BILL ANALYSIS Ó
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|`Hearing Date:June 16, 2014 |Bill No:AB |
| |1174 |
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SENATE COMMITTEE ON BUSINESS, PROFESSIONS
AND ECONOMIC DEVELOPMENT
Senator Ted W. Lieu, Chair
Bill No: AB 1174Author:Bocanegra
As Amended:May 21, 2014 Fiscal: Yes
SUBJECT: Dental professionals.
SUMMARY: Extends the duties of a registered dental hygienist (RDH),
registered dental hygienist in alternative practice (RDHAP) and
registered dental assistant in extended functions (RDAEF) to include
performing radiographs, determining which radiographs to perform and
placing protective restorations. Also requires a dentist to be
responsible to provide to the patient, or the patient's
representative, a written notice including specified contact
information and disclosing that the care was provided at the direction
of that dentist. Prohibits a dentist from concurrently supervising
more than five dental auxiliaries. Provides that face-to-face contact
between a health care provider and patient is not required under the
Medi-Cal program for teledentistry.
Existing law:
1) Establishes the Dental Practice Act, administered by the Dental
Board of California (Board), to regulate the practice of dentistry.
(BPC § 1600 et seq.)
2) Establishes the Dental Hygiene Committee of California (DHCC) to
regulate the practice of registered dental hygienists (RDHs),
registered dental hygienists in extended functions and registered
dental hygienists in alternative practice (RDHAPs). (BPC § 1900;
1901)
3) Specifies that the DHCC shall make recommendations to the Board
regarding dental hygiene scope of practice issues. (BPC §
1905(a)(8))
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4) Further specifies that recommendations by the DHCC regarding scope
of practice issues shall be approved, modified or rejected by the
Board within 90 days of submission to the Board. (BPC § 1905.2)
5) Defines "direct supervision" as supervision of dental procedures
based on instructions given by a licensed dentist who must be
physically present in the treatment facility during the performance
of these procedures. (BPC § 1902(c))
6) Defines "general supervision" as supervision of dental procures
based on instructions given by a licensed dentist but not requiring
the physical presence of the supervising dentist during the
performance of these procedures. (BPC § 1902(d))
7) Specifies the practice included in and excluded from dental hygiene
as follows:
(BPC § 1908)
a) The practice of dental hygiene includes :
i) Dental hygiene assessment and development,
planning and implementation of a dental hygiene care plan,
oral health education, counseling and health screening.
b) The practice of dental hygiene does not include :
i) Diagnosis and comprehensive treatment planning;
ii) Placing, condensing, carving or removal of
permanent restorations;
iii) Surgery of cutting on hard and soft tissue
including, but not limited to, the removal of teeth and
the cutting and suturing of soft tissue;
iv) Prescribing medication; and
v) Administering local or general anesthesia or
oral or parenteral conscious sedation, except for the
administration of nitrous oxide and oxygen.
8) Specifies the procedures a dental hygienist is authorized to
perform under direct supervision of a dentist after submitting
evidence of specified education requirements including:
(BPC §1909)
a) Soft-tissue curettage;
b) Administration of local anesthesia; and
c) Administration of nitrous oxide and oxygen.
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9) Specifies the dental hygienist services that can be provided
without direct supervision :
(BPC § 1911)
a) Educational services, oral health training programs,
oral health screenings; and
b) Dental hygiene preventive services in addition to
oral screenings including, but not limited to, the
application of fluorides and pit and fissure sealants.
10)Specifies the procedures dental hygienists are authorized to
perform under general supervision : (BPC § 1910)
a) Preventative and therapeutic interventions,
including oral prophylaxis, scaling and root planning;
b) Application of topical, therapeutic and subgingival
agents used for the control of caries and periodontal
disease;
c) Taking impressions for bleaching trays and
application and activation of agents with non-laser
light-curing devices; and
d) Taking impressions for bleaching trays and
placements of in-office tooth whitening devices.
11)Specifies that any procedure performed or service provided by a
RDH, that does not specifically require direct supervision, shall
require general supervision so long as it does not give rise to a
situation in the dentist's office requiring immediate services for
alleviation of severe pain, or immediate diagnosis and treatment of
unforeseeable dental conditions that, if not immediately diagnosed
and treated, would lead to serious disability or death.
