FTC Staff Comment to Georgia State Senator Valencia Seay Concerning Georgia House Bill 684

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Office of Policy Planning
Bureau of Competition
Bureau of Economics
January 29, 2016
The Hon. Valencia Seay
Georgia State Senate
420 State Capitol
Atlanta, Georgia 30334-2000
Dear Senator Seay:
The staffs of the Federal Trade Commission’s Office of Policy Planning, Bureau of
Economics, and Bureau of Competition1 appreciate the opportunity to respond to your invitation
for comments2 on the likely competitive impact of House Bill 6843 (“HB 684”), which would
expand the safety-net settings where Georgia dental hygienists may work without the direct
supervision of a dentist. In addition, HB 684 provides that dental hygienists would no longer
require direct supervision to screen patients for conditions warranting referral to a dentist,
regardless of their location. Removing the direct supervision requirements under these
circumstances would likely enhance competition in the provision of preventive dental care
services and thereby benefit Georgia consumers, particularly underserved populations with
limited access to preventive care.
I. 	INTEREST AND EXPERIENCE OF THE FEDERAL TRADE COMMISSION
The FTC is charged under the FTC Act with preventing unfair methods of competition
and unfair or deceptive acts or practices in or affecting commerce.4 Competition is at the core of
America’s economy,5 and vigorous competition among sellers in an open marketplace gives
consumers the benefits of lower prices, higher quality products and services, and increased
innovation. Because of the importance of health care competition to the economy and consumer
welfare, anticompetitive conduct in health care markets has long been a key focus of FTC law
enforcement,6 research,7 and advocacy.8
FTC staff has addressed competition issues related to oral health care,9 including
supervision of dental hygienists in public health settings, in both law enforcement actions and
policy initiatives. In 2003, the Commission sued the South Carolina Board of Dentistry charging
that the Board had illegally restricted the ability of dental hygienists to provide preventive dental
services in schools without a prior examination by a dentist,10 thereby unreasonably restraining
competition and depriving thousands of economically disadvantaged schoolchildren of needed
dental care, with no justification.11 The Board ultimately entered into a consent agreement
settling the charges.12
UNITED STATES OF AMERICA
FEDERAL TRADE COMMISSION
WASHINGTON, D.C. 20580

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In December 2010, FTC staff urged that the Georgia Board of Dentistry not adopt
proposed rule changes that would have required indirect supervision by a dentist for dental
hygienists providing dental hygiene services at approved public health facilities, and which could
have been interpreted to require a dentist’s initial diagnosis of all patients in such settings.13 In
November 2011, FTC staff urged the Maine Board of Dental Examiners not to adopt proposed
rules that would have restricted the scope of practice of Independent Practice Dental Hygienists
participating in a pilot project designed to improve access to care in underserved areas of the
state, by preventing them from taking certain radiographs without a dentist present.14
Several FTC staff advocacy comments also have addressed supervision requirements for
advanced practice registered nurses (“APRNs”). A 2014 FTC staff policy paper, Policy
Perspectives: Competition and the Regulation of Advanced Practice Registered Nurses, presents
an in-depth analysis of the issue and explains that undue supervision requirements may
exacerbate health provider shortages, increase health care costs and prices, and constrain
innovation in health care delivery models.15 In the context of analyzing APRN regulations in
many states, FTC staff has concluded that removing excessive supervision requirements can
promote competition and achieve significant consumer benefits.16
II. 	CURRENT GEORGIA LAW AND PROPOSED AMENDMENTS TO
SUPERVISION REQUIREMENTS FOR DENTAL HYGIENISTS
With few exceptions, current Georgia law requires dental hygienists to work under the
direct supervision of a licensed dentist,17 typically the highest supervision level imposed by a
state.18 In Georgia, direct supervision means that a licensed dentist “is in the dental office or
treatment facility, personally diagnoses the condition to be treated, personally authorizes the
procedures and remains in the dental office or treatment facility while the procedures are being
performed by the dental hygienist and, before dismissal of the patient, examines the patient.”19
This direct supervision requirement restricts the conditions and locations in which hygienists
may provide services by limiting their practice to facilities where a dentist is physically
present.20 Accordingly, the potential negative effect of a direct supervision requirement is
greatest precisely where there is the most need for dental health professionals—underserved
communities in dental health professional shortage areas, where dentists are often scarce or
unavailable.
