FTC Staff Comment To the Ohio State Senate Regarding the Competitive Effects of SB 330 In Increasing Access To Quality Dental Care, Including Its Provisions For Licensing Dental Therapists

1
Office of Policy Planning
Bureau of Competition
Bureau of Economics
March 3, 2017
The Hon. Peggy Lehner
The Ohio State Senate
Ohio Statehouse
Columbus, OH 43215
Dear Senator Lehner:
We appreciate the opportunity to respond to your invitation for comments on the likely
competitive impact of Senate Bill 330 (“S.B. 330” or “the Bill”).1 In particular, you asked us to
comment on the competitive effects of the Bill in increasing access to quality health care,
including the Bill’s provisions for licensing dental therapists—a relatively new type of “mid-
level” dental practitioner who offers some of the same basic services offered by dentists.2
S.B. 330 may allow dental hygienists to work more often under general supervision
without a dentist on the premises, which could enhance competition and expand access to
hygiene services. Under the Bill, however, dental hygienists would still have to obtain written
supervision agreements from dentists. Hence, the Bill’s competitive benefits would depend on
how often supervising dentists authorize general supervision in these written agreements.
S.B. 330 also would provide for the licensure of dental therapists, which could increase
consumer choice among providers of certain dental services, enhance competition, reduce prices,
and expand access to dental care. S.B. 330 would, however, limit these potential benefits by
allowing dental therapists to practice only in certain underserved settings. This restriction would
prevent many patients in Ohio from obtaining lower-cost and more accessible dental care from a
dental therapist. In addition, as with dental hygienists, dental therapists could practice under
general supervision only if they had explicit written authorization by potentially competing
dentists. This requirement could further restrict the availability of benefits that otherwise would
result from introducing the dental therapy profession in Ohio.
Accordingly, we encourage the Ohio legislature to consider expanding general
supervision of dental hygienists and licensure of dental therapists, and to avoid limiting general
supervision and dental therapy practice, except as necessary to address well-founded patient
health and safety concerns.
UNITED STATES OF AMERICA
FEDERAL TRADE COMMISSION
WASHINGTON, D.C. 20580

2
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.3 Competition is at the core of
America’s economy.4 It 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,5 research,6 and advocacy.7 In particular, many of our
recent state advocacy comments have considered the competitive benefits of affiliated
practitioners such as advanced practice registered nurses (“APRNs”) and physician assistants,
focusing on how proposed scope of practice and supervision provisions affect those benefits.8
FTC staff has addressed similar competition issues related to oral health care9 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 dental hygienists from
providing preventive dental services in schools unless students were first examined 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
In January 2016, FTC staff urged the Georgia State Senate to consider the procompetitive
benefits of a bill that sought to broaden the availability of dental hygiene services by expanding
the settings where hygienists could provide their services without direct supervision by a dentist
on the premises.13 Thus, the bill could have increased access to hygiene services in rural or
underserved areas where dentists are scarce or unavailable.14 Similarly, FTC staff opposed rules
proposed by the Georgia Board of Dentistry in 201015 and the Maine Board of Dental Examiners
in 201116 because they would have required a dentist to be present for a dental hygienist to
provide certain preventive services, which likely would have reduced access and increased costs.
FTC staff comments have also supported establishing a dental therapy profession because
it could increase the output of basic dental services, enhance competition, reduce costs, and
expand access to dental care. In letters to the Commission on Dental Accreditation (“CODA”),
FTC staff commended CODA’s proposed accreditation standards as an important first step in
encouraging the development of a nationwide dental therapy profession. Staff pointed out,
however, that statements in the proposed standards regarding supervision of dental therapists
could inhibit state-level legislation allowing dental therapists to conduct certain procedures in the
absence of an on-site dentist, thereby limiting the competitive benefits that could arise from the
establishment of the profession.17
As always, the FTC comments on pending legislation with a focus on promoting
competition consistent with patient safety for the benefit of consumers.
II. 	CURRENT OHIO LAW AND S.B. 330’s PROPOSED AMENDMENTS
A. 	Supervision of dental hygienists
S.B. 330 would expand the circumstances in which dental hygienists can work under
general supervision, without a dentist on the premises. Although the default supervision level in
Ohio’s dental practice act is direct supervision,18 currently there are certain circumstances where
a dentist need not be present: for a limited time and a limited set of procedures, when the dentist

3
has examined the patient within the past year;19 for school-based dental hygiene, public health,
and other programs approved by the dental board, after examination and diagnosis by a dentist;20
and to apply fluoride varnish and discuss nutrition.21 S.B. 330 retains these provisions, but would
potentially allow a dental hygienist to work under general supervision in additional
circumstances, pursuant to a written supervision agreement.
Specifically, under certain circumstances S.B. 330 would allow a dental hygienist to
work under the general supervision of a remote dentist, even when the dentist has not previously
examined the patient.22 Dental hygienists would be required to enter into a supervision
agreement with a dentist that specifies the conditions under which general supervision is
authorized,23 and demonstrate proficiency in each service authorized in the agreement.24 S.B.
330 also would reduce the number of hours of supervised practice required before a dental
hygienist is eligible for general supervision from “at least one year and a minimum of one
thousand five hundred hours,”25 to 400 hours.26
The potentially broad general supervision provisions in S.B. 330 would replace the more
limited provisions of Ohio’s Oral Health Access Supervision Program (“OHASP”),27 which
would be repealed.28 OHASP only allows general supervision of dental hygienists when they
provide services at certain public health facilities and settings, such as facilities that are located
in a dental health resources shortage area and provide services to the indigent or those covered
by Medicaid.29 Although OHASP has no prior examination requirement, it requires hygienists to
schedule an appointment with a dentist after a patient receives care pursuant to the program.30 In
addition, both dentists and dental hygienists must obtain a special permit to participate in the
program, and dental hygienists must take a course in the practice of dental hygiene under the oral
health access provision.31
S.B. 330’s provisions for general supervision of dental hygienists, as well as the current
general supervision provisions at OHIO R EV. C ODE ANN . § 4715.22 that would be retained by the
Bill, have no comparable requirements limiting general supervision to certain public health
facilities or underserved locations, no prior or subsequent examination requirements, and no
permit requirements.
