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Dentists share their personal licensure examination story, including two experiences with failing the clinical exam.

A Candidate's Story: Failing the Clinical Exam

Robert Leland, DMD – Tufts, Class of 2001

Come spring 2001, I had met all of my requirements for graduation, was working as a dental hygienist and looking forward to moving on to practicing as a GP.

I had prepared well for the NERB exam--all of my patients were lined-up for the day of the exam and each patient was verified by multiple members of the dental school faculty as to their validity for the exam. I was feeling confident.

The day of the live-patient portion of the exam arrived and thankfully all of my patients showed-up (never a certainty when it comes to these exams). The day went smoothly. I didn’t “pulp-out” on the restorations. I had plenty of time to scale and root plane twelve surfaces of clinical/radiographic calculus. I was done with the NERBs once and for all.

I graduated and moved on to the real world. I elected to forego a GPR or AEGD program to move on to a private practice. The dentist-owner of the practice had taken me under his wing after college and was an excellent mentor during my four years in dental school. He was willing to work with me as I transitioned into becoming his full-time associate. He was looking forward to his summer break where he could leave many office responsibilities to his new associate come July when NERB results came out and I could apply for my license.  It was not to be.

The NERB results came in while I was working full-time for hygienist compensation in my new office (as Massachusetts law allows, I took the NERB perio section in my 3rd year and was able to obtain a hygiene license). I was meeting the patients of the practice and learning all the aspects of running a dental office. As interesting as that time was, I was ready to practice as a dentist.

I failed the perio portion of the NERB.

What a blow. Here I was, working as a hygienist for the past two years and I failed the NERB because of incorrect patient selection. It wasn’t really spelled out in the results section of the exam, but apparently my periodontal patient didn’t have the right amount of calculus. If that’s the case, you fail. I had two periodontists and a current NERB examiner look at my patient before the exam. How could this be? Well, it was. Plans were on hold.

Thankfully, my mentor/boss was, though disappointed, pretty understanding about this set-back. He didn’t quite understand how someone who finished requirements early, honored both sections of the boards and finished in the top 20% of his class could fail, but we moved on. Now I had to retake the perio section. The next NERB exam in our area was in August. But, the problem was that once you graduated, you couldn’t see patients at the school. There also wasn’t a formal program to help to find patients for the exam. I was on my own.

My first thought was to ask a patient from the practice where I worked sit for the exam. This is tough to do for a couple of reasons. First, patients in private practice are there for the quality of care they receive and generally wouldn’t qualify for the NERB because the practice is actively working with them to maintain their periodontal health. Except for perhaps new patients to the practice, the private practice patients  won’t have “enough calculus” to qualify for the NERBs. Second, private practice patients in the area come for convenience and location and are not going to make the trip to have six of their teeth cleaned.  

I had a number of friends in the classes the year behind me who were very accommodating and agreed to let me exam some of their periodontally compromised patients. The toughest part, though, is that our school closes the end of July, so I had a limited number of clinic days to do my search.

In the end, I was able to find a patient who I thought marginally fit the qualifications (I had less confidence in her eligibility than I did in my previous patient). What else was I going to do?

I took the exam and felt pretty good about it. I was amazed to see how many of my peers were there retaking portions of the exam with me….peers who I knew had top skills and never would have expected to see there.

I passed the section the second time around, and have moved on with my career. I guess looking back on that summer; it wasn’t the end of the world. It helped to have a supportive situation around me. The toughest part was the temporary blow to my confidence. It just didn’t seem right that all other indications in my dental school career signified that I was ready to practice dentistry, but the variability in the live-patient portion got me.

Where is Rob today?

Dr. Leland continues to live and practice in Massachusetts. He bought the practice where he first worked as an associate, which he aptly renamed Leland Dental. In addition, he has gone on to hold numerous leadership roles in organized dentistry, serving as the chair for the council on Membership for the Massachusetts Dental Society in 2006-2007, and as vice chair to the ADA Committee on the New Dentist for 2009-2010, among others. Dr. Leland was the 2007 recipient of the ADA Golden Apple Award for New Dentist Leadership.

