A State Advocacy Tool Kit
An alternative dental provider model is a model of oral
health care delivery that utilizes a nondentist, acting
outside the direct supervision of a dentist, as a primary
provider of dental care.
While various alternative dental provider models have
been proposed in different states, all models promote
the position that the creation and incorporation of new
nondentist dental providers within state rules, regulations
or statutes, is essential to improving access to oral health
and improving the oral health status of Americans.
Proponents of alternative dental
Three sectors of the dental marketplace are currently driving
the movement for alternative dental providers: public health,
dental educators, and mid-level professional organizations.
These segments also promote faulty presumptions regarding
the challenges to improving oral health and the role that
new nondental providers will play. These presumptions are
Proponents of alternative dental provider models who
have voiced support for alternate dental provider models
and may advocate for these models in your state include The
Pew Center on the States, W.K. Kellogg Foundation, the
American Association of Public Health Dentistry (AAPHD),
the American Dental Education Association (ADEA), and
the Institute of Medicine (IOM).
Alternative dental provider models
The two leading alternative dental provider models that are
likely to be proposed in your state are the dental therapist
and the advanced dental hygiene practitioner (ADHP).
Additionally, the American Dental Association (ADA) has
presented an alternative to dental therapists or the ADHP in
its community dental health coordinator (CDHC).
Dental therapists (dental health aide therapist [DHAT]
and variations thereof) are favored by The Pew Center
on the States and the W.K. Kellogg Foundation, and are at
the forefront of the race for new nondentist providers.
Minnesota’s dental therapist models provide the blueprint
for most alternative proposals in the contiguous states.
In 2009, Minnesota passed legislation creating two types
of providers: the dental therapist who works within a practice
under the indirect or direct supervision of a dentist, and
the advanced (master’s level) dental therapist who works
remotely under the general supervision of a dentist. Both
may perform irreversible dental procedures.
It should be noted that Minnesota is the only state in
which non-dentist providers can practice independently
upon the general population, rather than being relegated
to treating tribal populations only. The Minnesota
practitioners were modeled after New Zealand, British, and
Canadian dental therapists.
The ADHP, created by the American Dental
Hygienists Association (ADHA), may diagnose and
treat patients, including the restoration and extraction of
teeth, under general or no supervision of a dentist.
The Pew Center on the States has cast some doubt upon
the ADHP. In its report, “Help Wanted: A Policy Maker’s
Guide to New Dental Providers,” Pew voiced concern that
independent hygienists may not be able to afford to practice
in underserved areas.
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The ADA’s CDHC primarily provides education
and prevention under general, indirect, or direct
supervision, but leaves the door ajar for some treatment,
including scaling and excavation. However, the CDHC
has failed to gain significant traction and is unlikely to be
proposed in your state.
Faulty presumptions presented by
proponents of alternative models
A fundamental presumption relied upon by advocates of new
providers is that there will be a shortage of dentists.
The ADEA presented this presumption as fact in 2007;
as support, ADEA cited Dr. Jackson Brown’s ADA article,
“Selling Your Practice at Retirement: Are There Problems
Ahead?” (2000), to assert that, in the coming years, only one
dentist will graduate for every two dentists who retire.
However, with numerous new dental schools opening, and
many dentists with empty chairs, the truth is that there is not a
shortage of dentists but only an uneven distribution of dentists.
Pew and other proponents also assert that dentists simply do
not want to practice in underserved areas or accept Medicaid
patients. Pew has repeatedly gone on the record as saying
that the rate of dentists accepting Medicaid is lower than
that of physicians; however, they fail to make any mention
of the differences in Medicaid coverage and reimbursement
rates between medicine and dentistry. While the Kellogg
Foundation echoes Pew’s characterization of dentists’ unwillingness
as a challenge, ADEA has not yet broached this subject.
A third presumption shared by the proponents of midlevel
providers is that an area can be deemed to be underserved
solely by examining the dentist-to-patient population
ratio, without consideration of practice capacity. However,
dentist-to-patient ratios used by proponents are outdated
and fail to consider technological advances and the increase
in capacity produced by the use of existing mid-level providers—dental
assistants, hygienists, and expanded function
dental assistants (EFDAs)—within the dental team under
the supervision of a dentist.