B. 	Licensure of dental therapists and dental hygienist therapists
S.B. 330 would provide for licensure of dental therapists who graduate from a CODA-
accredited dental therapy education program and pass a board-required examination.32 S.B. 330
would, however, allow dental therapists to practice only in certain underserved settings,
including designated dental care health professional shortage areas and any practice in which at
least 20 percent of the supervising dentist’s patients are Medicaid recipients.33 S.B. 330 imposes
these restrictions on all practice settings, regardless of the supervision level.
The default level of supervision of a dental therapist would require a dentist to be
physically present at the dental therapist’s location of practice.34 S.B. 330 would, however, allow
dental therapists to practice under general supervision – without a dentist present or having
previously examined or diagnosed the patient – if authorized by a written supervision agreement
between the dentist and dental therapist.35 The required terms of an agreement for the
supervision of dental therapists36 would be the same as those for supervision of dental
hygienists.37

4
S.B. 330 also would provide for licensure of dental hygienist therapists (practitioners
holding both dental hygiene and dental therapy licenses).38 The Bill appears to require dental
hygienist therapists to maintain both underlying licenses. S.B. 330 would, however, apply any
continuing education requirements completed to maintain a dental hygienist license toward the
satisfaction of dental therapy continuing education requirements, and vice versa.39
III. 	LIKELY COMPETITIVE IMPACT OF S.B. 330
A. 	General Supervision of Dental Hygienists
Laws and regulations that require hygienists to work under the direct supervision of
dentists are a significant barrier to the use of dental hygienists outside of dentists’ offices and in
dental shortage areas.40 When dentists are not physically available for in-person supervision,
dental hygienists may be completely excluded from providing dental services within the scope of
their training, skills, and experience. Even when dentists are available, a direct supervision
requirement can result in duplication of efforts and inefficient use of resources.41 Similarly,
blanket requirements for the prior or subsequent examination of a patient by a dentist, regardless
of whether that examination is medically necessary, encumber the provision of hygiene services,
especially in dental shortage areas.42 Over the last 20 years, the trend among most states has been
to enhance access to dental hygienists by relaxing supervision requirements and requiring only
general supervision.43 Many states go even further, allowing direct access to dental hygienists
under certain circumstances.44
By avoiding rigid limitations on the settings, procedures, and circumstances under which
a dental hygienist can provide preventive services under general supervision, S.B. 330 would
likely enhance access and competition in the provision of dental hygiene services. The Bill
would likely be more effective than OHASP in promoting less restrictive supervision because
dentists could authorize general supervision in any setting, without the need for licensed
practitioners to obtain an additional permit. 45 Although states sometimes allow less restrictive
supervision in underserved settings to improve access in those areas,46 that limitation is not
based on a health and safety rationale, and the need for improved access is not limited to such
settings. Indeed, the Institute of Medicine 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[.]”47
By increasing the availability of dental hygienists’ services outside of dentists’ offices,
SB 330 could increase the number of providers of preventive dental care and the convenience of
care, especially at times and locations where dentists are not available.48 The resulting increase
in competition, greater use of lower cost practitioners, and avoidance of unnecessary payments to
dentists could reduce the cost of providing dental care and prices.49 Increasing the availability of
dental hygienists at settings where dentists are unavailable would not only make care more
convenient, but also would likely reduce patients’ transportation costs, potentially leading to
savings for government benefit programs that pay for transportation.50
Greater competition arising from lower supervision levels may thus enhance access to
affordable preventive services and mitigate the broader health consequences of dentist
shortages.51 Indeed, one study found that enabling “hygienists to provide services within their
professional competencies under reasonable supervision requirements may yield improvements
over time in the oral health status of the populations served.”52

5
By contrast, retention of the current restrictions on general supervision would likely limit
competition and decrease access to dental hygienists without furthering any legitimate health and
safety concerns. 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’ alleged
concerns about quality and safety, which boards sometimes raise to justify restricting hygienists
from practicing without supervision in settings where dentists are not available.53 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.54
One potentially significant drawback of S.B. 330’s provisions for general supervision of
hygienists is that, despite enhanced opportunities for dentists to allow general supervision, S.B.
330 does not guarantee that improvement. Rather, the extent of the change would depend entirely
on the decisions of dentists regarding authorization of general supervision in each written
supervision agreement. A written supervision agreement might not authorize general supervision
at all, or it might allow general supervision only in certain settings or circumstances, such as
after a dentist’s examination of the patient.55 While granting such discretion to a dentist provides
flexibility, it could undercut the Bill’s potential to increase the use of general supervision in a
wide range of settings. Importantly, some dentists might perceive a threat of competition from
dental hygienists for the provision of certain dental services, which might affect dentists’
willingness to authorize general supervision.
Accordingly, we encourage Ohio legislators to consider the potential effects on
competition and access of possible limitations on general supervision in written supervision
agreements. We also urge legislators to consider less restrictive alternatives that would still
address any legitimate and substantiated health and safety concerns. For example, the Bill could
make general supervision the default supervision level, with no prior examination requirements.
