N at ion a l C onf e r e nc e o f S tat e L e g i sl at u r e s

Many Americans lack access to basic, affordable oral health care. Tooth decay is the most preventable unmet health need in the United States, yet one-quarter of children have tooth decay before they enter kindergarten and one-third of adults report having it.1 Growing evidence links oral disease to chronic health conditions such as diabetes, heart and lung disease and potential pregnancy complications. Costly for families, communities and states, untreated tooth decay can lead to pain and infection, missed school days, and problems with eating and

speaking. Dental expenses for U.S. children ages 5 to 17 were about $20 billion in 2009—almost 18 percent of all health care costs for this group.2

In sum, tooth decay and unaddressed oral health problems add up to poor health outcomes and rising health care costs. Emergency room (ER) visits for preventable dental conditions cost $1.6 billion in 2012,3 and the cost of a procedure, such as a tooth extraction, can increase nearly 10 times when performed in

Improving Lifetime Oral Health: Policy Options and InnovationsBY TAHRA JOHNSON AND KRISTINE GOODWIN

NATIONAL CONFERENCE OF STATE LEGISLATURES 2

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 Invest-ments in Oral Health: State Policy Options for Improving Care and Reducing Costs,” featured national expert Andrew Sny-der 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.

• SignificantdisparitiesexistamonggroupsintheU.S.,andtherearelong-standing,persistentbarrierstolow-incomepeople 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 car-diovascular disease, stroke, and diabetes.

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 re-ceive treatment that addresses the symptoms of pain, not the underlying causes, which could be better addressed in the dentist’soffice,Allensaid.Thetrendiscostlytothestate:Dentalemergencydepartment(ED)visitscostabout$300pervisit 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.

Expand access

Increase preventive care Fewer ED vists

Healthier patients and

less-costly care

Source: Representative Susan Allen, “Missouri Oral Health Initiatives,” NCSL Legislative Summit, August 2015.

IMPROVING ACCESS RESULTS IN BETTER, LESS COSTLY CARE

3 NATIONAL CONFERENCE OF STATE LEGISLATURES

anemergencyroominsteadofadentaloffice.4 These factors are costly for states and affect the quality of life for individuals and families.

Concerned about these cost and health sta-tus 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 im-prove 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 Cen-ters for Disease Control and Prevention (CDC). Total U.S. dental expenditures for children up to 21 years old exceeded $25 billion5 in 2012, plac-ing a significant financial burden on state bud-gets. 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.

Assess and Screen in Primary Care Settings

Pediatriciansareoftenthefirstmedicalprovidersto examine a baby or toddler’s mouth. By the age of 6 months, oral health screenings should be-gin and continue as a routine part of every doc-tor’s visit, according to the American Academy of Pediatrics. The American Academy of Pediatric Dentistry (AAPD) recommends that a child go to the dentist by age 1. The federal Health Re-sources and Services Administration (HRSA) es-tablished the Bright Futures Guidelines in 1990 to improve the standard of care for children and adolescents. Since 2002, the American Academy of Pediatrics (AAP) has overseen development and dissemination of these guidelines.6 The majority of states use the recommendations in Bright Futures to guide which services the state Medicaid program covers.

Bright Futures offers pediatric care providers and families tools for evidence-based care for children from birth to age 21. For example, oral health risk assessments are recommended at the 6- and 9-month well-child visits with primary care providers. A pediatrician can identify conditions likeplaque,cavitiesorinflammationofthegums,and also refer a patient to a dental provider. Oral health risk assessments provide early tracking for a child’s oral health history that can be later referenced by his or her future dental provider. Early evaluation can help maintain good oral health and prevent or treat disease.

Applyingfluoridevarnishisanotherwaypediatri-cians and primary care providers can help with preventive oral health procedures. States have now begun reimbursing doctors through Med-icaid. According to The Pew Charitable Trusts, most Medicaid programs pay between $15 and

NATIONAL CONFERENCE OF STATE LEGISLATURES 4

$30 for the procedure. Fluoride varnish can re-duce the rate of tooth decay by one-third, lead-ingtosignificantcostsavings,suchasavoidingrestorative dental care or hospital visits.7

School-based Prevention and Care

Most dental disease can be prevented by early identification and intervention with care suchas dental sealants and fluoride treatments.Sealants—plastic coatings applied to vulner-able molars—help prevent decay and may save

money by preventing the need for dental-related emergency room visits and other costly den-tal care. Not all policymakers embrace sealant programs, and some concern exists about the safety of sealants; however, one-time applica-tion of sealants has not been found to provide chronic exposure, and applying them properly re-duces exposure. Based on a review of evidence about sealant safety and risks, the Association of State and Territorial Dental Directors recom-mends sealants for all children. Dental sealants