(BPC § 1912)
This bill:
1) Removes the dental auxiliary's ability to "expose" and instead
permits a dental auxiliary to "determine and perform" emergency
radiographs upon direction of the dentist.
2) Expands the auxiliary's authority to determine and perform
radiographs for the specific purpose of aiding a dentist in
completing a comprehensive diagnosis and treatment plan for a
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patient.
3) Specifies that if dental treatment is provided to a patient by a
dental auxiliary, pursuant to the diagnosis and treatment plan
authorized by a supervising dentist, the supervising dentist shall
ensure that the patient, or the patient's representative, is
notified in writing of the supervising dentist's name, practice
location address, telephone number and email address, and that the
care was provided at the direction of the dentist.
4) Specifies that a dentist shall not concurrently supervise more the
five dental auxiliaries providing services.
5) Specifies that a RDAEF, RDH or RDHAP, licensed on or after January
1, 2010, or having completed the educational requirements to
perform specified duties, is authorized to perform both of the
following additional duties pursuant to the order, control and full
professional responsibility of a supervising dentist:
a) Determine which radiographs to perform on a patient,
who has not received an initial examination by the
supervising dentist, for the specific purpose of the dentist
making a diagnosis and treatment plan for the patient.
b) Place protective restorations, which for this
purpose are identified as interim therapeutic restorations,
and defined as a direct provisional restoration placed to
stabilize the tooth until a licensed dentist diagnoses the
need for further definitive treatment.
6) Defines "interim therapeutic restoration" (ITR) as "the removal of
soft material from the tooth using only hand instrumentation,
without the use of rotary instrumentation, and subsequent placement
of an adhesive restorative material."
7) Specifies that local anesthesia shall not be necessary for ITR
placement.
8) Specifies the clinical settings in which ITRs can be placed.
9) Authorizes the Board to promulgate regulations establishing
requirements for courses of instruction for the procedures
authorized to be performed by a RDAEF, RDHAP or RDH no later than
January 1, 2018.
10)Specifies that prior to January 1, 2018, the Board shall use the
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competency-based training protocols established by Health Workforce
Pilot Project No. 172.
11)Removes the specifications for RDAEFs, RDHs and RDHAPs to "choose"
radiographs after a dentist has examined the patient and instead
authorizes RDHEFs to "determine which radiographs to perform" on a
patient who has not received an initial examination by the
supervising dentist for the specific purpose of the dentist making
a diagnosis and treatment plan for the patient under protocols
established by the supervising dentist applicable in specified
settings.
12)Provides that the specified functions may be performed by the RDAEF
only after completion of a program that includes training in
performing those functions, or after providing evidence,
satisfactory to the Board, of having completed a Board-approved
course in those functions.
13)Directs the DHCC to review proposed regulations and any subsequent
proposed amendments to the promulgated regulations and submit any
changes to the Board for review to establish a consensus.
14)States that the office shall extend the duration of the HWPP No.
172 until January 1, 2016, in order to maintain the competence of
the clinicians trained during the course of the project, and to
authorize training of additional clinicians in the duties specified
in HWPP No. 172.
FISCAL EFFECT: This measure has been keyed "fiscal" by Legislative
Counsel. According to the Assembly Committee on Appropriations
Committee analysis dated January 23, 2014, the fiscal effect of this
bill is as follows:
1) "Annual fee-supported special fund costs to the Dental Hygiene
Committee of California (DHCC) and the Dental Board of California
(DBC) to approve training courses and to oversee the expanded scope
of dental personnel would be incurred as follows:
a. $150,000 to the DBC, which regulates RDAs (State
Dental Assistant Fund).
b. $80,000 to the DHCC (State Dental Hygiene Fund).
2) Minor one-time Information Technology (IT) costs to incorporate
changes to the licensing system (State Dental Assistant Fund/State
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Dental Hygiene Fund).
3) Denti-Cal, the dental program within Medi-Cal, may incur
additional costs, potentially in the hundreds of thousands of
dollars, as a result of increased utilization of dental services.
Increased costs are more likely if personnel performing the
expanded functions, and/or using teledentistry, reach populations
that may otherwise forgo dental care. Given utilization rates of
Denti-Cal services are extremely low, there appears to be ample
opportunity to increase utilization, leading to commensurate cost
increases.