Alternatively, the Bill could allow direct access to dental hygienists without a supervision
agreement, as many states have done.56
B. 	Licensure of Dental Therapists
By providing for the licensure of dental therapists, S.B. 330 could potentially enhance
competition, access, and quality, and also lead to lower prices for a range of dental services.
Because the oral health workforce is not well distributed, access to dental care may be
inadequate in some parts of Ohio, as it is in some other parts of the United States.57 In dental
care, as in other areas of health care, workforce modifications expanding the use of mid-level
providers, such as dental therapists, can increase the supply of basic services and improve the
overall quality and convenience of care. Such measures are viewed as an important strategy to
address access and cost challenges.58
Dental therapists are likely to be most effective in expanding access to cost-effective
care, especially to the underserved, when they are allowed to practice under the general
supervision of a remotely-located dentist.59 Although dental therapists generally receive lower
compensation than dentists because of their more limited training and the narrower scope of
services they are typically authorized to provide,60 the main potential for cost savings from the
use of dental therapists depends “on whether duplication in providers arises and whether the
profit arising from care provided by lower-paid therapists accrues to dentists, insurers, or

6
patients.”61 A requirement to have a supervising dentist on the premises will likely lead to
unnecessary duplication of resources and thereby undercut the cost savings that otherwise might
arise from the use of lower-cost providers, effectively defeating a major purpose of expanding
the supply of dental therapists.62
While S.B. 330 would allow supervision of dental therapists by remotely located dentists,
the Bill lets dentists decide whether to permit general supervision and under what circumstances.
Thus, as discussed above with regard to dental hygienists, we encourage Ohio state legislators to
consider whether and to what extent dentists might include limitations on the use of general
supervision in written supervision agreements, how such limitations could affect competition and
access, and whether less restrictive alternatives could better promote competition while also
addressing any legitimate and substantiated health and safety concerns.63
We also encourage Ohio legislators to consider less restrictive alternatives to S.B. 330’s
requirement that dental therapists practice only in underserved settings. While underserved
settings, by definition, have the most acute shortage of practitioners, the need for greater access
to oral health care is not limited to formally designated shortage areas or practices with at least
20 percent Medicaid recipients. Because many people do not have dental insurance, and even the
insured typically have significant out-of-pocket expenses, cost is a major barrier to oral health
care.64 Thus, restricting dental therapists to specific underserved settings would likely inhibit the
ability of dental therapists to provide dental services to many people who would benefit from
lower-cost dental care.65
Restricting dental therapy practice solely to underserved settings may also discourage
entry into the field and development of the profession,66 further limiting the potential
competitive benefits arising from dental therapy licensure. An individual considering a dental
therapy career may consider the limited practice settings, as well as the small number of states
that currently provide for dental therapy licensure,67 when deciding whether to make the
financial and time commitment that licensure would entail. Thus, Ohio legislators may wish to
consider whether less restrictive alternatives could be equally, or perhaps more, effective in
improving access to oral health care in underserved areas and populations.
In other health care professions, programs that aim to encourage practice in underserved
areas often require a time-limited commitment to serve at an underserved location. For example,
the National Health Service Corps of the Health Resources & Services Administration provides
scholarships or loan repayments to students or graduates of medical, dental, and mental health
professional schools in exchange for a two-to-three-year commitment to work in a health
professional shortage area.68 Ohio also took this approach in 2014 when it enacted the Dental
Hygienist Loan Repayment Program, which provides repayment for loans in exchange for at
least a two-year commitment to provide hygiene services in a dental health resources shortage
area.69 We suggest that Ohio legislators consider whether this approach or another less restrictive
alternative could address the goals of S.B. 330 with respect to encouraging dental therapists to
practice in underserved settings.70
C. 	Licensure of dental hygienist therapists
S.B. 330 would recognize those who hold both dental hygiene and dental therapist
licenses as dental hygienist therapists, but this would create tension in light of the Bill’s other
provisions: on the one hand, allowing general supervision of dental hygienists in any setting
(regardless of whether it is underserved), while on the other hand requiring that more highly

7
trained dental therapists practice only in underserved settings. Dental therapy is often viewed as
a potential next step up the career ladder for dental hygienists who seek greater responsibility
and compensation.71 Ohio legislators should consider whether dental hygienists, empowered by
S.B. 330 to provide preventive services under general supervision in any setting, might be
discouraged from seeking licensure as dental therapists. They might perceive it as a step
backwards on the career ladder if they are restricted to practicing solely in underserved settings
when providing dental therapy services not within the dental hygiene scope of practice.
IV. 	CONCLUSION
By potentially broadening the ability of dental hygienists to work under general
supervision and by providing for the licensure of dental therapists, S.B. 330 could benefit
consumers by increasing choice, competition, and access to care, especially for the underserved.
The ability of hygienists and dental therapists to work without a dentist on site is particularly
important in underserved areas, where dentists may not be available. Accordingly, we
respectfully suggest that legislators consider whether requiring a dentist to authorize general
supervision of these practitioners is necessary to address any legitimate and substantiated health
and safety concerns, and whether a less restrictive alternative might achieve such goals without
unduly burdening competition. We also encourage the legislature to consider the effects on
competition, access to care, and development of the dental therapy profession of allowing dental
therapists to practice only in underserved settings. There is no health and safety basis for this
restriction. In our view, less restrictive alternatives could be equally, or perhaps more effective,
in encouraging dental therapists to enter the profession and provide care in underserved settings.
We appreciate your consideration.
Respectfully submitted,
Tara Isa Koslov, Acting Director
Office of Policy Planning
Ginger Zhe Jin, Director
Bureau of Economics
Deborah Feinstein, Director
Bureau of Competition

8
1 This letter expresses the views of staff in 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 authorized us to submit these
comments.