A Candidate's Story: Failing the Clinical Exam


I failed the restorative portion of the NERB exam administered in March 2006.  I had patients from my own pool of patients who I had established relationships with as well as back-ups who all showed up.  I felt admittedly nervous, but from what I had heard, as long as I did what I was trained to do, I would pass.  I chose to prepare and restore the anterior CIII composite first.  I performed the procedure as I had been trained, but after submitting my patient for final check, I was told to temporize the tooth and dismiss the patient with a failing grade for that portion.  I was able to proceed with the periodontal portion of the exam during the afternoon, but I had to send away all three of my other patients without treatment or compensation for their time.  The test was a blow to my esteem, and in my opinion, reflected poorly on the students and the school since what I had been trained to do was apparently "clinically substandard."  The testing agency is not required to provide feedback so I will never know what aspect of my performance was inadequate.  As a learning experience, this day had been a complete waste of time.  Conversely, I have since retaken the restorative portion of the exam and scored a 99, but without feedback, and I will never know in what way the Board considered this attempt so drastically different from the first.

In the long run, the extra $700 to retake the one portion of the exam (on top of the original $1,600) wasn't an unbearable burden, but it certainly created some difficulty.  It was $700 that my family couldn't use to move to our new practice location, spend on prenatal medical care for our coming baby, or subsist on while starting my new job as an associate.  The stress of making life decisions (if or where to move, how to recover if I failed a second time, and how to adjust my expectations of new employment) could not have had a price attached.  The biggest impact was that my state license was held up while I awaited the results of the retake.  I was unemployable for all the months between graduation and licensure.

On the day of the retake, I felt even less prepared than on my first attempt.  The only restorative procedures I had done in the previous two months were on the typodont in practice for this event.  My clinical time had been spent completing crown and bridge cases and looking for new board patients.  I found suitable patients from junior students who still had restorative patients in their pool.

For these students in our class, retaking the exam and passing had become a necessity for matriculation into the post-graduate orthodontic, oral surgery, and pediatric residencies that had accepted them.  The sheer volume of students retaking the exam also shocked me; nearly one in four students who took the NERB at our school had to retake at least one section over.  , ,

My future employer was sympathetic to my cause and  made tremendous adjustments to the office and patient schedule during this interim unemployment phase of my career.  This was a great consolation to my family and me.  I have been encouraged to see that support in private practice; most dentists want to see their young colleagues succeed, which was contrary to the feeling I had after failing the NERB regional exam.

A Candidate’s Story: The PGY-1 Option

Chris Salierno, DDS – SUNY Stony Brook, Class 2005

As a second year dental student, I sat as a patient for the NERB exam.  Unfortunately, the candidate failed for a rather controversial reason.  This incident led me to investigate licensure exams and their alternatives.

Since I was a student In New York, I had another pathway to licensure: PGY-1.  The prior year I attended a General Practice Residency on Long Island.  I improved my skills in endo, perio, restorative, fixed prosthodontics and fields of dentistry that are not tested on clinical exams such as implantology, removable prosthodontics and oral surgery.  I also saved a substantial sum of money by not having to pay fees for the examination, patients and assistants.  It comforted me to know that I didn't delay treatment on patients for my own benefit, nor did I perform said treatment under a one-shot high-stakes scenario.

The PGY-1 option is not for everyone, however.  If you plan on practicing immediately after graduation, this may not be the pathway for you.  In addition, you would not be able to moonlight as a dentist during the year since you are not licensed.  Finally, the most significant drawback is portability.

However, if I ever want to move to another state, I may have to take a licensing exam.
Portability is a tricky issue.  There is no clinical licensure examination that is truly "national."  As it currently stands, any exam you take will not license you in certain states.  So my advice is to consider the states in which you are likely to practice and research which pathways to licensure they accept.

Where is Chris today?
Dr. Salierno completed his PGY-1 training at Stony Brook Hospital’s General Practice Residency program. Shortly after graduating from Stony Brook, he returned as an Assistant Clinical Professor and continues to lecture on various topics across the country. In 2010, Dr. Salierno opened a private practice in Melville, NY and serves as the New York State representative for the ADA Committee on the New Dentist and the Treasurer for the Suffolk County Dental Society.