Additionally, proponents of alternative models have promoted
the following faulty presumptions, arguments that
you may hear or read in your state:
1. The new providers will practice in underserved areas.
2. The new providers are not truly independent practitioners,
but collaborative practitioners.
3. The new providers are still a part of the dental team and
will preserve and expand the prevention aspect.
4. The new providers fit into the dental home concept
by bringing the dental home to where the
5. The new provider models provide safe care (Note:
Although Kellogg alleged that the Alaska DHAT had
proven to be safe, the Kellogg study was very limited in
scope and did not prove that the new provider models
were in fact safe).
6. The new provider models have successfully improved
oral health status in other countries and will therefore
work in the United States.
Rebutting the myth of the alternative
In 2008, the Academy of General Dentistry (AGD) adopted
its “White Paper on Access to and Utilization of Oral Health
Care Services,” decrying the advances of independent midlevel
providers as obstacles that detract from the funding and
effort to further more than 30 proven solutions.
Since then, arguments presented in various states by
proponents of mid-level provider models have grown
increasingly more sophisticated. Notably, these entities do
not always claim a move toward independent practice, nor
do they claim to offer an alternative to the traditional dental
Independence from dentists has been rephrased as an opportunity
for expanded collaborations with dentists. Proponents
tout the Minnesota therapist models, which market advanced
dental therapists as off-site practitioners who work in collaboration
with dentists, not as independent practitioners.
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The divided dental
team concept proposed
by new provider
proponents creates too
for lapses in patient
Suzanne Beatty, DDSa dentist and curriculum coordinator
at Metropolitan State University for the advanced dental
therapist master’s program stated, “There are so many people
who are underserved. This [the advanced dental therapist]
would free up the dentist to do more complex procedures.
It’s not an independent practice. It’s part of a collaboration.”
Therefore, refocus your response on detailing the nature
of specific procedures that are likely to trigger the need
for a dentist to be readily available on-site (direct supervision),
rather than to take a defensive approach that seeks
to dismiss independent practice.
The proponents’ re-characterizations compel the AGD and
other organizations that stand for the preservation of the oral
health of the public to concentrate on the most fundamental
elements that generate concern about patient health and
safety. Simply echoing or restating terms such as “independent
mid-level provider” may not be effective much longer.
Instead, explain that the minimal level of “collaboration”
that is necessary to ensure the safety of the patient is
the direct supervision by a licensed dentist.
Further, rather than offering an alternative model of
oral health care delivery, proponents of the new practitioners
claim an enhancement of the “dental team concept.”
Advances in technology have also allowed these entities to
claim that teledentistry, historically a term indicating consultation
between a generalist and specialist, for example, allows
for an expansion of supervision.
Proponents of new providers argue that the dental team
concept is enriched by the addition of a nondentist who
can remotely collaborate with the dentist without his or her
It may be beneficial to focus your response on the fact that
expansion of the dental team to include nondentists who
treat patients without the direct supervision of a dentist
undermines the most fundamental tenet of the dental
team concept—patient safety through the supervision of
a licensed and educated dentist—which has proven to be
the beacon of success of the prevention model.
The cohesive and concurrent acts of practitioners of different
levels of education and expertise, under the direction of a
dentist trained for that purpose, create the symbiosis needed
to ensure the integrity of each patient’s health.
Intentionally splintering the dental home constitutes
poor parenting of the oral health of the public and is mere
steps from possible neglect.
The divided dental team concept proposed by new provider
proponents creates too many opportunities for lapses in
patient diagnosis, planning, and treatment: The insufficient
training of the first point of contact (a nondentist without
direct supervision) will create a burden on the next point
of contact and the entire system, all the way down the line,
from the general dentist who must correct the alternative
provider’s errors which stem from a lack of training, all
the way to the specialist to whom the general dentist may
refer when the patient’s disease state is especially critical or
advanced, with each level adding to the cost of care.
With a alternative practitioners passing the baton to the
dentist, the alternative providers’ version of a dental team
functions as a relay team of sorts; this is not in the best interest
of the patient.
