Navigating Dental Legislation: The ADA’s Response to ALEC’s Model Bills
The American Legislative Exchange Council (ALEC) has been a feature topic in the American Dental Association’s (ADA) policy circles over the last 6 months. Conversation began in earnest with ALEC’s release of model legislation designed to enable dental therapy. After issuing a rebuttal, ADA returned to ALEC with competing model legislation designed to practically increase access to dental care, without the cost and complication of introducing a new member to the dental team. ALEC has accepted both model bills, and ADA intends for their model bill to, “serve as a guide for legislators looking to address dental workforce issues.”
Who is the American Legislative Exchange Council?
ALEC identifies itself as, “America’s largest nonpartisan, voluntary membership organization of state legislators dedicated to the principles of limited government, free markets and federalism.” They maintain a model policy library which contains policies which ALEC’s members argue are conducive to, “[reducing] the cost of everyday life and [ensuring] economic freedom.” ALEC’s decision to adopt dental therapy legislation was a surprise to many given its potential conflicts with ALEC’s stated values. Rather than simply offer critical feedback, ADA pitched an alternative.
What’s in the ADA’s Model Legislation?
ADA’s bill, the Dental Access Model Act, contains 3 components allowing for:
Certification of expanded function dental auxiliaries
Certification of oral preventative assistants
Authorization of teledentistry services
Understanding each component requires defining terms and taking a moment to appreciate the broader landscape of dental workforce regulation in the United States.
Some key terms:
Expanded Function Dental Auxiliary (EFDA)- a dental assistant who may perform a list of additional duties following successful completion of a certification process. The process requires dental assisting experience (1,000 hours and a Dental Assisting National Board certification or 2,000 hours) and 70 hours of classroom instruction in expanded function duties.
Oral Preventative Assistant (OPA)- a dental assistant who may perform periodontal probe readings and perform supragingival scaling and polishing, following successful completion of an expanded function training course. Prior to enrolling in a training, the assistant would need to complete a board-approved course containing an appropriate level of didactic and hand skills assessment or hold a Dental Assisting National Board certification. OPAs are required to work in Health Provider Shortage Areas or rural areas for 5 years following certification.
Teledentistry- the use of technology, synchronously or asynchronously, to provide dental services and education when patient and dentist are in separate locations. Teledentistry does not typically include response to basic online inquiries and patient questions.
How Might This Impact Georgia?
Since the ADA’s Dental Access Model Act is only model legislation, it will not affect Georgia dentists unless Georgia legislators choose to introduce and pass it. Georgia has already implemented its own version of some of the bill’s provisions, and it is working on legislating teledentistry regulation. The way in which the bill differs from existing Georgia standards deserves consideration because model legislation can influence local and national conversations about the topics they contain.
While the model bill has 3 sections, it really does 2 things: It creates opportunities for expanded scope of practice for dental assistants and regulates teledentistry.
Dental Assistants
Regarding dental assistants, the bill creates an expanded function tier that looks similar to existing Georgia regulation. The Dental Access Model Act enables EFDAs to do things that expanded duties assistants can already do in Georgia. Its primary difference is that it provides a single certification for 11 additional duties. In Georgia, expanded duty dental assistants can acquire separate certifications for up to 27 additional duties based on which ones they expect to perform. Other states operate like Georgia. Missouri permits EFDAs for 5 types of care ranging from assisting with restorative procedures to orthodontics.
The second section of the bill continues to focus on dental assistants by creating an additional certification category that would enable assistants to do supragingival scaling and polishing and basic periodontal tasks after appropriate didactic and hand skills training. The concept of an OPA dates back to 1977 when the Indian Health Service began using dental assistants for similar tasks. Missouri is conducting a pilot study starting in December of 2024 that will explore this option. Data from the Indian Health Service does appear to indicate increased volume in preventative services rendered to patients. Currently, dental assistants of any category in Georgia cannot be authorized to do supragingival scaling and polishing.
Teledentistry
The final section of the model bill is an active topic in Georgia. Georgia Dental Association’s (GDA) teledentistry bill passed unanimously through the legislature only to be vetoed by the governor. GDA is currently addressing the concerns expressed by the governor’s office while ensuring any new bill protects the safety and well-being of Georgians. That includes an effort to ensure that dentists providing teledentistry are subject to oversight by the Georgia Board of Dentistry.
The Dental Access Model Act makes of use of language from Iowa. It covers general points of concern ranging from requiring a state license to informed consent. The model bill’s language departs from GDA’s last bill in 2 key ways. GDA’s most recent bill requires an in-person examination to establish a dentist-patient relationship prior to doing teledentistry, and it requires dentists doing teledentistry to be prepared to refer patients to a dentist within reasonable geographic proximity if required. Meanwhile, the model act’s language is broader. It allows for the establishment of a dentist-patient relationship virtually, “if…conducted in accordance with evidence-based standards of practice.” It also only requires dentists providing teledentistry to have, “adequate knowledge,” of local resources in order to provide appropriate follow-up care.
The timing of in-person appointments, requiring state licensed dentists, and establishing referral relationships are key components of teledentistry policy. The American Academy of Orthodontists justifiably emphasizes the need for an in-person examination prior to orthodontic treatment, and the fact of the matter is that most dental care is provided in person by necessity. As such, the ability of a dentist to move patients from a teledenistry interaction to an in-person one when necessary is a vital component of any effective remote care model. Teledentistry modalities will continue to evolve with available technology. Patient protection and quality of care must remain a priority.
While it may seem silly to quibble over details like this, words matter when it comes to laws. Gaps and loopholes in law have created business opportunities that harm patients, and many are already willing to ignore state laws governing dentistry altogether. New laws governing any aspect of dental practice must be written clearly enough to be enforceable. Otherwise, bad actors may choose to take advantage of vague laws to exploit patients. There is already a fair amount of state level variation in teledentistry regulation which should prove illuminating in the near future as the consequences of specific provisions, or the lack thereof, become more readily apparent.
What Can I Do?
Georgia Dental Association members have many opportunities to get involved with GDA’s ongoing legislative advocacy. To get more involved in advocating for dentistry in the state of Georgia, consider attending LAW Day, signing up as a contact dentist, or donating to GDAPAC.