5 NATIONAL CONFERENCE OF STATE LEGISLATURES

applied in school-based programs reduce tooth decay by as much as 60 percent.8 They also can reduce dental health disparities and lead to fol-low-up care and enrollment in health insurance. The U.S. Preventive Services Task Force rates school-based sealant programs as an evidence-based approach for reducing tooth decay. The task force evaluated four sealant delivery pro-grams in 2013 and found that sealants reduced tooth decay up to 48 months after application. In-school sealant programs also help raise aware-

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 cost-efficientworkforce,andeliminatereimbursementand regulatory barriers for providers. Some pro-grams 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 pre-ventive services, especially for underserved chil-dren and adolescents.

• Arkansas lawmakers created a collabora-tive care program in 2011 that allows quali-fieddentalhygienists—whocollaboratewithconsulting dentists—to provide sealants and other procedures in public health settings.

• Colorado lawmakers established a grant pro-gram in 2013 to support school-based dental sealantprograms,communitywaterfluorida-tion and other strategies.

• A 2009 Massachusetts law authorized public health dental hygienists to provide sealants and certain other preventive services with-out a dentist’s prior examination. The law also allows reimbursement under Medicaid and the Children’s Health Insurance Pro-gram (CHIP).

Raise Awareness About Healthy Behaviors

Around 80 million Americans have limited health literacy—the ability to understand and interpret health information—which puts them at greater risk for lacking access to care and having poor health.10 People with poor health literacy are more likely to have fewer preventive procedures, potentially leading to costly ER visits or chronic health conditions. This group can include older

NATIONAL CONFERENCE OF STATE LEGISLATURES 6

adults, people with limited education and those with limited English proficiency. Some stateshave launched oral health campaigns to spread awareness like Delaware’s “Healthy Smile. Healthy You.”

STATE OPTIONS FOR IMPROVING ADULT ORAL HEALTH

Poor access to dental services has economic consequences for states. Visits to the emergen-cy room for dental reasons cost $1.6 billion in 2012 and rarely addressed the underlying con-dition. Estimates show that 79 percent of these patients could have been treated in a commu-nity setting.11

Medicaid is a major payer of these costs. Case in point: A study of Maryland’s Medicaid costs showed a potential savings of $4 million if dental visits to the emergency room were diverted to a more appropriate setting.12 In addition, poor adult oral health is costly to both working peo-

ple and employers. Employed adults lose more than 164 million work hours annually because of oral health problems or dental visits, according to the CDC.13

Expand Coverage for Low-Income Adults

The vast majority of adults who gained or will gain some dental coverage through the Afford-able Care Act (ACA)—about 17.7 million—will do so through state Medicaid programs.14 An estimated 800,000 will gain coverage through the state or federal health insurance exchanges. According to a February 2016 report from the Center for Health Care Strategies, 46 states and the District of Columbia currently cover at least emergency dental services (e.g., relief for uncontrolled bleeding or trauma) for adults with Medicaid; of those, 13 states cover emergency care only, 18 states and the District of Columbia cover certain limited services (such as preventive and restorative procedures), and 15 states offer extensive coverage to their base Medicaid adult population.

VT

RI

DE

NH

NJ

CT

DC

MA

AS GU MP VI PR

MD

AK

WA

OR

NV

CACO

MN

HI

MT

WY

UT

AZ NM

TX

ND

SD

NE

KS

OK

IA

WI

IL

MO

AR

LA

MI

INOH

PA

NY

KY

TN

MS AL GA

FL

WV VA

NC

SC

ME

ID

No dental benefits

Emergency only

Limited

Extensive

STATE MEDICAID COVERAGE OF ADULT DENTAL BENEFITS

Source: Center for Health Care Strategies, Inc., “Medicaid Adult Dental Benefits: An Overview,” February 2016

No dental benefits

Emergency only

Limited

Extensive

7 NATIONAL CONFERENCE OF STATE LEGISLATURES

• Several states have restored adult dental coverage in recent years, after eliminat-ing them during the economic recession. A 2014 California law covers certain den-tal benefits for all adults onMedi-Cal (thestate’s Medicaid program). In 2014, Idaho lawmakers reinstated dental benefits foradults enrolled in Medicaid, including cover-age for routine exams and preventive and other dental services. Washington restored dental coverage in 2013 for Medicaid-en-rolled adults to include restorative and pre-ventive services, emergency services, root canals, cavity care, and routine checkups and cleanings.