2 Letter from State Senator Peggy Lehner, Ohio Senate, to Tara Koslov, Acting Dir., Office of Policy Planning, FTC
(Sept. 16, 2016) (on file with Office of Policy Planning). We understand that bills containing nearly identical
provisions will be introduced for consideration by the Ohio legislature imminently.
3 Federal Trade Commission Act, 15 U.S.C. § 45.
4 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.”).
5 See generally M ARKUS H. M EIER ET AL., FTC, O VERVIEW OF FTC ACTIONS IN H EALTH C ARE SERVICES AND
P RODUCTS (2017), https://www.ftc.gov/system/files/attachments/competition-policy-
guidance/overview_health_care_january_2017.pdf.
6 See, e.g., FTC & U.S. D EP’T OF J USTICE , I MPROVING H EALTH C ARE : A D OSE OF COMPETITION (2004),
http://www.ftc.gov/reports/healthcare/040723healthcarerpt.pdf.
7 FTC and staff advocacy can include letters or comments addressing specific policy issues, Commission or staff
testimony before legislative or regulatory bodies, amicus briefs, or reports. See, e.g., Comment from FTC Staff to
the Delaware Bd. of Speech/Language Pathologists, Audiologists & Hearing Aid Dispensers (Nov. 29, 2016),
https://www.ftc.gov/system/files/documents/advocacy_documents/ftc-staff-comment-delaware-board-
speech/language-pathologists-audiologists-hearing-aid-dispensers-regarding-its-proposed-revisions-
its/161130_ftc_dealers_final_.pdf; Brief of Amicus Curiae Federal Trade Commission in Support of No Party, In re
Nexium (Esomeprazole) Antitrust Litig., 842 F.3d 34 (1st. Cir. 2016) (No. 15-2015),
https://www.ftc.gov/system/files/documents/amicus_briefs/re-nexium-esomeprazole-antitrust-
litigation/160212nexiumbrief.pdf; FTC STAFF, P OLICY P ERSPECTIVES: COMPETITION AND THE REGULATION OF
ADVANCED P RACTICE N URSES (2014), https://www.ftc.gov/system/files/documents/advocacy_documents/policy-
perspectives-competition-regulation-advanced-practice-nurses/140307aprnpolicypaper.pdf.
8 See, e.g., Comment from FTC Staff to the Dep’t of Veterans Affairs (July 25, 2016),
https://www.ftc.gov/system/files/documents/advocacy_documents/comment-staff-ftc-office-policy-planning-bureau-
competition-bureau-economics-department-
veterans/v160013_staff_comment_department_of_veterans_affairs.pdf(supporting proposed rule that would allow
APRNs to provide services required by the VA without the oversight of a physician); Comment from FTC Staff to
the Iowa Dep’t of Public Health (Dec. 20, 2016),
https://www.ftc.gov/system/files/documents/advocacy_documents/ftc-staff-comment-professional-licensure-
division-iowa-department-public-health-regarding-
proposed/v170002_ftc_staff_comment_to_iowa_dept_of_public_health_12-21-16.pdf (regarding the appropriate
level of supervision of physician assistants); FTC S TAFF, P OLICY P ERSPECTIVES, supra note 7 (presenting an in depth
analysis of the competitive effects of statutes and rules governing the scope of practice and supervision of APRNs.)
9 See, e.g., Comment from FTC Staff to the Tex. State Bd. of Dental Exam’rs (Oct. 6, 2014),
https://www.ftc.gov/system/files/documents/advocacy_documents/ftc-staff-comment-texas-state-board-dental-
examiners/141006tsbdecomment1.pdf (concerning proposed restrictions on the ability of Texas dentists to enter into
agreements with non-dentists for administrative services); 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),
https://www.ftc.gov/sites/default/files/documents/advocacy_documents/ftc-staff-comment-louisiana-state-board-
dentistry-concerning-proposed-modifications-louisianas/091224commentladentistry.pdf (concerning proposed rules
on the practice of portable and mobile dentistry); Comment from FTC Staff to Timothy G. Burns, State
Representative, La. House of Representatives (May 1, 2009),
https://www.ftc.gov/system/files/documents/advocacy_documents/ftc-staff-comment-louisiana-house-
representatives-concerning-louisiana-house-bill-687-practice/v090009louisianadentistry.pdf; Comment from FTC

9
Staff to Sam Jones, State Representative, La. House of Representatives (May 22, 2009),
https://www.ftc.gov/sites/default/files/documents/advocacy_documents/ftc-staff-comment-louisiana-house-
representatives-concerning-louisiana-house-bill-687-practice/v090009louisianahb687amendment.pdf (concerning
legislation on the practice of in-school dentistry); see generally Advocacy Filings by Subject, Dentistry, FED. T RADE
COMM ’N, https://www.ftc.gov/policy/advocacy/advocacy-filings? field_advocacy_document_terms_tid=5302.
10 See S.C. State Bd. of Dentistry, 138 F.T.C. 229, 233-40 (2004).
11 See id. at 232, 268-80.
12 S.C. State Bd. of Dentistry, 144 F.T.C. 615, 628 (2007) (decision and order). 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 For an explanation of “direct supervision” and other terms used to describe supervision of dental hygienists by
dentists, see Am. Dental Hygienists’ Ass’n (“ADHA”), Dental Hygiene Practice Act Overview: Permitted Functions
and Supervision Levels by State (Dec. 2016), https://www.adha.org/resources-
docs/7511_Permitted_Services_Supervision_Levels_by_State.pdf (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”).
