Licensure

Policy Statement

In recent years some states have changed the requirement for dental licensure.  These changes have been prompted by developments that include:

• technological advances with simulated models, the Internet, and with dental materials and instruments
• increased professional mobility
• increased collaboration among testing agencies leading to similar test formats and procedures
• accreditation of educational programs that require the assessment of student competencies rather than performance-based assessments
• adoption of alternative licensure methods (i.e., licensure by credential; post-graduate year)
• both the California Dental Association and the American Dental Association investigating alternatives to the use of live patients for clinical licensure examination process

Additionally, dialogue on the current licensure process have included concerns about the ethics of using live patients and increased commercialization of acquiring exam patients.  Attaining licensure by graduation is also desirable as it would help ease the financial pressure faced by dental school graduates.  Questions have also been asked about exam validity. 

In California there are three pathways to licensure: clinical examination, licensure by credential, and successful completion of at least one year of a Commission on Dental Accreditation (CODA)-approved general practice residency or advanced education program in general dentistry (referred to as PGY-1).  The PGY-1 pathway legislation, effective January 1, 2007, is in the process of being implemented after successful passage of CDA-sponsored legislation.  The Dental Board implemented a licensure-by-credential pathway in 2003, again after successful passage of CDA-sponsored legislation.  Since implementation through October 2006, the Dental Board reports granting more than 1200 licenses through this pathway. 

Licensure-by-examination requires a candidate to successfully pass Parts I and II of the National Board Dental Examinations, a state exam on law and ethics, and either the state clinical exam or the Western Regional Exam Board (WREB) exam.  The state can accept results from WREB exams taken after January 1, 2005.  A candidate who graduated from a non-accredited dental school may take the state clinical exam or WREB exam if the candidate has completed a two-year program at an approved dental school.  An alternative is the RT pathway, which is due to sunset in 2008. The RT pathway requires a successful candidate to have passed the National Boards by December 31, 2003 as well as the restorative techniques (RT) exam by December 31, 2008.  CDA supports the sunset of the RT exam pathway to licensure.

Both CDA and the ADA created task forces the last few years to examine the licensure process, alternatives and other changes to the process.  The task forces no longer exist, but interest in alternatives remains high.  Current alternatives to the state clinical exam are:

• Regional and national examinations:  In 2004 there were four regional examinations, plus individual state examinations. Two agencies came forward in 2005 to offer “national” exams, WREB and the American Board of Dental Examiners (ADEX). North East Regional Board (NERB) and Central Regional Dental Testing Service (CRDTS) administer the exam created by ADEX since ADEX does not actually administer its exam. States can accept none, one, or all testing agency results for initial dental licensure.

• Curriculum Integrated Format (CIF) examination:  This term has been used most often by the NERB which began in 2003 to administer its exam in a time sequence during the senior year of dental school.  The CIF provides opportunity for remediation, and the ability to re-test a number of times prior to graduation. Candidates must pass a section of the exam before going on to take the next section. A candidate may still opt to take the clinical exam in its traditional format offered after completion of the candidate’s senior year.  The CIF allows for licensure by graduation.  However, it leaves unresolved the concerns about the ethics of using live patients and potentially the issue of patient-brokering or commercialization. 
  
  Offering California’s clinical exam as a CIF was discussed in 2005-2006 by a CDA-Dental Board-dental school deans workgroup.  The term “segmented licensing exam (SLE)” was used instead of CIF because it was thought to be a better description of the format.  Adding to the discussion on the use of the term “CIF,” the 2006 ADA House of Delegates referred to internal agencies two resolutions that seek to define “curriculum integrated format of an initial clinical licensure exam.”  The ADA agencies will report to the 2007 House of Delegates.

• Post-graduate year (PGY-1):  Licensure applicants who complete one year of a CODA-accredited advanced education in general dentistry program (AEGD) program or general practice residency (GPR) after January 1, 2007 may be licensed in California.  California follows the states of New York, Minnesota, and Connecticut which also offer licensure through this pathway.  Other states may allow completion of specialty residency programs to qualify for licensure.  The Dental Board is in the process of adopting regulations to implement the provisions of CDA-sponsored SB 683 which allowed this new licensure pathway.

• Objective, structured clinical examination (OSCE):  The objective, structured clinical examination has been used in Canada since 1994, and it does not use live patients.  It is a timed, station examination.  Candidates have to review the information supplied (e.g., case history, photographs, radiographs, casts, models) and answer multiple-choice questions or write a prescription.  OSCE exams are being used more frequently in medical schools and other health care fields in the U.S.  The U.S. Medical Licensing Exam Step 2 Clinical Skills exam, for example, is an OSCE.

• Portfolio:  This system is used extensively in postdoctoral general dentistry programs and for board certification by the dental specialties.  It is not currently used for initial dental licensure.

CDA adopted policy in 2005 that supports elimination of human subjects/patients in the clinical licensure process with the exception of alternative methods of licensure examinations that are carried out within the dental schools’ curricula.  The association also supports the concept of a national clinical licensure exam with the following as objectives for an ideal exam:

• Be an activity involving an independent party within the educational process.
  
• Allow for assessment of the full continuum of a candidate’s competence.
  
• Instill public confidence.
  
• Evaluate candidate competence within the context of a treatment plan that meets the patient’s needs.
  
• Provide valid data for outcomes assessments as required by the accreditation process.
  
• Be provided at a reasonable cost to the applicant. 
  
• Psychometrically valid and relevant to current dental practice.
  
• Policies and procedures treat candidates fairly and professionally, and ensure timely and complete communication of exam logistics and results.
  
• Eliminates circumstances that allow commercial procurement of exam patients.
  
• If patients are used, processes exist to ensure their safety and protection.
  
• Regular calibration and consistent implementation.
  
• Allows for remediation at candidate’s school.

CDA continues to seek cooperative dialogue with the dental schools and the Dental Board to implement a valid licensure-at-graduation process and to pursue pilot testing of exam models.  Progress on these efforts is reported annually to the House of Delegates.

Resources

American Association of Dental Examiners -- http://www.aadexam.org/
American Dental Association. Topic Index: Licensure -- http://www.ada.org/prof/prac/licensure/index.asp
California Dental Association summary reports of Dental Board meetings – http://www.cda.org
California Dental Board – http://www.dbc.ca.gov/
National Dental Examining Board of Canada -- http://www.ndeb.ca/
North East Regional Board -- http://www.nerb.org/
Western Regional Examining Board --  http://www.wreb.org/     

December 2006