Georgia law does not require direct supervision when dental hygienists provide care “at
approved dental facilities of the Department of Public Health, county boards of health, or the
Department of Corrections.” 21 At these locations, Georgia’s regulations require a dentist to
authorize the dental hygienists’ services, but the dentist need not be physically present.22 Georgia
law also allows dental hygienists to provide “dental screenings” without direct supervision in a
number of public settings, including “schools, hospitals, and clinics and state, county, local, and
federal public health programs.” A screening is a visual assessment of the oral cavity to
determine whether a dentist should provide a more thorough examination.23
HB 684 would amend Georgia law to permit dental hygienists to provide care without
direct supervision in additional settings: “at approved safety-net settings, including nonprofit

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clinics, health care facilities, long-term care facilities, and school based programs; or at other
facilities or settings approved by the board.”24 In addition, HB 684 would allow dental hygienists
to provide dental screenings in any setting without direct supervision.25
III. 	LIKELY COMPETITIVE IMPACT OF HB 684
Laws and regulations that require hygienists to work under the direct supervision of
dentists to provide preventive services are a significant barrier to the use of dental hygienists
outside of dentists’ offices and in dental shortage areas.26 A 2001 law review article describes the
effects of the direct supervision requirement when hygienists sought to provide dental screenings
at schools and health fairs before Georgia amended its supervision laws in 2001 to remove the
requirement of direct supervision of such screenings in public health settings. The article found
that when dentists were available, the direct supervision requirement sometimes resulted in an
inefficient duplication of efforts by dentists and dental hygienists. When dentists were not
available, however, the requirement had an even more dramatic effect, resulting in the complete
exclusion of dental hygienists who sought to provide screenings.27
Georgia continues to rely primarily on direct supervision of most functions provided by
dental hygienists. Indeed, it is one of only a handful of states that did not relax its supervision
requirements for dental hygienists between 1993 and 2011.28 Most states require only general
supervision, which requires a dentist to authorize care by hygienists, but does not require the
dentist to be physically present.29 Thirty-eight states have gone even further, allowing direct
access to dental hygienists without a dentist’s authorization under certain circumstances.30
HB 684 takes a step toward reducing the barrier to preventive oral care created by direct
supervision requirements.31 Its proposed expansion of settings where dental hygienists may
provide care without the direct supervision of a dentist is consistent with trends in a majority of
states, which typically have lower supervision levels in public health and non-dental office
settings such as schools, prisons, and nursing homes; some also reduce supervision for the care
of homebound individuals in private homes.32 By increasing the availability of dental hygienists’
services outside of dentists’ offices, these initiatives can increase the number of suppliers of
preventive dental care. The initiatives thereby promote greater competition in the provision of
oral health services. Greater competition may, in turn, enhance access to affordable preventive
services, mitigate the broader health consequences of dentist shortages, and facilitate the
development of innovative models for delivering care.33 Indeed, dental hygienists are well-
positioned to alleviate limited access to preventive dental care arising from dentist shortages
because they outnumber dentists by approximately 20%.34
The enhanced supply of providers likely to result from reduced supervision requirements
could be especially effective in improving access to dental services in Georgia’s underserved
areas, where dentists may not be available.35 In the United States, the oral health workforce is
not well distributed, and access to dentists and dental care is inadequate in many areas. This is
the case in some parts of Georgia, where 148 locations have been designated as Dental Care
Health Professional Shortage Areas (“DCHPSA”). In Georgia, 14.5% of the population lives in a
DCHPSA, and the percent of need met by dentists is only 27%.36 Elimination of the direct
supervision requirement will help alleviate some of these dental care shortages, and facilitate

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greater competition, which could reduce costs and prices. Even though dental hygienists earn
considerably less than dentists,37 their ability to provide cost-effective care is tied to their ability
to offer safe and effective services without a dentist on site. Direct supervision requiring the
physical presence of a dentist undercuts the cost savings that would otherwise arise from the use
of a dental hygienist because it requires payment for the dentist’s services, as well as costs
related to transporting the dentist to non-dental facilities.38 Moreover, the increased availability
of dental hygienists at local safety-net settings that would arise if the direct supervision
requirement were eliminated would also be likely to reduce patients’ transportation costs.39 Thus,
elimination of the direct supervision requirement and the likely increase in competition and
access arising from HB 684 could reduce the costs of treatment for patients and lead to savings
for government benefit programs.40
By contrast, retention of the direct supervision requirement would likely limit
competition and decrease access to dental hygienists without providing any countervailing
benefits to health care consumers. Various authorities have concluded that direct supervision of
dental hygienists is not necessary for them to provide preventive services safely. According to
the National Governors Association, there is no clear evidence to support state dental boards’
concerns about quality and safety, which boards sometimes raise to justify restrictions on
hygienists’ practicing without supervision in settings where dentists are not available.41 The
Institute of Medicine has likewise concluded that restrictive scope of practice and supervision
laws and regulations governing dental hygienists “are often unrelated to competence, education
and training, or the safety” of the services they provide.42 The IOM recommends that state
legislatures increase access to basic oral health care by amending dental practice acts to allow
allied dental professionals such as hygienists to work to the full extent of their education and
training “in a variety of settings under evidence-supported supervision levels[.]”43 HB 684
appears to be a step in this direction. By eliminating the requirement of direct supervision for
dental screenings in any setting, and for preventive dental care in expanded safety-net settings,
HB 684 will likely increase dental hygienists’ ability to provide services within the scope of their
education and training, such as prophylaxis and the application of fluoride and dental sealants.