14 See Comment from FTC Staff to Valencia Seay, State Senator, Ga. State Senate (Jan. 29, 2016),
https://www.ftc.gov/system/files/documents/advocacy_documents/ftc-staff-comment-georgia-state-senator-valencia-
seay-concerning-georgia-house-bill-684/160201gadentaladvocacy.pdf. The Georgia State Senate did not adopt the
bill.
15 Comment from FTC Staff to the Ga. Bd. of Dentistry (Dec. 30, 2010),
https://www.ftc.gov/sites/default/files/documents/advocacy_documents/ftc-staff-comment-georgia-board-dentistry-
concerning-proposed-amendments-board-rule-150.5-0.3-governing-supervision-dental-
hygienists/101230gaboarddentistryletter.pdf (opposing adoption of 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). The Board did not adopt the proposed rule requiring indirect supervision. See Comment from FTC Staff to
Valencia Seay, supra note 14, at n.13 and accompanying text. Currently, Georgia regulations require a dentist to
authorize the services provided by dental hygienists in certain approved 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).
16 Comment from FTC Staff to the Me. Bd. of Dental Exam’rs (Nov. 16, 2011),
https://www.ftc.gov/sites/default/files/documents/advocacy_documents/ftc-staff-comment-maine-board-dental-
examiners-concerning-proposed-rules-allow-independent-practice/111125mainedental.pdf (opposing adoption of
proposed rules that would have restricted the scope of practice of Independent Practice Dental Hygienists (“IPDH”)
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). The Board subsequently voted to allow IPDHs to
take only those certain x-rays.
17 See Comment from FTC Staff to CODA (Dec. 2, 2013),
https://www.ftc.gov/sites/default/files/documents/advocacy_documents/ftc-staff-comment-commission-dental-
accreditation-concerning-proposed-accreditation-standards-dental/131204codacomment.pdf (concerning supervision
requirements in proposed accreditation standards for dental therapists); Comment from FTC Staff to CODA (Nov.
21, 2014), https://www.ftc.gov/system/files/documents/advocacy_documents/ftc-staff-comment-commission-dental-
accreditation-concerning-proposed-accreditation-standards-dental/141201codacomment.pdf (urging implementation
of accreditation standards for dental therapists). CODA did not include statements about supervision of dental
therapists by dentists and dentists’ responsibility for diagnosis and treatment planning in the accreditation standards
that it adopted. See id. CODA subsequently voted to implement the standards. See CODA, ACCREDITATION

10
STANDARDS FOR D ENTAL T HERAPY E DUCATION P ROGRAMS 3 (2015),
http://www.ada.org/~/media/CODA/Files/dt.pdf (standards implemented on Aug. 7, 2015).
18 See O HIO REV. CODE ANN. § 4715.22(B).
19 See O HIO REV. CODE ANN. § 4715.22(C) (dental hygiene services may be provided under general supervision for
not more than 15 consecutive business days; cannot include “procedures while the patient is anesthetized, definitive
root planning, definitive subgingival curettage, or other procedures” identified by the state dental board; and the
supervising dentist must have “examined the patient not more than one year prior to the” provision of services by the
hygienist). If dental hygiene services are provided in a health care facility, all other requirements must be met, and a
physician must be present in the facility when the services are provided. See O HIO REV. C ODE ANN.
§ 4715.22(C)(9).
20 See O HIO REV. CODE ANN. § 4715.22(D) (the dental hygienist’s services must be “in accordance with the dentist’s
written treatment plan”).
21 See O HIO REV. CODE ANN. § 4715.22(E).
22 Proposed Sec. 4715.22(A)(1), (E) (allowing dental hygienists to provide “dental hygiene services to a patient
when a dentist is not physically present,” even though the dentist has not “examined, diagnosed, or provided
treatment planning for the patient . . .”). All proposed statutory sections referred to in this letter are set forth in S.B.
330, Section 1, except for the repeal of certain sections listed in S.B. 330, Section 2. See infra note 28.
23 See Proposed Secs. 4715.22(E), 4715.221 (describing required provisions of a written supervision agreement,
including exclusions, limitations or conditions on the services the dental hygienist may provide; the dental
hygienist’s agreement to comply with the protocols and standing orders of the supervising dentist; and a description
of circumstances requiring the dental hygienist to refer patients to a dentist).
24 See Proposed Sec. 4715.22(E)(5).
25 O HIO REV. CODE ANN. § 4715.22(C)(1).
26 See Proposed Sec. 4715.22(E)(4). Proposed Sec. 4715.22(E) also has the potential to avoid other restrictions in
O HIO REV. CODE ANN. § 4715.22(E), such as its limitation of general supervision without a prior examination by a
dentist to certain services, including application of fluoride varnish and discussion of general nonmedical nutrition.
27 See O HIO REV. CODE ANN. §§ 4715.36-4715.375.
28 See S.B. 330, preamble; Sec. 2 (repealing certain existing sections, including sections 4715.36, 4715.361-
4715.369, 4715.37, 4715.371-4715.375).
29 See O HIO REV. CODE ANN. § 4715.365 (allowing dental hygienists who hold an OHASP permit to provide
services at a “facility” when no dentist is present, if certain conditions are met); O HIO REV. CODE ANN. §
4715.36(G) (defining “facility”). In addition to specific locations listed in O HIO REV. CODE ANN. §§ 4715.36(G)(1)-
(18), such as state correctional institutions, schools, federally qualified health centers, shelters, and non-profit
clinics, O HIO REV. CODE ANN. § 4715.36(G)(19) defines a “facility” as any location “that is an area designated as a
dental health resource shortage area . . . and provides health care services to individuals who are medicaid recipients
and to indigent and uninsured persons . . . .”
30 See O HIO REV. CODE ANN. § 4715.366 (requiring dental hygienists to “attempt to schedule the patient’s
appointment with the dentist not later than six months after the completion of the dental hygiene services.”).