• Some states are providing preventive den-tal benefits to adults for the first time. In2013, Colorado lawmakers passed Sen-ate Bill 242,whichprovideddentalbenefitsto all adult Medicaid enrollees, with up to $1,000indentalbenefitseachyear.SouthCarolinawillcovercleaning,fillingsandex-tractions for adults with very low incomes or disabilities.

Expand Oral Health Workforce

States struggle to find an adequate numberof oral health providers who accept Medicaid. Dentists often decline to participate in Medic-aid because of lower reimbursement rates than in the commercial market. According to the American Dental Association (ADA), 35 percent of dentists accept Medicaid patients. For adult services in stateswithat least limitedbenefits,the reimbursement rates averaged 40.7 percent of commercial reimbursement in 2014. Alaska, Arkansas and North Dakota had the highest re-imbursement rates, at around 60 percent of the commercial rate.15

Somestateshaveadoptedfinancialandotherin-centives—including enhanced reimbursement or reduced administrative burden (less time fillingout forms)—to increase the number and avail-ability of oral health providers who are willing to provide care to Medicaid patients. States also have taken steps to increase the capacity of the existing oral health workforce to meet demand by, for example, using telehealth (providing ser-

NATIONAL CONFERENCE OF STATE LEGISLATURES 8

vices remotely) or changing provider roles and practice settings. California lawmakers passed legislation in 2014 to reimburse hygienists and dentists for telehealth dental services.

Improve Oral Health Access for Pregnant Women

Dental disease in pregnant women is associated with pre-term birth, low birthweight and gesta-tional diabetes, all of which can harm the baby and may result in a more costly pregnancy. Den-tal care is safe throughout pregnancy, although misapprehension about treatment safety and

concerns about liability may cause dental profes-sionals to delay treatment for pregnant women. In addition to the consequences of dental health problems during pregnancy, a woman’s oral health also can affect her children.

Pregnant women and young children often are more likely to see a primary care provider than a dental professional, so other providers such as obstetricians, gynecologists and pediatricians may be engaged in their patients’ oral health care. The New York State Department of Health created “Oral Healthcare During Pregnancy and Early Childhood: Practice Guidelines,” which pro-

9 NATIONAL CONFERENCE OF STATE LEGISLATURES

vide screening and treatment recommendations for prenatal care providers, oral health profes-sionals and child health professionals.16

STATE OPTIONS FOR IMPROVING ORAL HEALTH FOR ALL POPULATIONS

Although some state policies are focused on specific populations, many states are tak-ing steps to improve oral health for everyone through improved access to providers, im-proved systems of care and other overarching strategies described here.

Ensure an Adequate Oral Health Workforce

Evenwithnewprofessionalsenteringthefield—the number of dentists has slightly increased each year since 2001—some 49 million Ameri-cans live in a designated dentist shortage area.17 The Health Resources and Services Administra-tion estimates that the country needs 7,300 new dentists tofill thegaps.State legislatureshaveexplored creative ways to ensure access to oral health care by addressing the workforce.

For example, many states expanded dental hy-gienists’ licenses to allow greater scope of prac-tice or practice in community-based settings. In 2014, 37 states allowed dental hygienists to provide certain preventive services to patients, often without direct supervision by a dentist, and 16 states allowed direct Medicaid reimbursement to hygienists, according to the American Dental Hygienists’ Association.

States such as Alaska, Maine and Minnesota have created new provider types, such as dental therapists and community dental providers. Den-tal therapists typically are trained to perform ba-sicrestorativeservices,suchasfillingsandrootcanals on baby teeth, and non-surgical extrac-tions. Data show the addition of a mid-level pro-vider allows participating clinics to see more pa-tients and adds revenue, in part by allowing the dentist to work at the top of his or her license.18

Eight states—Arizona, California, Montana, Min-nesota, Oklahoma, Pennsylvania, Texas and

Wisconsin19—are piloting another new type of provider, Community Dental Health Coordinators (CDHC), who are trained by the American Dental Association. CDHCs are usually recruited from the same communities they serve and in addition to some basic, preventive services, may provide health education, connect patients with dental treatment, and arrange additional services such as transportation and child care.

