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Dental licensure reform: The case for eliminating the clinical exam

July 14, 2021

By Jonathan Nash

This year I am celebrating my 50th anniversary of graduation from dental school (New York University) and as the American Student Dental Association’s first chair of dental licensure reform. I decided, out of curiosity, to take a peek at the current landscape of licensure reform, with the vague idea of writing a retrospective essay about the subject I had been so passionate about many years ago. This led to several months of personal research into archival and current publications, and public facing statements on the websites of the ADA, American Dental Education Association, ASDA, and the Coalition for Modernizing Dental Licensure (CMDL).

Photo of Dr. Nash
Dr. Nash
I must admit that in the course of this effort it was painful for me to discover that our profession is still debating and lamenting about the same two fundamental issues that we confronted 50 years ago:  The dental licensure exam itself, and the inability of license holders to freely relocate and practice in other states (aka “reciprocity,” “portability,” and “licensure by credentials”).

For this particular essay I have chosen to focus solely on the clinical exam, coined the “single-episode/performance-based” exam in the Report of the Task Force on Assessment of Readiness for Practice or TARP; and shall leave the portability issue for another time. For brevity, I will use the acronym SE/PB throughout the following text.

General Considerations

Some may argue that progress has indeed been made in the administration of the licensure exam over the last 50 years given that regional testing authorities have increased from two in 1971 to the current number of five.

Although undoubtedly there has been improvement in the uniformity, the ease of test-taking, and the administration of the examination, the traditional mode of testing essentially remains the same. That is, dentists and dental students in 44 States (per the CMDL website) still have to endure the SE/PB high-stakes clinical exam, whether it be on patients or mannikins. It is striking (and embarrassing) that our dental profession remains the only health care profession that subjects its candidates for licensure to this mode of testing i.e. M.D.s don’t need to perform surgery, nurses and EMTs don’t need to demonstrate CPR or start an IV, midwives don’t need to deliver a baby, and osteopaths don’t need to perform various manipulations, etc.

Some stakeholders, such as ASDA, proclaim that real progress has been made by fighting for the substitution of manikins for patients, thereby attempting to score a meaningful victory for patient rights. While this is undoubtedly a noble, feel-good cause, it is not something new (it has been official ADA policy since 2005, and ADEA policy since 2011), and I would argue that it is not a fundamental licensure concern. It takes the focus off the real target – the objectionable SE/PB itself, which still persists, as does the degradation of our dental profession. There are many compelling reasons which support the elimination of this form of testing, whether it uses live patients or manikins:

1. It is not logical, nor in the public interest, to accept that the SE/PB method of testing and evaluation is appropriate simply because it is the way licensure exams have been conducted for over 100 years.

2. Educators and advocates have been arguing for decades that graduation from an accredited dental school and passing the National Boards should be sufficient, and is a far more reliable measure of competency than performing clinical procedures in a high-stakes environment on a single day. For dental students to take the position that they accept and welcome this level of scrutiny is to essentially belittle their preparation for dental practice bestowed by their education and certification for graduation from their accredited dental schools.

3. By accepting this type of exam as a valid test for licensure, dental students and educators are separating themselves from the licensure and certification requirements of their health profession colleagues in other disciplines. It begs the question, why is it necessary that public safety and protection requires a SE/PB clinical exam by dentist applicants, but not for physicians, midwives, nurses, EMTs, etc.?

Image of exam
Image credit: Banannaanna/iStock/Getty Images Plus
4. There is no evidence to support that this level of scrutiny actually protects the public interest. To the contrary, it is well documented that the SE/PB exam demonstrates a concerning lack of reliability and validity. The ASDA website presents a comprehensive review of these studies from their 2016 white paper. Unfortunately, I could not find any published research on this topic since 2011.

Some may argue that it would be beneficial if there were more recent studies on the manikin SE/PB, particularly the recent ADEX exam which was developed by the American Board of Dental Examiners. However, I contend that ADEX is merely a modification of kind, and not of essence. It does not change the fact that a SE/PB exam, whether on patients or manikins, does not demonstrate any valid connection to the public interest mandate. State Boards exist as legislative-authorized entities, created by laws and statutes. Their public policy statements and procedures (aka rules and regulations) should be based on, and supported by, legitimate concerns and real data. As such, the onus falls on these government entities to justify their policy positions with cogent arguments and supportive data — for which most dental boards have been totally remiss.

