Big Changes Proposed for Dental Licensure

Laird Harrison

October 08, 2018

Dental licensure exams should be standardized nationwide and no longer include live patients, three dental organizations have proposed.

The change, supported by the American Dental Association (ADA), the American Dental Education Association (ADEA), and the American Student Dental Association (ASDA), would allow dentists to more easily move across state lines and would dispense with an ineffective approach to testing students' competency, Cecile Feldman, DMD, MBA, dean of the Rutgers School of Dental Medicine in Newark, New Jersey, told Medscape Medical News.

"We've got much more reliable ways of showing that a student is ready," said Feldman, the co-chair of a task force that developed the recommendations and whose members were drawn from the three groups.

On October 1, the organizations announced the formation of a new coalition to push for the changes.

However, the proposal faces opposition from the American Association of Dental Boards (AADB), whose president, Luis Fujimoto, DMD, from New York, New York, maintains that a student's clinical competency should be evaluated by someone other than the student's professors.

For the change to occur, individual state dental boards would have to agree to the proposal, and in some states this might require legislation, according to Phillip Marucha, DMD, PhD, dean of the Oregon Health Sciences University School of Dentistry, Portland, who represented dental school deans on the task force.

State dental boards would maintain their role in granting licenses and would be likely to continue requiring that dentists show knowledge of state laws.

States could apply different methods by which students could demonstrate their clinical competence. But these methods would be applied similarly enough so that every state would recognize a license granted by any of the others.

Dentists would still be required to pass the National Board Dental Examination.

Live patient exams date back many decades to a time before dental education was standardized and before dental schools were all accredited, Marucha told Medscape Medical News.

But dental schools must now meet national standards, and this includes about 2500 hours spent treating live patients under the supervision of professors, Feldman said.

It should be sufficient that the professors attest to their students' competence with live patients, she argued . Yet nearly all states still require that students prove they can carry out particular procedures on live patients in front of state examiners, she said.

As they are currently administered, the live patient exams require a student to find a patient with the type of dental condition required by the student's state board. The patients vary, which creates inequality in the difficulty of the exams, Feldman said.

And the need to stop and show progress to examiners may draw out the length of the procedure. "A procedure that you might have been able to do in 45 minutes takes 3 hours," Feldman said. "So from a patient's standpoint, it's not ideal care."

Patients often charge students about $1000 for appearing at the exam, and some have extorted additional money from students at the last minute, knowing that if they leave the exam the student's licensure could be delayed for months, said Marucha. "There are things that happen during those live patient exams that are unethical."

Among the health professions, cosmetologists are the only other group still required to prove their competency with live patients, he said.

But Fujimoto said dispensing with the patient-based examinations could put the public at risk.

Dental professors cannot be trusted to verify their students' competency because they may develop bonds with their students and be invested in their students' success, he told Medscape Medical News. "It should be someone from outside the dental school who has an unbiased opinion."

In contrast to examinations that involve live patients in dental schools, the examinations by independent agencies are blinded, Fujimoto explained; students typically leave the room when the examiner comes to check on their work so they don't know which candidate treated which patient.

The task force's recommendations on portability would also make dentistry more similar to medical licensure.

Currently five regional testing agencies administer dental licensure examinations. Although the exams are similar, many states will not accept exam results from all these agencies. As a result, dentists who move to new states are sometimes required to take new exams. More than 10,000 dentists moved across state lines from 2011 to 2016, according to the ADA.

Fujimoto argues that trade associations such as the members of the task force should not drive standardization. The AABD is working on its own "mechanism to enhance mobility and portability," he said.

Instead of the patient-based exams by independent agencies, the task force proposes three alternatives:

  • An objective structured clinical examination (OSCE) consisting of multiple standardized stations presenting candidates with different tasks, such as reading radiographs, writing prescriptions, and working with simulated patients and haptic technology;

  • Graduation from an accredited residency of at least 1 year; and

  • Completion of a compilation of clinical competency assessments done in dental schools.

The latter system is offered in California; candidates there can present a portfolio of their work. "This portfolio process is wonderful and we'd love to see it adopted by other states," Sig Abelson, DDS, MACM, associate dean of clinical affairs at the University of the Pacific in San Francisco, California, told Medscape Medical News.

The task forces' proposal resulted from years of conversation, Feldman said. "This was a major landmark event, so we're very excited that this would happen."

Feldman, Marucha, and Abelson are faculty at dental schools. Fujimoto works for an organization representing dental boards.

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