A Candidate’s Story: The Missing Patient 

Nikko Lee, DDS, Columbia, Class 2010

Leading up to the NERB exam, I had everything in order. Filling out the application was relatively simple. The application form came in the candidate guide. I wasn’t too worried about the dentistry part of the exam.
I knew how to do a class II. I knew how to do a class III. I knew how to remove calculus. The part that stressed me out the most in the weeks leading up to the test was finding reliable patients that had lesions that fulfilled the NERB criteria.

I heard that I could save myself a lot of stress by reading the manual thoroughly. I heard that the test wasn’t so much about whether you can fill a cavity as it was about whether you can follow directions in a stressful situation. For example, proper patient selection, managing the required paperwork (consent forms, medical history, recent radiographs, perio worksheets, evaluation forms), properly requesting modifications, and so on.
I got to clinic around 7 a.m. to set up my area for the operative portion of the test. I got lucky and had a class II and III to do on the same patient. It wasn’t perfect, but things went relatively smoothly. On both preps my patient returned from evaluation with an “Instructions to Candidate” form. This meant I had to make a few changes before proceeding, but it was nothing major and I finished on time. Then, I got to the perio part of the test….

We had from 2 - 5 p.m. for the perio section. I told my patient to arrive at 1:30 p.m. so that I could have him seated, get forms signed, and ready to start the test at 2. It was 2 p.m. and still no patient. Of course, by this time I had called the patient repeatedly, checked the waiting room, even went down to the lobby to see if she got lost. 2:45 rolls around, still no patient. Since I didn’t have a back-up, it was looking like I was going to fail and have to retake a few months later. Needless to say, I was frustrated, especially since I had met with the patient two days prior and we talked about the importance of showing up. 
I was hanging out near the waiting room venting to a friend about what had happened when I catch word that a patient of my classmate brought her father along (he was interested in getting treated at Columbia in the future). Another classmate of mine had already taken radiographs on the individual and I thought he may qualify to be a patient for the exam. I spoke with the patient through a translator (he only spoke Spanish) about the testing process and he agreed to let me screen him to see if he met the criteria. By this time it was after 3, and while two hours seems like a long time to scale a quadrant of teeth, the paperwork for getting a patient qualified is VERY cumbersome. It was going to be close…

Before candidates can start scaling, an evaluator will review the patient to determine if he or she is acceptable for the exam – and this must happen at least 45 minutes before the end of the test. I had about an hour to take a medical history, blood pressure, and obtain consent (in Spanish), make him a chart, examine the patient, fill out a worksheet with probing depths/calculus detection, and if he qualifies, take a full-mouth series, followed by approximately an hour for scaling.

It was 2 p.m. and still no patient… Since I didn’t have a back up, it was looking like I was going to fail and have to retake a few months later.

Thankfully I had awesome classmates and clinic staff who helped me with the radiographs and paperwork and I was able to get everything done in time. It was a frantic couple of hours that I never want to do again! Thankfully, it all worked out in the end. I got really, really lucky — not only was there an extra patient that happened to be in the waiting room, but he actually was qualified to be a patient. I screened a lot of patients prior to the exam and for one reason or another there was always something that made them not ideal for the test. And it’s no wonder considering the requirements were something like: 12 surfaces with detectable calculus, at least three sites with pockets of at least 5mm, no more than two-three canines/incisors, at least three premolars and molars, all of which needed an approximating surface within 2mm. I really lucked out that there was someone in the waiting room that fulfilled all the criteria.

The fact that I knew exactly what needed to get done when I finally found a patient went a long way in helping me finish everything in time. This is why it is so important to read the manual. Time is limited as it is, so when things don’t go your way, you don’t want to waste time familiarizing yourself with paperwork you’ve had for months but never bothered to look over.

Of course, if I could go back and do something differently, I would have found a more reliable patient! But honestly, some of those things are out of your control. My advice is to take care of the things you can control…in other words, be prepared! Even if you think your patient is reliable, things happen. Patients are still people, and anything can happen in a person’s life to prevent him or her from making it to an appointment. Despite the circumstances, in the end it’s still up to the student to pass the exam.

Where is Dr. Lee today?
After graduating from Columbia in 2010, Dr. Lee enrolled in a residency program at New York University, which will be completed in 2012.