By doing so, HB 684 has the potential not only to improve oral health, but also to contribute
more generally to Georgians’ physical health and well-being.44
IV. 	CONCLUSION
By eliminating the direct supervision requirement for dental hygienists’ services
delivered in expanded safety-net settings, and for dental screenings delivered in any setting, HB
684 will likely promote greater competition in the provision of preventive dental care services,
leading to increased access and more cost-effective care, especially for Georgia’s most
vulnerable populations. Retaining the direct supervision requirement in the settings covered by
HB 684 would likely preclude these benefits of competition. Finally, authoritative sources have
found no countervailing health or safety benefits to health care consumers from such
requirements. Accordingly, HB 684 appears to be a procompetitive improvement in the law that
would benefit Georgia health care consumers.

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Respectfully submitted,
Marina Lao, Director
Office of Policy Planning
Ginger Zhe Jin, Director
Bureau of Economics
Deborah Feinstein, Director
Bureau of Competition
1 This letter expresses the views of the Federal Trade Commission’s Office of Policy Planning, Bureau of
Economics, and Bureau of Competition. The letter does not necessarily represent the views of the Federal Trade
Commission or of any individual Commissioner. The Commission, however, has voted to authorize us to submit
these comments.
2 Letter from Valencia Seay, Senator, Georgia Senate, to Karen Goldman, Attorney Advisor, Office of Policy
Planning, Fed. Trade Comm’n (June 23, 2015) (on file with Office of Policy Planning).
3 HB 684 (LC 33 6136, 2015-2016) (to amend G A. C ODE ANN. § 43-11-74),
http://www.legis.ga.gov/Legislation/20152016/152664.pdf.
4 Federal Trade Commission Act, 15 U.S.C. § 45.
5 Standard Oil Co. v. FTC, 340 U.S. 231, 248 (1951) (“The heart of our national economic policy long has been faith
in the value of competition.”).
6 See generally FTC STAFF, O VERVIEW OF FTC A NTITRUST A CTIONS IN H EALTH C ARE SERVICES AND P RODUCTS
(2013), https://www.ftc.gov/system/files/attachments/competition-policy-guidance/hcupdaterev.pdf.
7 See, e.g., FTC & U.S. D EP’T OF J USTICE (“DOJ”), I MPROVING H EALTH C ARE : A D OSE OF COMPETITION (2004),
http://www.ftc.gov/reports/healthcare/040723healthcarerpt.pdf.
8 FTC and staff advocacies take many forms, including letters or comments addressing specific policy issues,
Commission or staff testimony before legislative or regulatory bodies, and amicus briefs. See, e.g., FTC Staff Letter
to the Hon. Rep. Stephen LaRoque, North Carolina House of Representatives, Concerning North Carolina House
Bill 698 and the Regulation of Dental Service Organizations and the Business Organization of Dental Practices in
North Carolina (May 25, 2012), http://ftc.gov/os/2012/05/1205ncdental.pdf; FTC and DOJ Written Testimony
before the Illinois Task Force on Health Planning Reform Concerning Illinois Certificate of Need Laws (Sept. 15,
2008), https://www.ftc.gov/sites/default/files/documents/advocacy_documents/ftc-and-department-justice-written-
testimony-illinois-task-force-health-planning-reform-concerning/v080018illconlaws.pdf; Brief of the FTC as
Amicus Curiae in Actelion Pharmaceuticals Ltd. v. Apotex Inc., No. 1:12-cv-05743-NLH-AMD (D. N.J.) (Mar. 11,
2013), http://www.ftc.gov/os/2013/03/130311actelionamicusbrief.pdf .