Further, it’s notable that none of the guidelines, articles,
and other documents produced by proponents of alternative
providers appears to challenge what the ADA Commission
on Dental Accreditation (CODA) has set out as minimal
competencies for graduating practitioners who can competently
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Failure to meet CODA’s minimum educational standards
for a dentist renders any alternative dental provider model
unsafe to provide those services currently relegated to
dentists without a dentist’s direct supervision.
Alternative provider models target those patients in
rural communities and of low socio-economic status.
These populations exhibit the greatest rate of medical
complications and therefore need health care providers
with the greatest of expertise.
Last, but not least, proponents of alternative providers
have not disagreed with our focus on oral health literacy and
patient utilization. Studies to develop benchmarks and data
on current and desired patient utilization, both in private
and public markets, may place the AGD in a significantly
stronger position to promote its long-standing and proven
solutions over these new provider proposals that may actually
jeopardize patients’ well-being.
Remind your state of the proven solutions presented
in the AGD’s White Paper, and the wisdom in funding
solutions that work, rather than experiments that may
Advocating in your state
Successful dental advocacy requires knowledge and action.
Now that you understand the issue, it’s time to take action,
which can be as simple as:
• Responding to a Capwiz action alert
• Visiting legislators
• Telephoning a legislator’s office or connecting with staffers
• Attending town hall meetings or fundraisers (maybe even
• Encouraging your colleagues to voice their concerns
• Presenting testimony at hearings
Each of these actions is easy and can be successful—
especially if it’s combined with the voices of your colleagues.
Become aware, educated, and informed
Becoming an effective dental advocate is easier than you
think. A little research, a little practice, and a little networking
are all that it takes to become a skilled representative
of—and for—your profession and the patients that you and
your colleagues serve.
Much of the basic information you need to know has
already been covered within the context of this tool kit. Of
course, you will need to read and become familiar with the
specific legislation being considered by your state legislature
or dental board. That information can be found on the
agency’s website, via the AGD’s StateNetmapTrac feature, or
through the AGD advocacy staff. Contact AGD advocacy
staff at firstname.lastname@example.org to request information.
Build grassroots support
While the AGD is the eyes, ears, and voice of the general
dentist, its representation of you and your profession are only
as strong as the involvement of individual members.
Since the AGD recognizes that constituents have limited
resources, the Government Relations staff at AGD
Headquarters monitors legislation and regulations relevant
to dentistry at the state level. They do this through a subscription
to State Net, an online service that monitors state
legislation and regulations, and provides regular updates on
key terms relevant to dentistry.
The AGD encourages each constituent to appoint a legislative
chairperson to monitor important issues and to alert the
board of any pending legislation and/or regulation that could
be problematic. In many cases, this individual also serves as
the conduit for promoting discussion with the state dental
association and other professional groups that might have a
stake in the issue.
Be sure not to overlook your state dental board since this
agency determines what is and is not allowed within the
various scopes of practice. Because this agency is so important,
AGD constituents are encouraged to have a member
appointed to the board or, at the very least, to have a
member attend dental board meetings to monitor the topics
discussed and to present testimony when appropriate.
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is the cornerstone of any
Regardless of whether your constituent has a constituent
legislative chairperson or a connection to the state dental
board, it’s critical that grassroots members get involved. So
how do you do that? Start by getting the word out. Tell your
constituent members about the issue. Explain how it will
impact their patients. Tell them what they can do to communicate
their concerns. And reassure them that it’s easy to do.
One of the easiest things members can do is contact their
legislators regarding pending votes and major initiatives.
They can do this by using Capwiz, an online communication
vehicle that allows AGD members—and even their
colleagues and patients—to share their opinions about
important topics with state and federal legislators. In most
cases, constituent leaders work in partnership with AGD
Headquarters’ staff to develop blast emails and Capwiz action
alerts that members can email directly to their legislators.
Capwiz is available under the “Advocacy” tab on the
AGD’s website (www.agd.org) and can be found by clicking
on “Government Relations,” and then selecting the “Contact
Lawmakers” tab. Members will be asked to enter some basic
contact information and Capwiz will automatically identify
their legislators’ names, contact information, political affiliations,
voting records, and more.
Each time the AGD issues an action alert, members can
click through the blast email message to a webpage that contains
the message to send to legislators. Members can use the
text provided or customize the message. The entire process
takes just a few minutes.
