oral
Pediatrics. The American Academy of Pediatric
health risk assessments provide early tracking
Dentistry (AAPD) recommends that a child go
for a child’s oral health history that can be later
to the dentist by age 1. The federal Health Re-
referenced by his or her future dental provider.
sources and Services Administration (HRSA) es-
Early evaluation can help maintain good oral
tablished the Bright Futures Guidelines in 1990
health and prevent or treat disease.
to improve the standard of care for children and
adolescents. Since 2002, the American Academy
Applying fluoride varnish is another way pediatri-
of Pediatrics (AAP) has overseen development
cians and primary care providers can help with
and dissemination of these guidelines. The
preventive oral health procedures. States have
majority of states use the recommendations in
now begun reimbursing doctors through Med-
Bright Futures to guide which services the state
icaid. According to The Pew Charitable Trusts,
Medicaid program covers.
most Medicaid programs pay between $15 and
6
3
NATIONAL CONFERENCE OF STATE LEGISLATURES
$30 for the procedure. Fluoride varnish can re-
money by preventing the need for dental-related
duce the rate of tooth decay by one-third, lead-
emergency room visits and other costly den-
ing to significant cost savings, such as avoiding
tal care. Not all policymakers embrace sealant
restorative dental care or hospital visits.7
programs, and some concern exists about the
safety of sealants; however, one-time applica-
School-based Prevention and Care
tion of sealants has not been found to provide
chronic exposure, and applying them properly re-
Most dental disease can be prevented by early
identification and intervention with care such
duces exposure. Based on a review of evidence
as dental sealants and fluoride treatments.
about sealant safety and risks, the Association
Sealants—plastic coatings applied to vulner-
of State and Territorial Dental Directors recom-
able molars—help prevent decay and may save
mends sealants for all children. Dental sealants
NATIONAL CONFERENCE OF STATE LEGISLATURES
4
ness about healthy oral hygiene for children who
do not regularly visit a dentist.9
School sealant programs exist in most states
and vary in scope, complexity, funding methods
and other factors. According to a 2013 report by
The Pew Charitable Trusts, successful sealant
programs target high-need children, use a costefficient workforce, and eliminate reimbursement
and regulatory barriers for providers. Some programs arrange to apply sealants at school-based
clinics or in mobile vans, while others link schools
to private dental practices where children can
receive the services. Policymakers have taken
steps to expand access to and reimburse for
sealant services and providers. Laws in several
states allow dental hygienists and assistants to
apply sealants in schools or other public health
settings. These policies expand access to preventive services, especially for underserved children and adolescents.
•
Arkansas lawmakers created a collaborative care program in 2011 that allows qualified dental hygienists—who collaborate with
consulting dentists—to provide sealants and
other procedures in public health settings.
•
Colorado lawmakers established a grant program in 2013 to support school-based dental
sealant programs, community water fluoridation and other strategies.
•
A 2009 Massachusetts law authorized public
health dental hygienists to provide sealants
and certain other preventive services without a dentist’s prior examination. The law
also allows reimbursement under Medicaid
and the Children’s Health Insurance Program (CHIP).
applied in school-based programs reduce tooth
Raise Awareness About
Healthy Behaviors
decay by as much as 60 percent.8 They also can
reduce dental health disparities and lead to follow-up care and enrollment in health insurance.
Around 80 million Americans have limited health
The U.S. Preventive Services Task Force rates
literacy—the ability to understand and interpret
school-based sealant programs as an evidence-
health information—which puts them at greater
based approach for reducing tooth decay. The
risk for lacking access to care and having poor
task force evaluated four sealant delivery pro-
health.10 People with poor health literacy are
grams in 2013 and found that sealants reduced
more likely to have fewer preventive procedures,
tooth decay up to 48 months after application. In-
potentially leading to costly ER visits or chronic
school sealant programs also help raise aware-
health conditions. This group can include older
5
NATIONAL CONFERENCE OF STATE LEGISLATURES
STATE MEDICAID COVERAGE OF ADULT DENTAL BENEFITS
AK
NH
WA
MT
ND
ID
MA
MN
OR
CA
PA
IA
NV
CO
IL
OH
IN
MO
KS
OK
NC
DC
GA
AL
LA
TX
MD
SC
AR
MS
No dental benefits
VA
KY
NM
NJ
DE
WV
TN
AZ
RI
CT
MI
NE
UT
NY
WI
SD
WY
HI
ME
VT
FL
Emergency only
Limited
Extensive
Source: Center for Health Care Strategies, Inc., “Medicaid Adult Dental Benefits: An Overview,” February 2016
No dental benefits
adults, people with limited education and those
Emergency only
with limited English proficiency. Some states
ple and employers. Employed adults lose more
have launched oral health campaigns to spread
Limited
awareness like Delaware’s “Healthy Smile.
