A Snapshot of Dental Licensure: California and the United States

Alan L. Felsenfeld, MA, DDS, and Nader A. Nadershahi, DDS, MBA, EdD

ABSTRACT Obtaining a dental license in California and the rest of the U.S. has been evolving in the mechanisms employed to ascertain competence. This article provides an overview of the history of licensure in California and a discussion of the various ways that one can be licensed to practice today. National licensure trends and discussion of potential future modalities are presented.

The second hurdle is getting through dental school. For those of us who found the academic requisites easy in college, the level of intensity was increased as we were required to learn in greater depth and with a vision of applying our knowledge and skills to patient care. Today, our students are inundated with more material in an ever-expanding foundation of education as we see expanding emphasis on interprofessional and medical-based patient evaluation, use of technological advances and materials in dental care, community and public health issues and an increased emphasis on person-centered care. Along with the basic, behavioral and clinical science academic requirements, the development of excellent hand skills is a critical component of education that may come easy to some but create a struggle for others.

The third hurdle, and arguably the most important to allow us to practice dentistry, is obtaining a license issued by the Dental Board of California or whichever state you choose for your practice career. Over the years, this has taken on a new meaning as singlestate, board administered, patient-based examinations are rapidly becoming a thing of the past and alternate means of licensure are the norm in most states.

This article is not science. While we feel that it is a contemporary compilation of current practices for licensure across the country, some may argue this is an op-ed piece. The landscape for licensure of dentists is a dynamic and at times politically charged process and continues to change and evolve for various states, including California, on a regular and rapid basis. With this disclaimer and with the understanding that the data presented may not be entirely accurate by the time it is published, let us explore licensure in California and the nation.

In the 1926 report “Dental Education in the United States and Canada, a Report to the Carnegie Foundation for the Advancement of Teaching,” Dr. William Gies surveyed the landscape of dental education in North America and made several recommendations that are as salient today as they were over 90 years ago. One such recommendation was to create a national licensure examination that would allow for interstate movement of licensees. The three-part examination recommended by Dr. Gies evolved into our current national board examination (which recently integrated its two parts into one) and the state or regional licensure examinations. [1]

Dental Board of California Examination

In 1885, the California legislature created the Board of Dental Examiners to regulate the practice of dentistry. Over time, its responsibilities grew to include allied dental staff as well. [2]

California Business and Professions Code Section 1601.2 articulates the charge to the board in the following: “Protection of the public shall be the highest priority for the Dental Board of California in exercising its licensing, regulatory and disciplinary functions. Whenever the protection of the public is inconsistent with other interests sought to be promoted, the protection of the public shall be paramount.” [3]

If one considers that most of the dentists who are either retired or close to that stage of life have been practicing for 40 to 50 years, we can start our journey with that group. The Dental Board of California is charged with protecting the public in the provision of dental care by dental practitioners as noted above. Part of that process is the licensing of dentists to practice. For many years, the board had its own examination with designated examiners that administered it at various times of the year in the dental schools. This was the only way one could obtain a license to practice in our state. In its earliest form, the exam consisted of a written treatment planning section, Class II amalgam, Class II, III or V gold foil, crown preparation on a typodont and setting denture teeth on an articulator.

Over the years, the board recognized that a better examination would be in the best interest of protecting patients by testing on the practice of dentistry, not on a theoretical construct. The gold foil was eliminated and periodontal treatment was incorporated. Gone also was the denture set up. The revised examination was given for many years.

Despite these changes, there were a number of concerns with this freestanding examination administered after completion of dental school competency examinations. It was a high-pressure, high-stakes examination that may not have been totally relevant to practice even with the changes that were made. Many concerning reports have been raised over the years, such as patient brokering at the time of examination by outside agencies that stockpiled patients with ideal lesions for testing and sold them to candidates at high fees in an unethical environment. Little concern was given to patient followup if the restoration was judged to be substandard resulting in a failing grade to the candidate. Finally, although there are reports of evaluations, there has been little released psychometric information on the validity and reliability of the examination.

Student Political Activities

The American Student Dental Association (ASDA) recognized the problems with the use of human subjects in freestanding postgraduate licensing examinations. In 2000 and again in 2005, they proposed a resolution at the American Dental Association House of Delegates philosophically suggesting that human subjects not be used in licensing examinations after graduation. While the policy was accepted, no specific changes occurred within the examination community.