Coordinate Primary Care and Oral Health

The connection between oral health and physi-cal health is well documented; for example, stud-iesshowsignificantannualcost-savingsfor themedical treatment of diabetic patients when they receive regular periodontal care.20 And on the medical side, almost all state Medicaid programs reimburse primary care doctors and nurses for providing oral exams, screenings and preventive services,suchasfluoridetreatmentsandparenteducation.

Several states have taken steps to integrate oral health into broader health system delivery reforms and to coordinate physical, mental, be-havioral and oral health for individuals enrolled in Medicaid. For example, Oregon lawmakers passed House Bill 3650 in 2011 to create a new payment and delivery system known as Coordi-nated Care Organizations (CCOs). The state’s 16 CCOs deliver physical, behavioral and oral health services to Medicaid enrollees.

Expand Access to Providers through Teledentistry

Telehealth can help achieve the goals of the triple aim—improving care and health while lowering costs—by improving access to ap-propriate, lower-cost services, such as timely primary or specialty care, or through lower-cost settings, including clinics, homes or workplaces. Telehealth adoption and expansion across the nation bring various challenges, some of which present policy questions for state leaders. For example, lack of broadband and cellular con-nectivity, and availability and affordability of devices for consumers and providers can hin-der telehealth.The telehealthfield ischangingrapidly, and in some cases, technology may be

NATIONAL CONFERENCE OF STATE LEGISLATURES 10

getting ahead of policy. Policymakers are work-ing to craft frameworks that capitalize on the ad-vancements and potential for telehealth, while maintaining an appropriate level of oversight to safeguard state investments and ensure effec-tive health care delivery.

Teledentistry can leverage and expand the reach of the existing workforce. For example, a 2010 California demonstration project called Virtual Dental Home showed that telehealth-enabled dental teams could provide comprehensive care for people who were inadequately served in a tra-ditional dental setting.21 The project’s success led to a 2014 law including teledentistry as a specialty for Medicaid reimbursement. Arizona, California, Florida and New York all have some form of cov-erage of teledentistry in Medicaid.

Understand the State Role with Community Water Fluoridation

Communitywaterfluoridationhasproventobea cost-effective public health measure to pre-vent tooth decay. For 70 years, adjusting the level of this naturally occurring mineral in public water supplies has helped prevent tooth decay for residents of all ages, but especially for chil-dren whose adult teeth are still forming. The CDC estimates that every $1 invested in water fluoridationsaves$38indentaltreatment.22

The decision to fluoridate the water supply istypically made at the local level and has met with resistance in some communities. A few statesmandatefluoridationorregulatehowthesystem functions. Twenty-six states and Wash-ington, D.C., meet or exceed the average na-tional percentage (74.6 percent) of citizens who get theirdrinkingwater fromafluoridatedsys-tem.23 These rates vary and in 13 states at least 60 percent of the adult population does not have accesstofluoridatedwatersystems.24

Maximize Current Data

Policymakers have enacted data and surveil-lance strategies that help them understand oral health challenges and unmet needs and develop targeted responses. For example, Colorado and Wisconsin use data to evaluate the effectiveness andefficiencyof their school sealantprogramsas well as to allocate funding.

CONCLUSION

As the examples provided in this report suggest, there is not one singular strategy for improving oral health for children and adults. Instead, leg-islators are adopting a wide range of strategies aimedataddressingspecificproblemsandre-moving barriers to good oral health care.

11 NATIONAL CONFERENCE OF STATE LEGISLATURES

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.

2.SusanO.Griffin,etal.,“UseofDentalCareandEffectivePreventive 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.

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%20Research/HPI/Files/HPIBrief_0415_2.ashx.

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-and-sports-safety/article/sw-281474979192045.

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-futures-guidelines-improving-children-s-health.aspx.

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.

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.

9. Ibid.

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.

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 2015).

12 Ibid.

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.

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-to-meet-dental-care-needs-but-states-can-pick-up-slack/.

15. K. Nassah, M. Vujicic, and C. Yarbrough, A Ten-Year, State-by-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%20Research/HPI/Files/HPIBrief_1014_3.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.

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.

19. Stacie Crozier, “CDHC program is nearly complete,” ADA News, (Oct. 21, 2013), http://www.ada.org/en/publications/ada-news/2013-archive/october/cdhc-program-is-nearly-complete.

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-Triple-Aim.pdf.

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/.

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.

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.

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.

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

Acknowledgments

Support for publication was provided by a grant from the DentaQuest Foundation.

See more at: http://dentaquestfoundation.org.

NCSL Contact

Tahra Johnson, MPHPolicy Specialist303-856-1389

tahra.johnson@ncsl.org