oral health problems or dental visits, according
Healthy You.”
than 164 million work hours annually because of
to the CDC.13
Extensive
Expand Coverage for Low-Income Adults
AS
GU
MP
VI
PR
STATE OPTIONS FOR IMPROVING
ADULT ORAL HEALTH
The vast majority of adults who gained or will
Poor access to dental services has economic
do so through state Medicaid programs.14 An
consequences for states. Visits to the emergen-
estimated 800,000 will gain coverage through
cy room for dental reasons cost $1.6 billion in
the state or federal health insurance exchanges.
2012 and rarely addressed the underlying con-
According to a February 2016 report from the
dition. Estimates show that 79 percent of these
Center for Health Care Strategies, 46 states
patients could have been treated in a commu-
and the District of Columbia currently cover at
nity setting.
least emergency dental services (e.g., relief for
gain some dental coverage through the Affordable Care Act (ACA)—about 17.7 million—will
11
uncontrolled bleeding or trauma) for adults with
Medicaid is a major payer of these costs. Case
Medicaid; of those, 13 states cover emergency
in point: A study of Maryland’s Medicaid costs
care only, 18 states and the District of Columbia
showed a potential savings of $4 million if dental
cover certain limited services (such as preventive
visits to the emergency room were diverted to
and restorative procedures), and 15 states offer
a more appropriate setting.
extensive coverage to their base Medicaid adult
12
In addition, poor
adult oral health is costly to both working peoNATIONAL CONFERENCE OF STATE LEGISLATURES
population.
6
•
Expand Oral Health Workforce
Several states have restored adult dental
coverage in recent years, after eliminat-
States struggle to find an adequate number
ing them during the economic recession.
of oral health providers who accept Medicaid.
A 2014 California law covers certain den-
Dentists often decline to participate in Medic-
tal benefits for all adults on Medi-Cal (the
aid because of lower reimbursement rates than
state’s Medicaid program). In 2014, Idaho
in the commercial market. According to the
lawmakers reinstated dental benefits for
American Dental Association (ADA), 35 percent
adults enrolled in Medicaid, including cover-
of dentists accept Medicaid patients. For adult
age for routine exams and preventive and
services in states with at least limited benefits,
other dental services. Washington restored
the reimbursement rates averaged 40.7 percent
dental coverage in 2013 for Medicaid-en-
of commercial reimbursement in 2014. Alaska,
rolled adults to include restorative and pre-
Arkansas and North Dakota had the highest re-
ventive services, emergency services, root
imbursement rates, at around 60 percent of the
canals, cavity care, and routine checkups
•
and cleanings.
commercial rate.15
Some states are providing preventive den-
Some states have adopted financial and other in-
tal benefits to adults for the first time. In
centives—including enhanced reimbursement or
2013, Colorado lawmakers passed Sen-
reduced administrative burden (less time filling
ate Bill 242, which provided dental benefits
out forms)—to increase the number and avail-
to all adult Medicaid enrollees, with up to
ability of oral health providers who are willing to
$1,000 in dental benefits each year. South
provide care to Medicaid patients. States also
Carolina will cover cleaning, fillings and ex-
have taken steps to increase the capacity of the
tractions for adults with very low incomes
existing oral health workforce to meet demand
or disabilities.
by, for example, using telehealth (providing ser7
NATIONAL CONFERENCE OF STATE LEGISLATURES
vices remotely) or changing provider roles and
concerns about liability may cause dental profes-
practice settings. California lawmakers passed
sionals to delay treatment for pregnant women.
legislation in 2014 to reimburse hygienists and
In addition to the consequences of dental health
dentists for telehealth dental services.