Similarly, the student delegation to the California Dental Association (CDA) brought forth resolutions that changed policies and reaffirmed the ASDA resolutions in 2001 and 2005. No examination changes were made in either year.

Transitions

Over the course of time, several alterations to the licensing process were developed by the board in response to prior actions of different groups within dentistry. The changes were in response to an evolution of the different modes of assuring that dentists who practiced in California were competent. The ability to introduce a new system of verification of competency for dentists who wished to practice in California is complex with many statutory and regulatory steps. At a minimum, new means of licensure must be based on an occupational analysis of the realistic functions of a professional and the ability of any means of examination testing those specific functions. Beyond that, there is the need for statutory changes that can be time-consuming. This is followed by the development of regulatory packages that potentially could take one or two years to be completed.

In addition to the traditional licensure examination described above, a number of different mechanisms for licensure have been proposed and completed to allow dental licensure based on varying mechanisms for assuring competency.

Licensure by Credential

Generally, licensure by credential implies that once a dentist has practiced in another state with a clean record for a prescribed period of time, they may apply for licensure in another jurisdiction. In 2003, legislation was enacted that allowed a dentist licensed in another state to apply for license in California without taking the Dental Board of California practical examination. There were a number of criteria that had to be met. The dentist had to be in active clinical practice or a full-time faculty member for a minimum of five years in the last seven and have an unrestricted license, a satisfactory National Practitioner Data Bank review, fingerprint clearance and sufficient continuing education credits. [4]

Additional legislation to modify this pathway was enacted in 2006 to allow licensure for individuals who had two-year contracts for full-time academic positions or to practice in a federally qualified health center (FQHC) without any restriction of time in practice in a prior state. [5]

In essence, licensure by credential permits the state of California to grant a license to any dentist from any other state regardless of the means of initial licensure if they come to California by credential in either the five-year or zero-year formats as long as all the requirements are met.

Licensure by Residency (PGY-1)

By 2007, legislation was enacted that allowed the board to begin issuing licenses by residency to dentists who completed at least one additional year of clinical training after graduating from an approved dental school without taking a clinical examination.

There were a number of requirements for the postgraduate year one (PGY-1) process. These included completing a one-year general practice or advanced education in general practice residency that is approved by the Commission on Dental Accreditation (CODA). In addition, the applicant must be a graduate of a CODAaccredited or board-approved dental school. [6] The time period in California for obtaining licensure is two years following the completion of the residency. [7]

The issue of why all accredited residencies were not acceptable relates to the equivalency of skills a licensing examination measures. For example, a residency in orthodontics or oral and maxillofacial surgery does not assure that a graduate of that program has the skills to do what a general dental licensing examination tests. This is essential as California does not issue specialty licenses, as do some other states, but instead grants all licensed dentists the full scope of practice of a general dentist.

Nationally, New York requires applicants to complete an accredited postgraduate dental education program of at least one year in length for initial licensure in that state. California, Colorado, Connecticut, Minnesota and Ohio offer licensure applicants the option of PGY-1 and Washington has an option for PGY-1 completed in that state in specific settings. Delaware requires completion of a PGY-1 in addition to a state-specific clinical examination for initial licensure.

Curriculum Integrated Format Examinations

A Curriculum Integrated Format (CIF) examination tests dental students on state board determined competencies during the final year of dental school rather than during a one-time clinical examination that occurs after or just prior to completion of the dental school program. This testing format incorporates several important elements for patient protection including ensuring that on any given day at the dental school, patients receive care according to their comprehensive dental care needs rather than a student’s examination requirements. Patients have access to ongoing, comprehensive care, emergency care and follow-up care as needed. Several national testing agencies described below offer a CIF format, including the Central Regional Dental Testing Agency (CRDTS), the Council of Interstate Testing Agencies (CITA), the Commission on Dental Competency Assessments (CDCA), the Southern Regional Testing Agency (SRTA) and the American Board of Dental Examiners (ADEX) examinations. California’s Hybrid Portfolio Examination uses a CIF format.

California Hybrid Portfolio Examination

The hybrid portfolio pathway to licensure, which is essentially a CIF examination, came about as a collaboration of representatives from the Dental Board of California, California-based dental schools and CDA with support from a psychometrics consulting team selected by the board. The goal of this group was to produce an examination that was relevant to the practice of dentistry while decreasing or eliminating the negative aspects of the existing examinations. The group met numerous times over several years to develop this pathway.