4) Any additional costs would likely be relatively small at first and
could grow with time, as the expanded functions and reimbursement
for teledentistry became the norm. A credible
fiscal estimate for initial years developed by the principal
investigators of Health Workforce Pilot Project (HWPP) #172, based
upon the number of participants in the project, pegged
increased Denti-Cal costs at about $300,000 annually, likely
growing slowly over time (GF/federal funds, majority federal
funds). This estimate may overstate costs directly resulting from
this bill, as existing law authorizes DHCS to reimburse for
teledentistry services.
5) In practice, however, it appears as though [there is] ambiguity as
to whether providers are allowed to bill Medi-Cal for teledentistry
services has limited provider interest in developing these systems
and billing Medi-Cal.
6) If this bill leads to greater utilization of relatively low-cost
preventive interventions such as ITRs, the state may eventually
experience some level of future cost savings by avoiding more
costly dental diseases and emergencies. However, an estimate of the
magnitude and likelihood of any such savings are beyond the scope
of this analysis."
COMMENTS:
1. Purpose. This bill is sponsored by the Author. According to the
Author, "This bill expands the scope of practice for registered
dental assistants in extended functions (RDAEFs), [registered
dental assistants in alternative practice (RDHAPs)], and
registered dental hygienists (RDHs) to further the practice of
teledentistry in accordance with the finding of a Health Workforce
Pilot Program (HWPP), and enables reimbursement by Medi-Cal for
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Virtual Dental Home (VDH) treatment. Specifically, the bill allows
RDAEFs, [RDHAPs], and RDHs, working out in the field under the VDH
model, to take x-rays without the consent of a dentist and place an
interim restorative therapy on a dentist's order?Changes are needed
to existing law to expand the scope of practice for these
individuals for specified procedures when performed under the VDH
model. HWPP 172 has shown that these individuals are capable of
performing the procedures as outlined in this bill."
2. Background.
a) Oral Health Statistics . According to an article published in
the Journal of the California Dental Association (JCDA, 2012),
"The Virtual Dental Home: Bringing Oral Health to Vulnerable and
Underserved Populations," the traditional office and clinic-based
oral health delivery system is failing to reach a large and
increasing segment of the population. The JCDA article indicates
that, in California, oral health disparities are more severe than
the national average, particularly among low-income and disabled
populations. Only 25% of Medi-Cal beneficiaries reported a
dental visit in 2007, and among pregnant women with Medi-Cal
coverage, only one in seven received dental services. Almost
one-quarter of children in California have never seen a dentist,
and approximately 40% of California's black, Latino, and Asian
preschoolers and approximately 65% of elementary school children
in these groups need dental care. In 2011, only 22% of the total
number of people eligible for Medi-Cal dental services received
any service, a decrease of 8% from 2009. A decrease was expected
for adults since most adult dental benefits were eliminated in
2009. However, there was also a decrease for children. In 2011,
only 27% of eligible children received any dental service
compared to 34% in 2009. In California, approximately 6.3
million children, or two-thirds of all children in the state,
suffer needlessly from poor oral health by the time they reach
the third grade. Approximately 7% of California children missed
school due to a dental problem in 2007, excluding time for
cleaning or routine check-up. In 2007, there were more than
83,000 visits to California hospital emergency departments for
preventable dental conditions.
b) Virtual Dental Homes . Virtual Dental Homes (VDHs) create a
community-based oral health delivery system in which people
receive preventive and basic therapeutic services in community
settings where they live or receive educational, social or
general health services. The VDH utilizes technology to link
practitioners in the community with dentists at remote office
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sites.
Equipped with portable imaging equipment and an Internet-based
dental record system, an RDA, RDAEF or RDH collects electronic
dental records such as X-rays, photographs, charts of dental
findings, dental and medical histories and uploads the
information to a secure website where they are reviewed by a
collaborating dentist. The dentist reviews the patient's
information and creates a tentative dental treatment plan. The
RDA, RDAEF, or RDH then carries out the aspects of the treatment
plan that can be conducted in the community setting. These
services include:
i) Health promotion and prevention education;
ii) Dental disease risk assessment;
iii) Preventive procedures such as application of fluoride
varnish, dental sealants and, for dental hygienists, dental
prophylaxis and periodontal scaling;
iv) Placing carious teeth in a holding pattern using ITRs to
stabilize patients until they can be seen by a dentist for
definitive care; and,
v) Tracking and supporting the individual's need for and
compliance with recommendations for additional and follow-up
dental services;
The RDA, RDAEF or RDH refers patients to dental offices for
procedures that require the skills of a dentist. When such
visits occur, the patient arrives with a diagnosis and treatment
plan already determined, preventive practices in place and
preventive procedures having been performed. Presumably, the
patient is more likely to receive a successful first visit with
the dentist as the patient's dental records and images have
already been reviewed. All of this adds up to a more successful
dentist visit.