31 See O HIO REV. CODE ANN. § 4715.362 (application for permit; dentist); O HIO REV. CODE ANN. § 4715.363
(application for permit; dental hygienist); O HIO REV. CODE ANN. § 4715.364 (permit required); O HIO REV. CODE
ANN. § 4715.365 (authority under permit); and O HIO REV. CODE A NN. § 4715.372 (adoption of rules; course
standards).
32 See Proposed Secs. 4715.70, 4715.71.
33 See Proposed Sec. 4715.72(B).
34 See Proposed Sec. 4715.72(A).

11
35 See Proposed Secs. 4715.72(A), 4715.74.
36 See Proposed Sec. 4715.72(B), (C).
37 See supra notes 23-24, 26, and accompanying text.
38 See Proposed Sec. 4715.80(B) (“No person shall hold that person’s self out as being able to function as a dental
hygienist therapist . . . without current, valid licenses to practice both dental therapy and dental hygiene issued
pursuant to this chapter.”).
39 See Proposed Secs. 4715.25(B)(3) (application of dental therapy continuing education requirements to
maintenance of dental hygiene license); 4715.76(B)(3) (application of dental hygiene continuing education
requirements to maintenance of dental therapy license). By contrast, other states that require applicants for licensure
as a dental therapist to be licensed as a dental hygienist may not require maintenance of both licenses. See, e.g.,
26 V T. STAT. ANN. TIT 26, § 611 (“a licensed dental therapist . . . shall not be required to maintain his or her dental
hygienist license”).
40 See Comment from FTC Staff to Valencia Seay, supra note 14 (regarding removal of direct supervision
requirements for dental hygienists); Nat’l Governors Ass’n, The Role of Dental Hygienists in Providing Access to
Oral Health Care 4-5 (Jan. 2014),
http://www.nga.org/files/live/sites/NGA/files/pdf/2014/1401DentalHealthCare.pdf; April V. Catlett & Robert
Greenlee, A Retrospective Comparison of Dental Hygiene Supervision Changes from 2001 to 2011, 87 J. D ENTAL
H YGIENE 110 (2013), http://jdh.adha.org/content/87/3/110.full.pdf (“direct supervision confines the dental hygienist
to a facility where the dentist is physically present”); I NST. OF M ED., A LLIED H EALTH SERVICES: A VOIDING 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.”). In 2015, the Institute of Medicine became the National Academy of
Medicine. See Press Release, The Nat’l Acads. of Scis., Eng’g, & Med., Institute of Medicine to become National
Academy of Medicine (Apr. 28, 2015),
http://www.nationalacademies.org/hmd/Global/News%20Announcements/IOM-to-become-NAM-Press-
Release.aspx.
41 See Comment from FTC Staff to Valencia Seay, supra note 14, at 3 (describing how Georgia’s direct supervision
requirement resulted in duplication of effort when dentists were available, and exclusion of dental hygienists when
dentists were unavailable).
42 See supra notes 10-11 and accompanying text; Margaret Langelier et al., Expanded Scopes of Practice for Dental
Hygienists Associated with Improved Oral Health Outcomes for Adults, 35 H EALTH A FF. 2207, 2208 (2016)
(because some people lack access to dentists, regulations “requiring a dental visit before being seen by a dental
hygienists may be a barrier to receiving preventive care).
43 Langelier et al., supra note 42, at 2211 (from 2001-2014, many states adopted regulatory changes “that reduced
the direct supervision required for dental hygienists, most notably in public health settings”); Catlett & Greenlee,
supra note 40, at 114-15 (45 out of 51 jurisdictions reduced dental hygienists’ supervision requirements from 2001-
2011 (as compared to 1993-2000), but Alabama, Georgia, Mississippi, and North Carolina rely on direct supervision
and have made little progress in reducing supervision); see also Am. Dental Hygienists’ Ass’n, supra note 13.
44 See Am. Dental Hygienists’ Ass’n, Current Direct Access Map (Apr. 2016), http://www.adha.org/resources-
docs/7524_Current_Direct_Access_Map.pdf. 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.” Direct Access, AM . D ENTAL H YGIENISTS ’ ASS’N, http://www.adha.org/direct-access. See also Doreen
K. Naughton, Expanding Oral Care Opportunities: Direct Access Care Provided by Dental Hygienists in the United
States, 14 J. E VIDENCE -B ASED D ENTAL P RAC . (SUPPLEMENT ) 171 (2014). ADHA classifies Ohio as a direct access
state because of the limited direct access under OHIO REV. C ODE ANN. § 4715.22(D)(b), which allows dental
hygienists to place pit and fissure sealants in schools without the involvement of a dentist; and because of OHASP,

12
even though most practitioners do not participate in the program. See Am. Dental Hygienists’ Ass’n, Direct Access
States (Dec. 2016), http://www.adha.org/resources-docs/7513_Direct_Access_to_Care_from_DH.pdf.
45 According to the Ohio State Dental Board, only 31 dentists and 98 dental hygienists held Oral Health Access
Supervision Permits in FY 16. At that time there were 7,088 licensed dentists and 8,377 dental hygienists in Ohio.
Thus, only about 0.4% of Ohio dentists and 1.2% of hygienists held access supervision permits in FY 16. See Ohio
State Dental Bd., Annual Report, FY 15/FY 16 Biennium 7 (2016),
http://www.dental.ohio.gov/Portals/0/Board/Annual%20Reports/ANNUAL%20REPORT%20Dental%20Board%20
08%2018%2016.pdf?ver=2016-09-15-144407-677. Restrictions on settings for general supervision may have
discouraged practitioners from obtaining permits; indeed, the permit requirement itself may have discouraged
practitioners from availing themselves of the general supervision options provided by OHASP.