Assembly Bill 1524, enacted in 2010, enabled licensure candidates to assemble a portfolio of board-approved, predetermined clinical experiences and competencies during the course of comprehensive care for patients of record while completing a dental school program in California. After the applicant passes a final competency assessment of the submitted “portfolio” at the end of their dental school program, a dental license is issued without additional examination.

Each student who uses the portfolio licensure track needs to develop a minimum number of clinical experiences in six areas of education. Within the curriculum, students are required to take competency examinations given by calibrated faculty approved by the board as examiners. The final competency examination can be used for licensing as well as graduation. When a student has completed all of these experiences and competencies, they are granted a license after final board approval to practice upon graduation. [8]

Exam Development Agency

While not a regional testing agency, the ADEX is an organization of state boards. ADEX develops clinical dental licensure examinations to the specifications of its client states. It does not administer them. Currently, the regional testing agencies that administer the ADEX examination are the CDCA and CITA discussed below. ADEX exams are accepted in 45 states. [9]

ADEX was the most recently added licensure pathway in California, authorized in 2016 by AB 2331 and approved by the board in 2019. Prior to board approval, the ADEX exam underwent an occupational analysis and a psychometric evaluation and was determined to be in compliance with the requirements of Business and Professions Code Section 139. Candidates who initiate and successfully pass the ADEX examination on or after Nov. 15, 2019, may use those results within five years prior to the date of application for California licensure. [10]

Regional Testing Agencies

Regional testing agencies are commercial, usually nonprofit, organizations that are established to administer an examination for licensing of dentists in the states that subscribe or allow their agencies to act on their behalf. These testing agencies must meet the requirements of the states for licensure whether by adapting an examination to the state legislated needs or by having the state develop enabling legislation to accept the examination that the agency administers. These examinations, being acceptable in many states, support licensure portability as an applicant who passes the examination of a regional testing agency is eligible to obtain licensure in a multitude of states.

Thirty-one states accept all regional examinations for licensure, with possible modifications on a state-by-state basis. Only two states, New York and Delaware, accept no regional testing agency examination and require a PGY-1 or another form of examination for licensure. Three states accept only one of the examinations and six states only accept the two ADEX written examinations (CDCA and CITA). The CDCA and Western Regional Examining Board (WREB) have the largest acceptance with 45 and 38 states allowing their examinations respectively.

Listed below is a compilation of regional testing agencies that currently examine dentists (and hygienists in some jurisdictions) for state dental licensure. Information was obtained from organizational websites that may be referenced if greater depth of knowledge is needed.

Western Regional Examining Board

The WREB (wreb.org) was incorporated in 1976 and is an acceptable examination in 38 states. The WREB examination was the first examination to be allowed as a means of reciprocity for California and has been acceptable in California since 2005. [11]

Commission on Dental Competency Assessments

Formerly known as the Northeast Regional Board of Dental Examiners (NERB), the CDCA (cdcaexams.org) was founded in 1969 to facilitate the licensure process for candidates and eliminate the need for repetition of state board clinical examinations. The CDCA is a nonprofit, independent corporation comprised of a consortium of 29 state and international dental boards.

The CDCA offers an ADEX-prepared examination in 45 states. CDCA offers the traditional and the CIF of the ADEX licensure examination. [12]

TABLE Number of California Licenses Issued as Percent of Total Licenses Issued SEE TABLE IN THE FULL ISSIE OF THE JOURNAL

Central Regional Dental Testing Service

The CRDTS (crdts.org) is a testing service made up of 21 state boards of dentistry that have joined forces to develop and administer fair, valid and reliable examinations of competency to practice dentistry and dental hygiene.

The members of the CRDTS are the state boards of Alabama, Arkansas, California, Georgia, Hawaii, Illinois, Iowa, Kansas, Minnesota, Missouri, Nebraska, New Mexico, North Dakota, South Carolina, South Dakota, Texas, Washington, West Virginia, Wisconsin and Wyoming. Forty-one states accept the CRDTS examination for dental licensure. [13]

Southern Regional Testing Agency

The SRTA (srta.org) has been in existence since 1975 and administers its own examination that is currently accepted by 34 states. The member states include Arkansas, Alabama, South Carolina, Tennessee, Virginia and West Virginia. [14]