9 See, e.g., Comment from FTC Staff to the Texas State Bd. of Dental Exam’rs (Oct. 6, 2014) (concerning proposed
restrictions on the ability of Texas dentists to enter into agreements with non-dentists for administrative services),
https://www.ftc.gov/policy/policy-actions/advocacy-filings/2014/10/ftc-staff-comment-texas-state-board-dental-

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examiner-0; Comment from FTC Staff to the Comm’n on Dental Accreditation (Dec. 2, 2013) (concerning
accreditation standards for dental therapists), http://www.ftc.gov/policy/policy-actions/advocacy-filings/2013/12/ftc-
staff-comment-commission-dental-accreditation; N.C. State Bd. of Dental Exam’rs v. FTC, 135 S. Ct. 1101 (2015)
(upholding an FTC ruling that the North Carolina State Board of Dental Examiners illegally thwarted lower-priced
competition by engaging in anticompetitive conduct to prevent non-dentists from providing teeth whitening services
to consumers in the state); Comment from FTC Staff to the La. State Bd. of Dentistry (Dec. 18, 2009) (concerning
proposed rules on the practice of portable and mobile dentistry),
http://www.ftc.gov/os/2009/12/091224commentladentistry.pdf); Comment from FTC Staff to the La. House of
Representatives (May 1, 2009), http://www.ftc.gov/os/2009/05/V090009louisianadentistry.pdf; Comment from FTC
Staff to the La. House of Representatives (May 22, 2009) (concerning legislation on the practice of in-school
dentistry), http://www.ftc.gov/os/2009/05/V090009louisianahb687amendment.pdf; see generally Advocacy Filings
by Subject, Dentistry, FED. T RADE COMM ’N, http://ftc.gov/opp/advocacy_subject.shtm#detg (last visited Jan. 21,
2016).
10 See S.C. State Bd. of Dentistry, 138 F.T.C. 229, 233-40 (2004),
http://www.ftc.gov/os/decisions/docs/Volume138.pdf#page=234.
11 See id. at 232, 268-80.
12 S.C. State Bd. of Dentistry, Dkt. No. 9311 (F.T.C. 2007) (decision and order),
https://www.ftc.gov/sites/default/files/documents/cases/2007/09/070911decision_0.pdf. The Board sought to have
the complaint dismissed on the ground that its actions were exempt from the antitrust laws by virtue of the state
action doctrine, but the Commission denied the motion to dismiss. S.C. State Bd. of Dentistry, 138 F.T.C. 229
(2004).
13 FTC Staff Comment Before the Georgia Board of Dentistry Concerning Proposed Amendments to Board Rule
150.5-0.3 Governing Supervision of Dental Hygienists (Dec. 30, 2010),
http://ftc.gov/os/2010/12/101230gaboarddentistryletter.pdf. The Board did not adopt the proposed rule requiring
indirect supervision. In 2012, it adopted a revised rule that requires a supervising dentist to authorize the provision
of services, either in person, through video conferencing, by written standing orders, or through department
protocols. See infra note 22; Secretary of State/Professional Licensing Boards Division/Board of Dentistry, Notice
of intent to adopt amendments to the Georgia Board of Dentistry Board Rules 150-5-.03 Supervision of Dental
Hygienists and Notice of Public Hearing, 2012 GA Regulation Text 5775, Feb. 20, 2012.
14 FTC Staff Comment Before the Maine Board of Dental Examiners Concerning Proposed Rules to Allow
Independent Practice Dental Hygienists to Take X-Rays in Underserved Areas (Nov. 16, 2011),
http://ftc.gov/os/2011/11/111125mainedental.pdf. The Board subsequently voted to allow IPDHs to take only those
certain x-rays.