Communicate any updates or new information to your
members via your constituent newsletter, website, Facebook
page, etc. Highlight any positives, including any members
who received responses from their efforts to reach out since
that might encourage other members to participate the next
time an action alert is issued.
Cultivating relationships is the cornerstone of any successful
grassroots advocacy campaign. It doesn’t matter if those relationships
are with legislators, their staffers, leaders of other
dental associations, or members of other professions who
care about the issue.
Coalitions can make a difference as there is strength
in numbers and since other members might have access
to valuable information that can be shared with legislators.
Your constituent and your state dental association
likely already have an established relationship, which in
most cases can be used to send a strong and powerful
message to legislators.
Reach out to your legislators
Reaching out to legislators can be easy; after all, they’re
people too. Most legislators are deeply committed public servants
who want to:
1. Make effective public policy; and
2. Make decisions that will get them re-elected.
You and your general dentist colleagues are in an enviable
position to influence legislation since you are committed to
removing the barriers that prevent the public from getting
the safe, high-quality oral health care that everyone deserves.
Think about it: that’s just good public policy.
You also wield influence as a voting member of your legislator’s
constituent, and your legislator wants to hear from you
regardless of whether or not you supported his or her candidacy.
If you can, schedule a personal visit with your legislator
since face-to-face discussions are always the most effective
form of communication.
The state legislative process is essentially the same as the
federal process, with three primary differences:
• The lengths of legislative sessions vary by state, as some
meet for almost the entire year, while others meet for just a
few months, and still others meet for half the year.
• Some states require bills to be reintroduced in each legislative
session, while others allow bills to be carried over from
one legislative session to the next.
• The titles given to the legislators vary. Some are “assemblymen”
while others are “representatives” or delegates.
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State lawmakers can introduce bills or resolutions. A bill
is a proposal to enact new legislation or to amend an existing
statute. A resolution is a legislative proposal for an action
that does not affect statutory law. Bills are introduced and
sent to the appropriate committee for action, where the issue
is discussed, debated, and where public hearings might be
held. It is here, at the committee level, where you, as a citizen
of your state, have the opportunity to influence the outcome
of proposed legislation.
Since you already know about the issue and any specific
bills or resolutions that have been proposed in response to
it, it’s time to schedule a meeting with your legislator. First,
develop an agenda and determine what you want to accomplish.
Know your legislator’s position on the issue so you can
customize your remarks to gently redirect his or her position.
Then, practice your “pitch” and be sure to include relevant
personal anecdotes that illustrate your point and that position
you as a knowledgeable and caring professional.
Keep the meeting brief and stay on point. Introduce yourself
and state your case. Offer your solutions and explain why
they present better outcomes. Be polite if he or she declines
to commit on the spot. Leave a one-page fact sheet on the
issue, printed on your business stationery, and offer to provide
any other information that might be useful.
Be sure to send a thank you note after the meeting. Use
that note as an opportunity to remind the legislator about
areas where you were in agreement, to present any promised
information, and to again offer to serve as a resource on this
proposal and any future health care legislation.
Make this first meeting with your legislator the start of a
long-term relationship. Reach out to your legislator again
in the future, even on other issues. Doing that will help you
develop a positive relationship and could one day result in
your legislator reaching out to you for input.
Testify before state boards or legislature
Presenting testimony in front of your dental board or legislators
need not be intimidating. Odds are you’re already an
experienced public speaker who’s addressed the AGD House
of Delegates, members of a civic organization, an educational
board, etc. Here are some tips for successfully communicating
your position to a legislative or regulatory committee.
First, keep in mind that actually presenting the testimony
isn’t the real first step. The first step is determining how to
get on the roster of individuals presenting testimony.
Now identify the purpose of your testimony. You already
know the issue, the specific legislation being considered, and
what its impact will be. Your objective is to gain support for
efforts in your state
are fundamental to
halting the potentially
dangerous spread of
legislation you support, or to dissuade legislators from supporting
legislation you oppose. It’s helpful to know in advance
which legislators are on which side of the fence, as well as
which have a leg dangling over each side of that fence.