46 See Catlett & Greenlee, supra note 40, at 114-16; Nat’l Governors Ass’n, supra note 40, 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.”).
47 I NST. OF M ED. & N AT ’ L RESEARCH COUNCIL, I MPROVING A CCESS TO O RAL H EALTH C ARE FOR V ULNERABLE AND
U NDERSERVED P OPULATIONS 234-35 (2011).
48 In Ohio, 11.2% of the population lives in an area designated as a Dental Care Health Professional Shortage Area
(“DCHPSA”), and the percent of need met by dentists is only 38.2%. For the United States as a whole, 15.4% of the
population lives in a DCHPSA, and the percent of met need is similar to Ohio’s, 38.9%. See Dental Care Health
Professional Shortage Areas (HPSAs), K AISER F AMILY FOUND. (last updated Jan. 1, 2017), http://kff.org/other/state-
indicator/dental-care-health-professional-shortage-areas-hpsas/; Kaiser Comm’n on Medicaid & the Uninsured,
Kaiser Family Found., Oral Health in the US: Key Facts 2 (June 2012),
http://kaiserfamilyfoundation.files.wordpress.com/2013/01/8324.pdf (based on 2010 census data at
http://www.census.gov/2010census/data/). In addition, the oral health workforce is not well distributed, so many
counties are dental professional shortage areas. See infra note 57.
49 Dental hygienists earn considerably less than dentists. See I NST. OF M ED. & N AT ’ L RESEARCH COUNCIL, supra
note 47, at 87 (mean annual wage of $143,000 for salaried general dentists, compared to $66,500 for dental
hygienists). Requirements for direct supervision and examination of patients by a dentist could undercut the cost
savings that would otherwise arise from the use of a dental hygienist because they entail payment for a dentist’s
services. See infra note 62 and accompanying text (discussing supervision and cost savings from obtaining care from
dental therapists and APRNs).
50 See, e.g., Brian E. Whitacre, Estimating the Economic Impact of Telemedicine in a Rural Community, 40 AGRIC .
& RES. E CON. REV. 172, 176-78 (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; O HIO ADMIN. CODE 5160-15-01, 5160-15-11 (2016). See also
infra notes 58-59 (discussing how supervision of an affiliated practitioner can improve the convenience of care at
times and locations where a dentist is not available).
51 See Catlett & Greenlee, supra note 40, at 110-11, 116; Nat’l Governors Ass’n, supra note 40, at 4.
52 Langelier et al., supra note 42, at 2213.
53 See Nat’l Governors Ass’n, supra note 40, 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 40,
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”).
54 I NST. OF M ED. & N AT ’ L RESEARCH COUNCIL, supra note 47, at 234.

13
55 See FTC STAFF, P OLICY P ERSPECTIVES, supra note 7, at 29-31 (discussing various ways in which required
collaboration agreements establish physicians as gatekeepers who control APRNs’ access to the market and the
terms on which they may practice).
56 See supra note 44 and accompanying text. Although many states require supervision of APRNs pursuant to
collaboration agreements with physicians, we have suggested that state legislators and regulators “carefully consider
whether the goals of collaboration and coordination can be achieved via less restrictive alternatives.” See FTC
STAFF, P OLICY P ERSPECTIVES, supra note 7, at 34-35.
57 See supra note 48. Thirty-six Ohio counties (out of a total of 88) have been designated as countywide geographic
or special population Dental Health Professional Shortage Areas, while many other counties have community or
facility DHPSAs within them. See Ohio Dep’t of Health, Dental Health Professional Shortage Areas Map (Sept. 28,
2016), https://www.odh.ohio.gov/-/media/ODH/ASSETS/Files/ohs/oral-health/HPSA-Web-map-9_2016.pdf.
58 See, e.g, FTC STAFF, P OLICY P ERSPECTIVES, supra note 7, at 20-27; M INN. D EP’ T OF H EALTH & M INN. B D. OF
D ENTISTRY, E ARLY I MPACTS OF D ENTAL T HERAPISTS IN M INNESOTA (2014),
www.health.state.mn.us/divs/orhpc/workforce/dt/dtlegisrpt.pdf (reporting on the use of dental therapists in
Minnesota to improve access to care for underserved populations, increase the quality and convenience of care, and
reduce costs); Jane Koppelman et al., Expanding Where Dental Therapists Can Practice Could Increase Americans’
Access to Cost-Efficient Care, 35 H EALTH A FF. 2200, 2205 (2016) (“Dental therapy has the potential to provide
cost-effective care in both safety-net and private practice settings, and thus it may thrive in a climate in which health
care providers must deliver on access and outcomes.”); Heather Taylor, Parallels between the Development of the
Nurse Practitioner and the Advancement of the Dental Hygienist, 90 J. D ENTAL H YGIENE 6, 7 (2016) (like the
introduction of the nurse practitioner, dental hygiene-based workforce models, including dental therapy, are being
developed to address issues of access to care and costs).
59 See, e.g., M INN. D EP’ T OF H EALTH & M INN. B D. OF D ENTISTRY, supra note 58, at 22 (a rural clinic must close if its
one dentist isn’t available, because a dental therapist cannot provide certain services without a supervising dentist on
site; if the clinic had an advanced dental therapist (who can provide all services under the general supervision of an
off-site dentist), the clinic could remain open); supra notes 40-42 and accompanying text. See also T RACY A.