In some cases, the dentist may come to the community site and use
portable equipment to provide restorations or other services that
only a dentist can provide. In either case, the majority of
patient interactions and efforts to keep people healthy are
performed by the RDA, RDAEF, or RDH in the community setting,
thus creating a true community-based dental home.
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c) Institute of Medicine (IOM) Report on Oral Health (2011 ). In
2011, the IOM published a report titled, Improving Access to Oral
Health Care for Vulnerable and Underserved Populations. The
Health Resources and Services Administration and the California
HealthCare Foundation (CHCF) asked the IOM and the National
Research Council to assess the current oral health care system,
to develop a vision for how to improve oral health care for these
populations and to recommend ways to achieve this vision.
According to the IOM report, access to oral health care across
the life cycle is critical to overall health, and it will take
flexibility and ingenuity among multiple stakeholders, including
government leaders, oral health professionals and others, to make
this access available. The IOM report indicates that to improve
provider participation in public programs, states should increase
Medicaid and Children's Health Insurance Program reimbursement
rates. In addition, with proper training, non-dental health care
professionals can acquire the skills to perform oral disease
screenings and provide other preventive services. The IOM report
calls on dental schools to expand opportunities for dental
students to care for patients with complex oral health care needs
in community-based settings in order to improve the students'
comfort levels in caring for vulnerable and underserved
populations. Finally, the IOM report reports that states should
examine and amend state practice laws to allow healthcare
professionals to practice to their highest level of competence.
d) HWPP No. 172 . The HWPP at the Office of Statewide Health
Planning and Development (OSHPD) permits temporary legal waivers
of certain practice restrictions or educational requirements to
test expanded roles and accelerated training programs for health
care professionals. In December 2010, OSHPD approved HWPP No.
172 which allowed RDAs and RDHs to perform an expanded scope of
practice. The project has been extended twice, with the second
extension running from December 1, 2012 to December 1, 2013.
Funding for HWPP No. 172 comes from various sources including
California Health Care Foundation (CHCF), American Dental Hygiene
Association, American Dental Association, Paradise Foundation and
Verizon Foundation. Evaluation of the project is also funded by
CHCF. The long-term objective of the project is to facilitate the
development of new models of care designed to improve the oral
health status of underserved populations.
HWPP No. 172 is a project at the University of Pacific School of
Dentistry which creates a virtual dental home and is testing a
concept where patients interact with RDAs and RDHs after a
telehealth consultation with a collaborating dentist who makes
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diagnostic and treatment decisions and determines the best
location for treatment. There are nine sites currently operating
this model of care in California. Preventive and early
intervention care is being provided in the community (two
elementary schools in Sacramento and San Diego counties, a
consortium of Head Start centers in San Francisco and San Diego,
residential facilities associated with three regional centers for
persons with developmental disabilities, four long-term care
facilities, and one community clinic). Patients with advanced
disease requiring the service of a dentist are being referred to
dental offices and clinics.
A policy brief describing the model and the results of the current
project indicates that under HWPP No. 172, allied dental
personnel completed the following types of procedures: collect
patient information (including medical and dental history,
consent forms, and caries risk assessment); chart pre-existing
conditions; take digital radiographs; take digital intra and
extra-oral photographs; prophylaxis; fluoride varnish; sealants;
ITRs; patient, parent, and staff oral health education;
nutritional counseling; oral hygiene instructions; case
management; referrals; and, communication with collaborating
dentists. As of March 31, 2013, a total of 1,494 patients have
been seen: Head Start centers (797); elementary schools (212);
long-term care facilities (176); multifunction community centers
(197); and, regional centers (112). The policy brief also
indicates that 110 ITRs were placed during the training phase of
the program in addition to the 295 placed in the utilization
phase for a total of 405.
e) ITR . According to the American Academy of Pediatric
Dentistry, an ITR may be used to restore and prevent further
decalcification and caries in young patients, uncooperative
patients, patients with special health care needs or when
traditional cavity preparation and/or placement of traditional
dental restorations are not feasible and need to be postponed.