15 See FED. T RADE COMM ’N STAFF, P OLICY P ERSPECTIVES: C OMPETITION AND THE REGULATION OF ADVANCED
P RACTICE N URSES III.A., 38 (2014) (mandatory supervision and agreement requirements are likely to lead to
“decreased access to health care services, higher health care costs, reduced quality of care, and less innovation in
health care delivery.”), https://www.ftc.gov/system/files/documents/reports/policy-perspectives-competition-
regulation-advanced-practice-nurses/140307aprnpolicypaper.pdf.
16 See Comment from FTC Staff to the South Carolina House of Representatives 2 (Nov. 2, 2015),
https://www.ftc.gov/policy/policy-actions/advocacy-filings/2015/11/ftc-staff-comment-south-carolina-
representative-jenny.
17 See G A. CODE ANN. § 43-11-74(a) (“Dental hygienists shall perform their duties only under the direct supervision
of a licensed dentist. . . .”).
18 See, e.g., April V. Catlett & Robert Greenlee, A Retrospective Comparison of Dental Hygiene Supervision
Changes from 2001 to 2011, 87 J. D ENTAL H YGIENE 110, 112 (2013); American Dental Hygienists’ Ass’n, Dental
Hygiene Practice Act Overview: Permitted Functions and Supervision Levels by State (Sept. 2015) (under direct
supervision, a “dentist needs to be present;” under indirect supervision, a “dentist must authorize [the] procedure and
be in the dental office when the procedure is performed;” under general supervision, a “dentist needs to authorize
prior to services, but need not be present;” under direct access, “hygienists can provide services as s/he determines
appropriate without specific authorization”), https://www.adha.org/resources-

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docs/7511_Permitted_Services_Supervision_Levels_by_State.pdf. There are no express provisions for indirect
supervision, general supervision, or direct access in Georgia laws or regulations, but the regulatory requirement of a
dentist’s authorization for dental hygienists services provided at certain public facilities is comparable to a
requirement of general supervision. See infra note 22 and accompanying text.
19 G A. COMP. R. & REGS. 150-5-.03 (Supervision of Dental Hygienists).
20 Catlett & Greenlee, supra note 18, at 110.
21 G A. CODE ANN. § 43-11-74(d).
22 Currently, Georgia regulations require a dentist to authorize the services provided by dental hygienists in these
settings, either in person, through video conferencing, by written standing orders, or through department protocols.
See G A. COMP. R. & REGS. 150-5-.03(3)(b).
23 G A. CODE ANN. § 43-11-74(e)(1), (2).
24 HB 684, G A. CODE A NN. § 43-11-74(d) (proposed). HB 684 would also strike the language at G A. CODE ANN. §
43-11-74(d) requiring the Georgia Board of Dentistry to provide regulations specifying a level of supervision at
public health and safety-net settings, suggesting that authorization by a dentist might not be required. However, HB
684 does not propose to amend current Georgia law that generally authorizes the Georgia Board of Dentistry to
adopt regulations on the scope of practice and supervision of dental hygienists. See G A. CODE ANN. § 43-11-9. Thus,
it is not clear whether HB 684 alters the authority of the Georgia Board of Dentistry to adopt or retain regulations
requiring a dentist to authorize services provided by dental hygienists.
25 See HB 684, G A. CODE ANN. § 43-11-74(e)(2) (proposed).
26 See N ATIONAL G OVERNORS ASS ’N, T HE ROLE OF D ENTAL H YGIENISTS IN P ROVIDING ACCESS TO O RAL H EALTH
C ARE 4-5 (2014); Catlett & Greenlee, supra note 18, at 110 (“direct supervision confines the dental hygienist to a
facility where the dentist is physically present”); Dental Hygienists: Demand for Dental Hygienists, in I NSTITUTE OF
M EDICINE , A LLIED H EALTH S ERVICES: AVOIDING CRISES 108 (1989) (“The opportunities for hygienist employment
outside dental offices today are limited by regulations that require them to work with dentists on site. Thus,
populations such as the elderly in long-term care facilities and physically and mentally retarded people in
institutions, whose access to care is limited by their lack of mobility, cannot be served by hygienists alone.”).
27 See Amy Pressley McCarthy, Dentists and Dental Hygienists: Allow Dental Hygienists to Perform Dental
Screenings without Supervision Under Certain Conditions; Provide for Information and Fees, 18 G A. ST. U.L. REV.
