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ADA calls for increased licensure portability

March 31, 2016

By Kimber Solana

Editor's note: This is the second in a series of articles on licensure reform, a debate occurring in various states as students, educators and dental leaders seek alternatives and/or changes to the licensure process.

Charleston, S.C. — The Medical University of South Carolina College of Dental Medicine — the only dental school in the state — is home to about 340 dental students and residents.

Of those, more than 25 percent are from out of state, such as neighboring North Carolina and Florida. Thirty-four students are on military scholarships; and many others are either married to military members or have spouses in the corporate world.

"Licensure portability is of tremendous importance to our students," said Dr. John Sanders, dean of the College of Dental Medicine. "Whether a dental student wants to practice in South Carolina, and I hope they do, there's a good chance he or she will be moving to other states."

However, a recommendation made by the Clinical Examinations Committee  of the South Carolina Board of Dentistry during a Dec. 18, 2015, meeting raised concerns among the school's administration, faculty and dental students.

The committee, during an executive session closed to the public, decided to recommend that the dental board accept only clinical examinations administered by the Central Regional Dental Testing Service Inc. and the Southern Regional Testing Agency Inc.

Dr. Sanders

Dr. Jeffers

Mr. Conzett

Dr. Griffin
On Jan. 15, after hearing from school and student leaders, the full board voted to maintain the status quo for 2016. But on April 15, the South Carolina Board of Dentistry is scheduled to discuss and vote on the recommendation for future years.

If board members accept the recommendation, South Carolina dental students will no longer be able to apply for dental licensure in that state by taking the American Board of Dental Examiners (ADEX) exam. ADEX had been administered by SRTA in South Carolina until ADEX and SRTA mutually severed ties last summer.

"To South Carolina dental students, taking the ADEX exam is important because it allows them to apply for licensure in South Carolina and gives them more portability to the states they may see themselves practicing in," said Dr. Sanders. These states include Florida and North Carolina, which accepts ADEX but not the exams currently being administered by SRTA or CRDTS.

According to the ADA, more than 40 states accept the ADEX examination results versus 30-plus for SRTA and CRDTS.

This upcoming decision revives calls by the ADA and partnering organizations for state boards across to the country to increase, rather than restrict, the portability of dental professionals.

More similar than different

There are five clinical test administration agencies for dentistry: the Commission on Dental Competency Assessments (CDCA, formerly NERB); CRDTS; Council of Interstate Testing Agencies, Inc. (CITA); SRTA; and the Western Regional Examining Board (WREB). Overall, the exams should be able to identify a "safe beginner" dentist for initial licensure.

The ADA has analyzed the examinations administered by each of the testing agencies — CDCA and CITA administer the American Board of Dental Examiners (ADEX) dental exam, while CRDTS, SRTA and WREB administer their own exams — and found that these examinations "adhere to a common set of core design and content requirements that renders them conceptually comparable." In other words, they're "nearly identical," said Dr. Chris Griffin, South Carolina Dental Association president.

For example, each agency:

  • Utilizes the Standards for Educational and Psychological Testing as the guidelines for evaluating the validity for their exams.
  • Produces a publicly available technical report that documents and summarizes available validity and reliability evidence concerning the examinations.
  • Utilizes conjunctive scoring, requiring candidates to pass each of a series of tests in order to pass the full examination.
  • Requires three examiners to evaluate performance on each exam and sub-exam.
  • Makes a determination of candidate minimal competency in restorative dentistry on a patient-based exam for a Class III composite resin preparation and restoration and either a Class II amalgam or composite resin preparation and restoration.
  • Makes a determination of candidate minimal competency in periodontics on a patient-based exam for scaling and root planning.
"Considering the competency exams are nearly identical as well as the core standard and administration procedures, it seems redundant [for students] to take several of these examinations when a universal exam should already have been developed and approved by all testing agencies and state boards," Dr. Griffin said, adding that despite what any organizations and schools want, the jurisdiction of granting licensure remains with the various majority opinions of the state board members.

Dental groups call for change

Regardless of the examination's similarities in measuring skills and qualifications of an applicant, many state dental boards remain reluctant to accept the results of any given legitimate state or regional examinations.

This reluctance forces graduating dental students and new dentists to spend money and time to take multiple versions of similar tests not given at their home dental school if they end up relocating to a different state.

The ADA, in February, sent a letter to about two dozen state dental boards, including the South Carolina Board of Dentistry, urging them that one standard of competency for licensure should exist. The decision of the boards of a number of other states to accept the test results of only a select number of clinical test administration agencies is "highly arbitrary," according to the letter, which was written and sent by the ADA, its Licensure Task Force, the ADA Council on Dental Education and Licensure and the American Dental Education Association.