problems during pregnancy, a woman’s oral
health also can affect her children. Improve Oral Health Access
for Pregnant Women
Pregnant women and young children often are
more likely to see a primary care provider than
Dental disease in pregnant women is associated
a dental professional, so other providers such
with pre-term birth, low birthweight and gesta-
as obstetricians, gynecologists and pediatricians
tional diabetes, all of which can harm the baby
may be engaged in their patients’ oral health
and may result in a more costly pregnancy. Den-
care. The New York State Department of Health
tal care is safe throughout pregnancy, although
created “Oral Healthcare During Pregnancy and
misapprehension about treatment safety and
Early Childhood: Practice Guidelines,” which pro-
NATIONAL CONFERENCE OF STATE LEGISLATURES
8
vide screening and treatment recommendations
Wisconsin19—are piloting another new type of
for prenatal care providers, oral health profes-
provider, Community Dental Health Coordinators
sionals and child health professionals.16
(CDHC), who are trained by the American Dental
Association. CDHCs are usually recruited from
the same communities they serve and in addition
STATE OPTIONS FOR
IMPROVING ORAL HEALTH
FOR ALL POPULATIONS
to some basic, preventive services, may provide
health education, connect patients with dental
treatment, and arrange additional services such
as transportation and child care.
Although some state policies are focused on
specific populations, many states are tak-
Coordinate Primary Care and Oral Health
ing steps to improve oral health for everyone
through improved access to providers, im-
The connection between oral health and physi-
proved systems of care and other overarching
cal health is well documented; for example, stud-
strategies described here.
ies show significant annual cost-savings for the
medical treatment of diabetic patients when they
Ensure an Adequate
Oral Health Workforce
receive regular periodontal care.20 And on the
medical side, almost all state Medicaid programs
Even with new professionals entering the field—
reimburse primary care doctors and nurses for
the number of dentists has slightly increased
providing oral exams, screenings and preventive
each year since 2001—some 49 million Ameri-
services, such as fluoride treatments and parent
cans live in a designated dentist shortage area.
education.
17
The Health Resources and Services Administra-
Several states have taken steps to integrate
tion estimates that the country needs 7,300 new
oral health into broader health system delivery
dentists to fill the gaps. State legislatures have
reforms and to coordinate physical, mental, be-
explored creative ways to ensure access to oral
havioral and oral health for individuals enrolled
health care by addressing the workforce.
in Medicaid. For example, Oregon lawmakers
For example, many states expanded dental hy-
passed House Bill 3650 in 2011 to create a new
gienists’ licenses to allow greater scope of prac-
payment and delivery system known as Coordi-
tice or practice in community-based settings.
nated Care Organizations (CCOs). The state’s
In 2014, 37 states allowed dental hygienists to
16 CCOs deliver physical, behavioral and oral
provide certain preventive services to patients,
health services to Medicaid enrollees.
often without direct supervision by a dentist, and
Expand Access to Providers
through Teledentistry
16 states allowed direct Medicaid reimbursement
to hygienists, according to the American Dental
Hygienists’ Association.
Telehealth can help achieve the goals of the
triple aim—improving care and health while
States such as Alaska, Maine and Minnesota
lowering costs—by improving access to ap-
have created new provider types, such as dental
propriate, lower-cost services, such as timely
therapists and community dental providers. Den-
primary or specialty care, or through lower-cost
tal therapists typically are trained to perform ba-
settings, including clinics, homes or workplaces.
sic restorative services, such as fillings and root
Telehealth adoption and expansion across the
canals on baby teeth, and non-surgical extrac-
nation bring various challenges, some of which
tions. Data show the addition of a mid-level pro-
present policy questions for state leaders. For
vider allows participating clinics to see more pa-
example, lack of broadband and cellular con-
tients and adds revenue, in part by allowing the
dentist to work at the top of his or her license.18
nectivity, and availability and affordability of
Eight states—Arizona, California, Montana, Min-
der telehealth. The telehealth field is changing
nesota, Oklahoma, Pennsylvania, Texas and
rapidly, and in some cases, technology may be
devices for consumers and providers can hin-
9
NATIONAL CONFERENCE OF STATE LEGISLATURES
getting ahead of policy. Policymakers are work-
The decision to fluoridate the water supply is
ing to craft frameworks that capitalize on the ad-
typically made at the local level and has met
vancements and potential for telehealth, while
with resistance in some communities. A few
maintaining an appropriate level of oversight to
states mandate fluoridation or regulate how the
safeguard state investments and ensure effec-
system functions. Twenty-six states and Wash-
tive health care delivery.