238, 239 (2001) (effects of the direct supervision requirement based on the author’s telephone interview of Martha
S. Phillips, Executive Director of the Georgia Dental Association). In 2001, Georgia dentists apparently recognized
that requiring direct supervision of screenings created a barrier to care in public health settings and determined that
such supervision was unnecessary for the health and safety of screenings in those settings. As a result, both dentists
and hygienists supported the 2001 bill drafted by the Georgia Dental Association, which ultimately eliminated the
requirement that dentists directly supervise hygienists’ screenings in schools, hospitals, clinics, and a number of
public health programs. See id. at 239-40.
28 See Catlett & Greenlee, supra note 18, at 114-115 (45 out of 51 jurisdictions reduced dental hygienists’
supervision requirements from 2001-2011, but Alabama, Georgia, Mississippi, and North Carolina rely on direct
supervision and have made little progress in reducing supervision); see also American Dental Hygienists’ Ass’n,
Dental Hygiene Practice Act Overview: Permitted Functions and Supervision Levels by State (Sept. 2015),
https://www.adha.org/resources-docs/7511_Permitted_Services_Supervision_Levels_by_State.pdf . By adopting a
regulation in 2012 that requires a dentist’s authorization for dental hygiene services provided at the Dept. of Public
Health, county boards of health, and the Dept. of Corrections, Georgia effectively increased the level of supervision
during the last 10 years. See supra notes 13, 22.
29 See American Dental Hygienists’ Ass’n, Dental Hygiene Practice Act Overview: Permitted Functions and
Supervision Levels by State (Sept. 2015), https://www.adha.org/resources-
docs/7511_Permitted_Services_Supervision_Levels_by_State.pdf ; see also Georgia Dental Hygienists’ Ass’n, It’s
Time for Georgia to “Catch Up” on Oral Health Care Provisions (2015) (45 states allow dental hygienists to work
under general supervision, which does not require a dentist to be present in the treatment facility).

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30 See American Dental Hygienists’ Ass’n, Current Direct Access Map 2016: 38 States (Jan. 2016),
http://www.adha.org/direct-access. The American Dental Hygienists’ Association defines direct access as “the
ability of a dental hygienist to initiate treatment based on their assessment of a patient’s needs without the specific
authorization of a dentists, treat the patient without the presence of a dentist, and maintain a provider-patient
relationship . . . .” American Dental Hygienists’ Ass’n, Direct Access States 1 (Sept. 2015),
http://www.adha.org/direct-access. See also D.K. Naughton, Expanding oral care opportunities: direct access care
provided by dental hygienists in the United States, 14 J. E VID . B ASED D ENT. P RACT. SUPPL. 171 (2014).
31 Consistent with the trends in other states, Georgia may wish to consider eliminating direct supervision altogether,
so that all consumers could benefit from increased access and other potential benefits of greater competition (e.g.,
expanded hours/locations of service, possible price competition, etc.).
32 See Catlett & Greenlee, supra note 18, at 114-116; N ATIONAL G OVERNORS ASS ’N , supra note 26, at 5
(“Typically, states require more supervision in private settings than in public settings. No state requires more
stringent oversight in public settings than in private settings.”).
33 See Catlett & Greenlee, supra note 18, at 110, 111, 116; N ATIONAL G OVERNORS ASS ’N, supra note 26, at 4.
34 See N ATIONAL G OVERNORS ASS ’N, supra note 26, at 4.
35 Some studies suggest that reduced supervision requirements for dental hygienists contribute to improved access to
dental health care for underserved populations in a number of states. See Catlett & Greenlee, supra note 18, at 111,
116. See also A Vision for the Delivery of Oral Health Care to Vulnerable and Underserved Populations, in
COMMITTEE ON O RAL H EALTH ACCESS TO SERVICES, I NSTITUTE OF M EDICINE AND N ATIONAL RESEARCH COUNCIL,
I MPROVING ACCESS TO O RAL H EALTH C ARE FOR V ULNERABLE AND U NDERSERVED P OPULATIONS 234 (2011) (As a
result of overly restrictive scope of practice and supervision regulations, “states may miss critical opportunities to
serve greater numbers of individuals in need of care.”).