Next, develop a written statement. While you won’t read
that statement to the committee, you can share photocopies
of your statement (on your professional letterhead) with the
committee members so they can review it once the hearing is
completed. Be sure your written statement contains accurate
facts and data that support your position.
Use your written statement to prepare note cards to use
during your testimony. Do not read your testimony and do
not ad-lib your remarks. Keep your verbal testimony brief
and to the point, generally between three and five minutes
in length. Allow time to thank the committee for the opportunity
to speak, and to give your name, and the name and
purpose of the organization that you represent. State whether
you support or oppose the legislation being considered.
Speak in a conversational tone and make eye contact with
each member. Try to include real-life examples that support
your position. When opposing a bill, open and close your
remarks with positive comments about the legislature’s interest
in addressing a problem that impacts many citizens. The
middle of your presentation should offer workable solutions,
not complaints. Of course, if you support the proposed legislation,
your remarks can be brief.
Close your testimony with another thank you and ask if
members have any questions. Be prepared to answer questions
that might be intended to support opposing viewpoints.
Keep your answers brief and if you don’t know the
answer, offer to research the answer and then be sure to
follow-up and provide it to committee members.
Your advocacy efforts in your state are fundamental to
halting the potentially dangerous spread of alternative provider
models. Please check out the resources provided below,
and contact AGD Advocacy staff at email@example.com if
you have any questions.
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The Academy of General Dentistry (AGD) offers its members many resources to guide them in effective advocacy at the
local, state, and federal levels. Many of those valuable resources are highlighted here:
“White Paper on Increasing Access to and
Utilization of Oral Health Care Services”
This document presents workable solutions in response
to many of the barriers to care reported by patients in
communities across the country.
The Academy of General Dentistry Position
on Workforce Issues
Only the dentist has the education and training
necessary to form a diagnosis, create a comprehensive
treatment plan, and perform irreversible procedures.
Direct supervision of the dental team by the dentist
is critical to ensuring the safety and well-being
of the patient.
Dental Assistant and Dental Hygienist
Duties and Functions
The level of supervision required and the duties allowed
for dental assistants and dental hygienists varies greatly
from state to state. See how your state measures up.
The AGD publishes regular updates on national legislation
that may affect general dentists.
Facilitate education about the issues and boost member
involvement in legislative issues via Capwiz.
This handbook can help your constituent work with the
AGD Legislative & Governmental Affairs Council to
represent the state legislative and regulatory interests of
Primer on Collaboration Between
ADA and AGD Constituents
This primer highlights the benefits to emphasize the
need for greater collaboration between ADA and AGD
constituents so that AGD constituents can be an effective
voice for general dentists in their respective states.
Access the AGD’s advocacy policies, including legislative
and dental care policies, which affect general dentistry
and advance the profession and allied agencies involved in
the maintenance and improvement of quality dental care.
This weekly state legislative update details local legislation
of interest to the profession.
Make your voice heard by participating in email
campaigns to lawmakers about legislation or simply
inform yourself about the issues by reading the brief
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AGD Articles on Alternative Provider Models
Legislation Prevents Funding for Mid-Level Providers
Dentists in MO Say NO to 2 Tiered Oral Health Care Delivery System
Get Engaged and Commit to Your Profession
Senate Defeats Funding for Mid-level Provider Demonstration Program
Members Promote AGD to the Public
An Opinion on Access to Care Solutions
Solutions for State Dental Boards on Access to Care
Mid-Level Dental Providers in Missouri?
Webinar: The Relationship Between Dentists and Their State Dental Boards.
Presentation by Dr. Malcmacher
Dentists and State Boards podcast October 17, 2011
Webinar: Keep Alternative Providers From Making Inroads in Your State
Presentation by Dr. W. Carter Brown and Dr. Myron “Mike” J. Bromberg: Making Inroads
www.agd.org/files/webuser/website/advocacy/keep alternative dental providers from making inroads in your state
webinar nov 10 2011 cb.ppt
AGD IMPACT & NEWS RELEASES
AGD Again Speaks Out Against W.K. Kellogg Foundation and New No-Dentist Provider Models
Questioning the Need for Independent Mid-Level Providers, AGD Impact
www.agd.org/files/webuser/website/advocacy/questioning the need.pdf
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