"While licensure portability is an important matter to dental professionals, particularly to those pursuing initial licensure or attempting to relocate to another state, it is clear that the dental boards of a number of states … continue to engage in conduct that restricts, rather than enhances, that portability," the letter said.

It's up to some state legislatures (by statute) and most state dental boards (via the rule-making process) to decide on the exams they want to administer and those they will accept. State dental societies are successful advocates with legislative bodies and can influence change in dental licensure laws.

"Portability issues have been around for a long time," said Dr. Gary E. Jeffers, ADA 9th District trustee and chair of the 2016 ADA Licensure Task Force. "We were talking about it 40 years ago when I was a student. While things have improved, we need to continue to find a way to make the licensure process better."

Search for a national exam

"A state board of dentistry isn't there to help people get a license but to help protect the public," said Dr. Jeffers. "But what we're trying to do is show them that there are other ways to do this."

The ADA, he said, continues to explore the feasibility of developing an exam similar to the high-stakes Objective Structured Clinical Examination (OSCE), which is required for licensure in Canada. The Canadian OSCE exam currently is administered at three sites in the U.S. (Boston, Minneapolis and Detroit). The Minnesota Board of Dentistry accepts OSCE exam results for University of Minnesota dental school graduates who apply for Minnesota licensure.

The goal: to find an exam that all state boards can accept while eliminating patient-based examinations that the testing agencies currently utilize.

"Of course, the problem is how are we going to get the various state boards to accept that," Dr. Jeffers said. "For example, in Michigan, the board will not currently support anything that is not patient-based. And Michigan is not alone."

For now, he said, one option is the curriculum integrated format supported by ADA policy. A new curriculum integrated format model was piloted at the State University of New York at Buffalo where board examiners come several times during the year to assess students providing care for patients of record.

"This so-called Buffalo model was developed by CDCA to help address ethical issues associated with patient-based exams," he said. These ethical issues range from some students paying thousands of dollars for a patient to participate in the exam to the lack of follow-up care.

After a successful pilot program, six other dental schools have since adopted the model this year. [An upcoming issue of ADA News will feature the curriculum integrated format exam in the third article of this series].

"We're trying to get to the point to provide full portability of licensure so it doesn't matter what state you're in," Dr. Jeffers said. "But I know this is going to take some time."

'A step backwards'

In South Carolina, student leaders see the debate and discussion over licensure portability as a good opportunity to make their voices heard in how to improve the profession.

"As students, we haven't been in the profession for an extended period of time, but our voice is an important one," said third-year dental student Chris Conzett, president of the MUSC chapter of the American Student Dental Association.

Mr. Conzett said he's prepared, if given the opportunity, to voice his and fellow students' concerns over a possible decision by the South Carolina Board of Dentistry to uphold a recommendation to only accept SRTA and CRDTS.

"If that recommendation is upheld, I believe it would be a step backwards," he said. "As students, we would like to work with the state board and others in the country in improving licensure portability and the licensure process."

The South Carolina Board of Dentistry, through a spokesperson, declined to comment until after the April 15 meeting on the importance of portability or why the committee made its recommendations. The Board had held a meeting Jan. 15 to discuss the committee's recommendation to only accept SRTA and CDRTS. However, Dr. Griffin said, after much discussion and the fact that there had been no problems with the existing acceptance examinations/selected agencies, which has been the same as the previous three years, the Board decided to keep the policy current for 2016.  

In similar turn of events, the Arkansas State Board of Dental Examiners voted in early March to only accept SRTA for initial licensure, effective 2017. Arkansas had previously accepted CITA, CDCA and SRTA.

The South Carolina Board of Dentistry will again meet April 15 to recommend a more long-term solution to the issue of licensure examination acceptance in the state.

For now, in lieu of a nationally accepted exam, Mr. Conzett said South Carolina students want its state board to accept all exams. By doing so, it would address dental students' needs to be mobile and provide dental care to patients wherever they are needed.

He said statistics show his generation is marrying and having children later in life.

"Many of my classmates are not married, and they don't know where they'll settle down," said Mr. Conzett. "With the rise of the cost of dental school, many are opting to join the military."

Many of his classmates are also interested in practicing in border areas. For example, the city of Charlotte, North Carolina, has suburbs that cross over to the South Carolina side of the border. If a graduate joins a group practice with offices in both North Carolina and South Carolina, he or she will need to pass two similar initial licensure examinations to practice if the committee's recommendation was upheld.

"I understand that change is difficult. But I also believe that professions need to adapt over time," Mr. Conzett said. "And this issue of licensure portability is a wonderful opportunity for us as a profession to advance and upgrade the licensure process at a time when mobility is as important for young dentists as ever."