Additionally, an ITR may be used for step-wise excavation in
children with multiple open carious lesions prior to definitive
restoration of the teeth. The use of an ITR has been shown to
reduce the levels of cariogenic oral bacteria (e.g., mutans
streptococci, lactobacilli) in the oral cavity. The ITR
procedure involves removal of caries using hand or slow speed
rotary instruments with caution not to expose the pulp. Leakage
of the restoration can be minimized with maximum caries removal
from the periphery of the lesion. Following preparation, the
tooth is restored with an adhesive restorative material such as
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self-setting or resin-modified glass ionomer cement. ITR has the
greatest success when applied to single surface or small two
surface restorations. Inadequate cavity preparation with
subsequent lack of retention and insufficient bulk can lead to
failure. Follow-up care with topical fluorides and oral hygiene
instruction may improve the treatment outcome in high caries-risk
dental populations.
f) Medi-Cal . The VDH treatment model is currently not
reimbursable by Medi-Cal because existing law requires
face-to-face contact between a health care provider and a
patient. This bill would delete that provision and allow
practitioners to receive payment for these services. This bill
also provides patient protections by ensuring contact with the
remote dentist upon request.
1. Arguments in Support. The Los Angeles Area Chamber of Commerce ,
Delta Dental , Mendocino Community Health Clinic, Inc ., California
Primary Care Association , First 5 Yolo Children and Families
Commission, Liberty Dental Plan of California , The Children's
Partnership , Worksite Wellness L.A. , Peninsula Family Service , The
Pew Charitable Trusts Children's Dental Campaign and the California
Coverage & Health Initiatives support the bill and write, "AB 1174
would increase access to dental care for underserved children and
adults who currently go without needed care by enacting policies
that would sustain the Virtual Dental Home. The VDH is a proven
and cost-effective system for providing dental care to California's
most vulnerable children and adults?The VDH is currently being
implemented on a pilot basis and is grant-funded. Therefore, it is
not replicable or sustainable as is. AB 1174 would ensure the VDH
could become a sustainable model and be implemented in sites
throughout California."
The California Society of Pediatric Dentistry supports the bill and
writes, "There is little question that segments of California's
population, for reasons of geography, economics, mobility and
disability face significant barriers accessing essential oral
health services in traditional delivery settings. CSPD views the
expanded functions authorized in AB 1174, and the ability to
perform these services as a Medi-Cal Dental Program benefit through
store-and-forward technology, not only as a way to reach many in
this population with diagnostic and interim stabilizing procedures,
but more importantly, as a bridge to entering into the full-scope
of treatment services available under out existing dental delivery
system."
2. Support if Amended. The Dental Board of California supports the
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bill if amended. In their letter, they share the following
concerns:
The formulation of the additional allowable duties for
registered dental assistants in extended functions (RDAEF)
should be authorized in the form of a permit once requirements
are successfully completed. This would be in contrast to the
current language, which would in essence add allowable duties
for those RDAEFs who met the necessary requirements. The Board
is concerned that it may be difficult for consumers and dental
healthcare professionals to discern between the varied allowable
duties that RDAEFs are allowed to perform. If the language was
to be amended in a format consistent with the issuance of a
permit to RDAEFs to perform these additional duties, it would
provide for better transparency between the Board and consumers
who wish to verify licensure status and the allowable duties of
the RDAEFs who provide them with dental healthcare services ;
accordingly, the Board would be provided with the tools
necessary to better protect the public.
The Board recommends that the following statement be removed
from the proposed amendments to Business and Professions Code
Section 1753.55(c) for the purpose of clarity: "The committee
shall review proposed regulations, and any subsequent proposed
amendments to the promulgated regulations, and shall submit any
recommended changes to the Board for review to establish a
consensus." While this provision would be applicable to the
proposed addition of Code Sections 1910.5 and 1926.05, as it
relates to the Board working with the Dental Hygiene Committee
of California (DHCC) on the formulation of the educational
requirements for RDHs and RDHAPs, it is not necessary for the
Board to consult with and establish a consensus with the DHCC on
scope of practice issues or regulatory proposals relating to
RDAEFs. This is because the Board provides direct oversight of
the licensure and regulation of RDAEFs and the DHCC has no
oversight authority for this licensure category.