ington, D.C., meet or exceed the average national percentage (74.6 percent) of citizens who
Teledentistry can leverage and expand the reach
get their drinking water from a fluoridated sys-
of the existing workforce. For example, a 2010
tem.23 These rates vary and in 13 states at least
California demonstration project called Virtual
60 percent of the adult population does not have
Dental Home showed that telehealth-enabled
access to fluoridated water systems.24
dental teams could provide comprehensive care
for people who were inadequately served in a tra-
Maximize Current Data
ditional dental setting.21 The project’s success led
to a 2014 law including teledentistry as a specialty
Policymakers have enacted data and surveil-
for Medicaid reimbursement. Arizona, California,
lance strategies that help them understand oral
Florida and New York all have some form of cov-
health challenges and unmet needs and develop
erage of teledentistry in Medicaid.
targeted responses. For example, Colorado and
Wisconsin use data to evaluate the effectiveness
Understand the State Role
with Community Water Fluoridation
and efficiency of their school sealant programs
as well as to allocate funding.
Community water fluoridation has proven to be
CONCLUSION
a cost-effective public health measure to prevent tooth decay. For 70 years, adjusting the
As the examples provided in this report suggest,
level of this naturally occurring mineral in public
water supplies has helped prevent tooth decay
there is not one singular strategy for improving
for residents of all ages, but especially for chil-
oral health for children and adults. Instead, leg-
dren whose adult teeth are still forming. The
islators are adopting a wide range of strategies
CDC estimates that every $1 invested in water
aimed at addressing specific problems and re-
fluoridation saves $38 in dental treatment.
moving barriers to good oral health care.
NATIONAL CONFERENCE OF STATE LEGISLATURES
22
10
13. Centers for Disease Control and Prevention, Division of Oral
Health, “Adult Oral Health” (Atlanta, Ga.: CDC, 2013), http://www.
cdc.gov/oralhealth/children_adults/adults.htm.
NOTES
1. Centers for Disease Control and Prevention, Division of
Oral Health, “Adult Oral Health” (Atlanta, Ga.: CDC, 2013), http://
www.cdc.gov/oralhealth/children_adults/adults.htm.
14. M. Vujicic and K. Nasseh, “Reconnecting Mouth and Body:
ACA Fails to Meet Dental Care Needs but States Can Pick up
Slack,” Health Affairs Blog (Aug. 26, 2013), http://healthaffairs.
org/blog/2013/08/26/reconnecting-mouth-and-body-aca-fails-tomeet-dental-care-needs-but-states-can-pick-up-slack/.
2. Susan O. Griffin, et al., “Use of Dental Care and Effective
Preventive Services in Preventing Tooth Decay Among U.S.
Children and Adolescents — Medical Expenditure Panel Survey,
United States, 2003–2009 and National Health and Nutrition
Examination Survey, United States, 2005–2010,” Morbidity and
Mortality Weekly Report 63, no. 2 (Sept. 12, 2014): 54-60, http://
www.cdc.gov/mmwr/preview/mmwrhtml/su6302a9.htm.
15. K. Nassah, M. Vujicic, and C. Yarbrough, A Ten-Year, Stateby-State Analysis of Medicaid Fee-For-Service Reimbursement
Rates for Dental Care Services (Health Policy Institute Research
Brief) (Chicago III.: American Dental Association, October
2014),
http://www.ada.org/~/media/ADA/Science%20and%20
Research/HPI/Files/HPIBrief_1014_3.ashx.
3. T. Wall and M. Vujicic, Emergency Department Use for
Dental Conditions Continues to Increase (Health Policy Institute
Research Brief) (Chicago, Ill.: American Dental Association, April
2015).
http://www.ada.org/~/media/ADA/Science%20and%20
Research/HPI/Files/HPIBrief_0415_2.ashx.
16. “Oral Health Care during Pregnancy and Early Childhood
Practice Guidelines” (Albany, NY: New York State Department of
Health, 2006), https://www.health.ny.gov/publications/0824.pdf.
4. Dianne Sefo, “Seeking Treatment for Oral Care Problems
in Emergency Rooms” (New York, N.Y.: Colgate Palmolive
Company, Colgate Oral Care Center, 2016). http://www.colgate.
com/en/us/oc/oral-health/conditions/dental-emergencies-andsports-safety/article/sw-281474979192045.