5. One of the inherent flaws in the public safety argument promulgated by state dental boards and others, is the hypocrisy of, what I term, the “anointment effect.” If the SE/PB clinical exam is truly a valid and necessary measure to protect the public interest, why then is there no interest in the periodic testing of practicing dentists to assure that the public is protected from below standard kinesthetic/clinical competency, and/or the degradation of clinical skills due to illness or aging? I mention this point not because I support such a ridiculous idea, but rather to point out the logical inconsistency in the testing-for-public-safety argument. If this level of scrutiny were truly valid and necessary, are we to believe, from a public advocacy point of view, that state dental boards are truly fulfilling their public trust and mandate by only scrutinizing recent graduates and not licensed practitioners? This situation creates a stench of hypocrisy, and a suspicion that there might be something else at play here other than protection of the public.

A review of current options for licensure assessment: a brief review of the current alternatives that are already supported by organized dentistry as valid and reliable options to replace the SE/PB.

The Buffalo CIF model: aka the Curriculum Integrated Format, approved by the ADA in 2007.

PGY – 1: the New York State licensure system (adopted into law in 2007) and supported by the CMDL per the TARP Report, requires licensure candidates in N.Y. to complete a one-year post-graduate residency program in lieu of a clinical exam. Per the CMDL website, seven states currently accept PGY-1 status.

The California Portfolio model: aka Compendium of Clinical Competency Assessments which was adopted by the State of California and all of its six dental schools in 2014. All three of the CMDL coalition partners, collectively and individually, support the general concept of the portfolio model as an alternative to the SE/PB clinical exam.

It should also be mentioned that the ADEA committed to developing a standardized portfolio in 2018, although I could not find any progress on this initiative on the ADEA website. Per the CMDL website, only three states accept a Portfolio in lieu of a SE/PB exam – California, Colorado, and Louisiana.

DLOSCE (Dental Licensure Objective Structured Clinical Examination) patterned after Canada’s OSCE dental licensure exam (since 1995) as an alternative to the SE/PB clinical exam, is administered by the Joint Commission on National Dental Examinations (JCNDE) and is endorsed by the ADA and the ADEA. Currently, per the JCNDE website, only six states have modified their rules and regulations to permit DLOSCE as full or partial fulfillment of their licensure requirements, but 44 states have not!

By way of background information, OSCEs, since their inception in the 1970s, have been widely used in the health professions, including: optometry, medicine, physical therapy, radiography, rehabilitation medicine, nursing, pharmacy, podiatry, and veterinary medicine. OSCEs are now part of the US Medical Licensing Examination for all US medical graduates. In 2020, the JCNDE released a detailed report which supported the validity and reliability of the DLOSCE test. Additional information can be found in this FAQ.

Conclusion – what can we do?

In retrospect, 50 years later, there are still 44 States which require some form of SE/PB. It is therefore reasonable to argue that the hard lesson learned is that “friendly” discussion and negotiation between organized dentistry and the various state dental boards is obviously not an effective strategy for meaningful reform. If we continue down this long road to nowhere our successors will probably be lamenting about the same intransigencies in another 50 years!

This is a state-by-state issue, embedded in the statutes and rules and regulations of each state. This stubborn feature of the licensure process in America cannot be wiped away in one fell swoop, regardless of how many manifestos, ‘earnest’ recommendations, and protestations are promulgated by the ADA, the ADEA, ASDA, and others. Sending letters and signing petitions will not get the job done.

Given this reality, I recommend following the impressive strategy employed in the ‘Ohio Model’ (as explained in the CMDL webinar series on their website).

In this case Mr. David Owsiany, the executive director of the Ohio State Dental Association, after failing to gain the cooperation of the state board over many years and many attempts, decided to take the legislative route. They succeeded in gaining substantive changes in the dental law. Today, Ohio accepts the test results from all five of the Regional Testing Agencies; accepts the credentials of all out-of-state practitioners with five years or more of experience; and accepts dentists holding the PGY-1 credential. If significant progress is to made to replace the SE/PB exam with other proven alternatives, the “Ohio Model” needs to be replicated all over the country. State legislators are interested and sympathetic to data and arguments showing the irrelevance of clinical testing to the public interest.

This method of intervention requires targeting one state at a time to build momentum and try to create a domino effect. Initially, a consortium of stake holders should carefully choose a vulnerable State with favorable dynamics i.e. strong and sympathetic: dental schools, state dental associations, and local ASDA chapters; and a legislative structure favorable for modifying the dental law. To that end, stake holders should seriously consider retaining the services of a local lobbying firm that is familiar with the particulars of that state — to advise, devise and implement strategies.

Inquiries and comments can be directed to:

Dr. Nash was ASDA chair of dental licensure reform in 1971, and founder and chairman of the National Council for Improvement of Dental Licensure 1969-73.