1. Oppose Unless Amended. The Dental Hygiene Committee of California
opposes the bill unless amended. In their letter they raise
several concerns and propose amendments:
1910.5 should reflect only ITRs and not the determination of
radiographs or settings for the RDH. BPC § 1913 establishes the
settings for RDHs.
1926.5 should reflect only ITRs and not the determination of
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radiographs or settings for the RDHAP. BPC § 1926 establishes
the settings for the RDHAP.
We are concerned that RDHAPs are being placed under general
supervision. When the legislature established the RDHAP
licensed, it was their intent for this professional to be an
independent practitioner, but have an existing relationship with
a dentist.
We believe that the determination of radiographs is more
appropriately located in BPC § 1910 by adding letter (e). Adding
"including but not limited to" is necessary in order to clarify
what we already believe to be true; that a RDH and RDHAP is
educated and trained to determine which radiographic projection
should be taken on patients:
o "Determine which radiographs to perform on a patient
including, but not limited to a patient who has not received
an initial examination by a dentist for the purpose of
making a diagnosis and treatment plan."
We oppose the additional training for RDHs and RDHAPs to
determine which radiograph to perform, as this is already a part
of all RDH education and training.
The bill mandates that the DBC promulgate regulations with
only a cursory review by the DHCC to establish a consensus.
However, the DHCC has the authority to promulgate its own
regulations as provided by BPC § 1906.
1. Arguments in Opposition. The California Dental Hygienists'
Association opposes the bill for myriad reasons including:
This bill will increase access to care in the 17 virtual
dental homes, but restrict the provision of care currently being
provided by RDHs in public health programs as well as those
being provided by the over 600 licensed RDHAPs.
Changing section 1684.5(1) will allow unlicensed dental
assistants and registered dental assistants to determine which
radiographs to take. Neither of these categories of dental
auxiliaries is currently allowed to perform this function.
Moreover, those who fall into these categories will not be
required to take the coursework required to perform this
function.
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Changing Section 1684.5(4)(c) is problematic in that it can
be interpreted to require RDHs and RDHAPs to have a supervising
dentist who will ensure that the patient or patient's
representative is notified in writing of the supervising
dentist's name, but RDHs in public health settings work
unsupervised and RDHAPs provide dental hygiene care
independently with no supervising dentist.
The addition of Section 1910.5(a)(1)(B) and 1926.5(a)(1)(B)
will require RDHs and RDHAPs to work under the general
supervision of a dentist. Currently, both of these categories
of licensed professionals work unsupervised.
CDHA firmly believes that requiring a dentist's order to
place an Interim Therapeutic Restoration is an unnecessary
barrier which decreases patient's access to care.
1. Policy Issues for Consideration. The CDHA raises several concerns
in their letter. One such concern is the use of the term
"auxiliary." Auxiliaries can be interpreted to include various
allied health professionals that assist dentists including
unlicensed dental assistants. It appears that the intent of this
legislation is only for RDHs, RDAEFs and RDHAPs to be permitted to
place ITRs and determine and perform radiographs. As such, the
Author may consider removing the term "auxiliary" and instead
specifying the groups the bill is intended to apply to.
In order to clarify that a dentist will only supervise RDAEFs,
RDHAPs and RDHs for specified procedures, the Author may wish to
amend the language of the bill to clarify that the dentist will
supervise RDAEFs, RDHAPs and RDHs specifically for the procedures
listed in BPC §§ 1753.55, 1910.5 and 1926.05 within virtual dental
homes.
NOTE : Double-referral to Rules Committee.
SUPPORT AND OPPOSITION:
Support:
California Coverage & Health Initiatives
California Dental Association
California Primary Care Association
California Society of Pediatric Dentistry
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California Telehealth Network
Connecting to Care
Delta Dental
First 5 Yolo Children and Families Commission
First 5 Los Angeles
Liberty Dental Plan of California
Los Angeles Area Chamber of Commerce
Maternal and Child Health Access
Mendocino Community Health Clinic, Inc.
Peninsula Family Service
Roseland Pediatrics
Shasta Community Health Center
The Children's Partnership
The L.A. Trust
The Pew Charitable Trusts Children's Dental Campaign
Worksite Wellness L.A.
4 individuals
Support if Amended:
Dental Board of California
Oppose Unless Amended:
Dental Hygiene Committee of California
Opposition:
California Dental Hygienists' Association
Consultant:Le Ondra Clark, Ph. D.