36 The Henry J. Kaiser Family Foundation, Dental Care Health Professional Shortage Areas (April 28, 2014),
http://kff.org/other/state-indicator/dental-care-health-professional-shortage-areas-hpsas/#; K AISER COMM ’N ON
M EDICAID & THE U NINSURED, K AISER F AMILY FOUND., O RAL H EALTH IN THE US 2 (June 2012),
http://kaiserfamilyfoundation.files.wordpress.com/2013/01/8324.pdf (based on 2010 census data at
http://www.census.gov/2010census/data/).
37 See COMMITTEE ON O RAL H EALTH ACCESS TO SERVICES, I NSTITUTE OF M EDICINE AND N ATIONAL RESEARCH
COUNCIL, I MPROVING ACCESS TO O RAL H EALTH C ARE FOR V ULNERABLE AND U NDERSERVED P OPULATIONS 87
(2011) (mean annual wage of $143,000 for salaried general dentists, compared to $66,500 for dental hygienists).
38 For a discussion of how requirements to have a dentist on-site could undercut the savings arising from the use of
dental therapists, mid-level dental providers who earn less than dentists, see Comment from FTC Staff to the
Comm’n on Dental Accreditation 5 (Dec. 2, 2013), http://www.ftc.gov/policy/policy-actions/advocacy-
filings/2013/12/ftc-staff-comment-commission-dental-accreditation. Similarly, FTC staff has concluded that
excessive supervision requirements may increase health care costs and prices for care provided by APRNs, who tend
to be low-cost providers. See FED. T RADE COMM ’N STAFF, P OLICY P ERSPECTIVES: COMPETITION AND THE
REGULATION OF A DVANCED PRACTICE N URSES 27-28 (2014),
https://www.ftc.gov/system/files/documents/reports/policy-perspectives-competition-regulation-advanced-practice-
nurses/140307aprnpolicypaper.pdf.
39 See, e.g., Brian E. Whitacre, Estimating the Economic Impact of Telemedicine in a Rural Community, 40 AG. RES.
E CON. REV. 172, 176-178 (presenting transportation savings and savings from not missing work arising from local
(virtual) availability of a health care provider in a rural community). Savings on patients’ transportation costs may
reduce state health care costs, because state Medicaid programs cover transportation and related travel expenses
necessary for treatment. See 42 C.F.R. § 440.170; Georgia Department of Community Health, Medicaid FAQs
(Georgia Medicaid program pays for “non emergency medical transportation services”).
40 For example, the Georgia Department of Public Health states that “[p]ublic health dental services are provided to
children who are enrolled in Medicaid and PeachCare programs, as well as to low-income patients on a sliding-fee

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scale (based on the patient’s ability to pay.” Georgia Dep’t of Public Health, Oral Health,
https://dph.georgia.gov/oral-health.
41 See N ATIONAL G OVERNORS ASS ’N, supra note 26, at 10 (2014). One study suggests that even without any
supervision, dental hygienists’ preventive care is “at least as good as hygiene care provided with dentists’
supervision,” and does not “increase the risk to the health and safety of the public or pose an undue risk of harm to
the public.” James R. Freed, Dorothy A. Perry, & John E. Kushman, Aspects of Quality of Dental Hygiene Care in
Supervised and Unsupervised Practices, 57 J. P UB . H EALTH D ENTISTRY 68, 74 (1997). See also Catlett & Greenlee,
supra note 18, at 111 (requiring the physical presence of a dentist is unnecessary for most dental hygiene care
because “there is little possible danger in most dental services provided”).
42 A Vision for the Delivery of Oral Health Care to Vulnerable and Underserved Populations, in COMMITTEE ON
O RAL H EALTH ACCESS TO SERVICES, I NSTITUTE OF M EDICINE AND N ATIONAL RESEARCH COUNCIL, I MPROVING
ACCESS TO O RAL H EALTH C ARE FOR V ULNERABLE AND U NDERSERVED P OPULATIONS 234 (2011).
43 Id. at 235.
44 See N ATIONAL G OVERNORS ASS ’N, supra note 26, at 1, 4; INST. OF M ED., N AT’ L ACADS., ADVANCING O RAL
H EALTH IN AMERICA 16-17, ch. 2 (2011) (discussing the connection between oral health and overall health and well
being), http://www.nap.edu/catalog.php?record_id=13086&utm_expid=4418042-5.krRTDpXJQISoXLpdo-
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