H ARRIS, I NST. OF M ED., T HE U.S. O RAL H EALTH W ORKFORCE IN THE COMING D ECADE : W ORKSHOP SUMMARY 86,
87 (2009) (summary of presentation of Dr. Paul Glassman, Univ. of the Pacific School of Dentistry) (“To better
accommodate all members of society, services need to be delivered in community locations where people work, live,
plan, and attend school. Delivery of many oral health services do not require a fully equipped dental operatory . . .
.”).
60 See, e.g., M INN. D EP’ T OF H EALTH & M INN. B D. OF D ENTISTRY, supra note 58, at 20 (reporting that the personnel
costs of employing a dental therapist are roughly half as much as a dentist, ranging from $35,000 - $62,000 less than
a dentist); Koppelman et al., supra note 58, at 35 (a Minnesota dental therapist’s annual salary is about $62,000 less
than a dentist’s).
61 Burton L. Edelstein, Examining Whether Dental Therapists Constitute a Disruptive Innovation in U.S. Dentistry,
101 AM . J. P UB . H EALTH 1831, 1832 (2011). See also Tryfon J. Beazoglou et al., Impact of Dental Therapists on
Productivity and Finances: II. Federally Qualified Health Centers, 76 J. D ENTAL E DUC . 1068, 1071 (2012) (even
assuming that a dental therapist’s wage is half that of dentist, the estimated reduction in costs from employing dental
therapists is about 6 percent, because dentists are responsible for only about 25% of clinic services and dental
therapists would account for 17% of children services); M INN. D EP’T OF H EALTH & M INN. B D. OF D ENTISTRY, supra
note 58, at 20-21 (explaining that employment of dental therapists does not immediately save money for state public
programs because the reimbursement rates for their services are the same as those for dentists, but that the “savings
resulting from the lower costs of dental therapists are allowing clinics to expand capacity to serve more underserved
and public program patients”).
62 See Comment from FTC Staff to CODA (Dec. 2, 2013), supra note 17. 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 FTC STAFF, P OLICY P ERSPECTIVES, supra note 7, at 27-28.
63 See supra notes 53-56 and accompanying text.

14
64 See, e.g., Marko Vujicic et al., Dental Care Presents the Highest Level of Financial Barriers, Compared to Other
Types of Health Care Services, 35 H EALTH A FF. 2176 (2016) (“irrespective of age, income level, and type of
insurance, more people reported financial barriers to receiving dental care, compared to any other type of health
care”); Elizabeth A. Mertz, The Dental-Medical Divide, 35 H EALTH A FF. 2168, 2170 (2016).
65 FTC staff raised similar concerns about restricted access to practitioners with respect to a West Virginia bill that
would have allowed only APRNs to obtain a prescribing license only if they practiced in a health professional
shortage area. See Comment from FTC Staff to Kent Leonhardt, State Senator, West Virginia Senate 6-7 (Feb.
2016), https://www.ftc.gov/system/files/documents/advocacy_documents/ftc-staff-comment-senate-west-virginia-
concerning-competitive-impact-wv-senate-bill-516-regulation/160212westvirginiacomment.pdf. FTC staff
considered the limitation on APRN practice setting unduly restrictive even though even though it was limited to a
particular function, prescribing. See id. S.B. 516 did not pass.
66 See id. at 7 (“APRNs – and institutional providers employing APRNs – may be discouraged from securing the
required [prescribing] license, and entering underserved areas, if a license does not permit any practice, however
limited, outside an HPSA.”).
67 See, e.g., Kavita Mathu-Muju et al., Current Status of Adding Dental Therapists to the Oral Health Workforce in
the United States, 3 CURRENT O RAL H EALTH REP. 147 (2016); Koppelman et al., supra note 58, at 35 (Although
about a dozen states have considered licensure of dental therapists, only three, Minnesota, Maine, and Vermont
enacted such legislation; only Minnesota has practicing dental therapists, a total of 58). In addition, Alaska has 35
practicing dental therapists through the federal Community Health Aide Program, which is limited to indigenous
Alaska Natives. Id.
68 See National Health Service Corps, H EALTH RES. & SERVS . ADMIN., https://nhsc.hrsa.gov/index.html (offering
scholarships to students in accredited schools (physicians, dentists, nurse practitioners, certified nurse midwives, and
physician assistants); and loan repayments for a broader set of practitioners, including dental hygienists and various
mental health practitioners as well as physicians, dentists, nurse practitioners, certified nurse midwives, and
physician assistants).
69 O HIO REV. CODE ANN. §§ 3702.96-3702.967.
70 Of the three states that provide for licensure of dental therapists, two (Minnesota and Maine) require them to
practice in underserved settings, while Vermont does not have such a restriction. See M INN. STAT. § 105A.105,
subd. 2, 8; M E . REV. STAT. tit. 32, § 18377(3)(A); V T. STAT. ANN. tit. 26, §§ 611-617.
71 See, e.g., Ann Battrell & Ann Lynch, Representing Dental Hygienists, P ERSP. ON M IDLEVEL P RACTITIONER , Oct.
2016, at 28 (Supplement to Dimensions of Dental Hygiene),
http://www.dimensionsofdentalhygiene.com/2016/perspectives_2016/policy_and_regulation/Representing_Dental_
Hygienists.aspx (ADHA developed policy supporting dental therapy as a career option for dental hygienists); See
Langelier et al., supra note 42, at 2211 (explaining that dental hygiene therapy builds on dental hygienists’
foundational competencies, skills and functions); Colleen M. Brickle et al., Minnesota Extends Oral Healthcare
Delivery to Impact Population Health, 16 J. E VIDENCE -B ASED D ENTAL P RAC . (SUPPLEMENT) 68, 69 (2016) (in
addition to improving public health, licensure of dental therapists “brings new opportunities to the dental hygiene
profession”).