17. Health Policy Institute, “Supply of Dentists” (Chicago, Ill.:
American Dental Association, February 2016), http://www.ada.
org/en/science-research/health-policy-institute/data-center/
supply-of-dentists.
18. The Pew Charitable Trusts, Expanding the Dental Team:
Increasing Access to Care in Public Settings (Washington, D.C.:
The Pew Charitable Trusts, June 2014), http://www.pewtrusts.
org/~/media/Assets/2014/06/27/Expanding_Dental_Case_
Studies_Report.pdf.
5. Centers for Disease Control and Prevention, Division of Oral
Health, “Preventing Tooth Decay,” (Atlanta, Ga.: CDC, 2015),
http://www.cdc.gov/policy/hst/statestrategies/oralhealth/.
6. National Conference of State Legislatures, The Bright
Futures Guidelines: Improving Children’s Health (Denver: NCSL,
2015),
http://www.ncsl.org/research/health/the-bright-futuresguidelines-improving-children-s-health.aspx.
19. Stacie Crozier, “CDHC program is nearly complete,” ADA
News, (Oct. 21, 2013), http://www.ada.org/en/publications/adanews/2013-archive/october/cdhc-program-is-nearly-complete.
7. Pew Centers on the States, “Reimbursing Physicians for
Fluoride Varnish” (Washington, D.C.: The Pew Charitable Trusts,
2011),
http://www.pewtrusts.org/en/research-and-analysis/
analysis/2011/08/29/reimbursing-physicians-for-fluoride-varnish.
20. A. Snyder, Oral Health and the Triple Aim: Evidence and
Strategies to Improve Care and Reduce Costs (Washington,
D.C.: National Academy for State Health Policy, April 2015),
http://www.nashp.org/wp-content/uploads/2015/04/Oral-TripleAim.pdf.
8. The Guide to Community Preventive Services, “Preventing
Dental Caries: School-Based Dental Sealant Delivery
Programs,” (Atlanta, Ga.: The Community Guide, 2014),
http://www.thecommunityguide.org/oral/supportingmaterials/
RRschoolsealant.html.
21. Paul Glassman, Maureen Harrington, Elizabeth Mertz, and
Maysa Namakian “The Virtual Dental Home: Implications for
Policy and Strategy” (Bethesda, Md.: HHS Public Access, July
2012), http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3477859/.
9. Ibid.
22. Centers for Disease Control and Prevention, “Cost Savings
of Community Water Fluoridation” (Atlanta, Ga.: CDC, updated
July 10, 2013), http://www.cdc.gov/fluoridation/factsheets/cost.
htm.
10. Nancy D. Berkman, et al., “Low Health Literacy and Health
Outcomes: An Updated Systematic Review,” Annals of Internal
Medicine 155, no. 2 (July 19, 2011): 97, http://citeseerx.ist.psu.edu/
viewdoc/download?doi=10.1.1.673.4819&rep=rep1&type=pdf.
23. Centers for Disease Control and Prevention,. “2012 Water
Fluoridation Statistics” (Atlanta, Ga.: CDC, updated Nov. 22,
2013), http://www.cdc.gov/fluoridation/statistics/2012stats.htm.
11. T. Wall and M. Vujicic, Emergency Department Use for
Dental Conditions Continues to Increase (Health Policy Institute
Research Brief) (Chicago, Ill.: American Dental Association, April
24. Oral Health America, “Are Older Americans Coming of Age
Without Oral Healthcare?” (Chicago, Ill.: OHA, 2014), http://
b.3cdn.net/teeth/1a112ba122b6192a9d_1dm6bks67.pdf.
2015).
12 Ibid.
11
NATIONAL CONFERENCE OF STATE LEGISLATURES
Acknowledgments
Support for publication was provided by a grant from the DentaQuest Foundation.
See more at: http://dentaquestfoundation.org.
NCSL Contact
Tahra Johnson, MPH
Policy Specialist
303-856-1389
[email protected]
William T. Pound, Executive Director
7700 East First Place, Denver, Colorado 80230, 303-364-7700 | 444 North Capitol Street, N.W., Suite 515, Washington, D.C. 20001, 202-624-5400
www.ncsl.org
© 2016 by the National Conference of State Legislatures. All rights reserved. ISBN 978-1-58024-852-5