Council of Interstate Testing Agencies

The CITA (citaexam.com) is a nonprofit corporation that was founded in 2005. It is an independent regional testing agency that administers an ADEX-developed dental clinical licensure examination at various testing sites. The organization has eight member jurisdictions: Alabama, Louisiana, North Carolina, Puerto Rico, the U.S. Virgin Islands, West Virginia, Arkansas and Utah. Forty-two states accept the CITA examination for dental licensure. [15] Current Licensure Status in California

The only option for obtaining a dental license in California 40 or 50 years ago was the Dental Board of California licensing examination. Today, an individual who wants to practice in California has six options that are acceptable and being used. The TABLE shows the total numbers of California licenses issued within the last three years and as a percent of the total number of all issued licenses. It is important to understand that these numbers are relatively labile and the percentage of dentists licensed through the various pathways will be increasing within each pathway for many years. As noted above, the ADEX examinations (CDCA and CITA) are acceptable for initial licensure in California if passed after Nov. 15, 2019. Additionally, changes in licensure being evaluated nationally are being monitored and reviewed closely by leaders of the board, CDA and the schools of dentistry.

Current National Discussions

There is a discussion within the profession, including the examining community, organized dentistry and dental education, for a national examination that meets the ethical examination and portability values adopted by the American Dental Association (ADA), CDA, the American Dental Education Association (ADEA) and ASDA. However, other than the CIF and hybrid portfolio, the examination currently administered by many of the regional testing agencies uses the traditional one-time human subject format with outside examiners coming into dental school testing sites periodically to administer the exam, disrupting school operation and, more important, comprehensive care for subject patients.

An additional licensure examination format that has been used successfully in Canada for many years and is gaining national attention in the U.S. is the Objective Structured Clinical Examination (OSCE). This examination is comprised of a series of short, timed stations or visual cues and is designed to assess the application of knowledge, rather than the recall of it. Examination questions are based on models, radiographs, casts and case histories and candidates respond objectively. Many stations have four questions and candidates typically have five minutes to review the information supplied and answer multiple-choice questions or write a prescription. Other stations require the candidate to review the information supplied and answer extended match-type questions. This examination methodology is considered an improvement over traditional exams because stations are standardized, enabling fair comparison of candidate performance.

In February 2017, the ADA Board of Trustees approved the development of an OSCE-type examination — the Dental Licensure Objective Structured Clinical Examination (DLOSCE) — that evaluates clinical and critical thinking skills. The board directed that a pilot of the examination be available in 2019 with an anticipated examination deployment in 2020. The ADA’s eventual objective is for the DLOSCE to serve as an additional pathway to licensure in every state. More about the DLOSCE is found on page 331.

Also, at the national level is the development of the Compendium of Clinical Competency Assessment for dental licensure. The result of an ADA, ADEA and ASDA 2018 report from the Task Force on Readiness for Practice, the compendium builds off of the California Hybrid Portfolio/Curriculum Integrated Format approach, providing a structure to assess psychomotor skills and patient care knowledge in the main domains of clinical dental practice (e.g., diagnosis and treatment planning, restoration of teeth, replacement of teeth, periodontics and endodontics). The compendium is also structured to support licensure portability across all licensing jurisdictions that use the model. (More about the Compendium is found on page 321.)

Further, ADA, ADEA and ASDA have joined forces to form the Coalition for Modernizing Dental Licensure. [16] Launched in October 2019 at the ADA headquarters, the coalition has two key goals: replacing the single-encounter, procedure-based patient exams with clinical assessments that have stronger validity and reliability evidence and increasing the portability of dental licensure among all states for the benefit of both the public and the profession. The coalition began as a 35-member organization and continues to grow.

Conclusion

There is much discussion and progress in dental licensure to ensure the development of a licensure process that allows for assessment of candidate competency for entry-level practice and a national system that supports portability. As these discussions continue, we are confident that there is a pathway forward for the many well-intentioned, ethical and caring members of our examining community, organized dentistry, dental educators and dental students to come together and create a sustainable licensure system for the practice of oral health care. Perhaps we are finally prepared to realize the recommendation for the national licensure examination put forth over 90 years ago in the Gies Report. California is certainly willing to participate and help lead that conversation.

The following appendix supports the discussion in this manuscript.

APPENDIX

Excerpt from CDA Licensure Examination Policies

Resolution #10S1-2005

Resolved, to rescind resolution 28-2001-H, and be it further Resolved, that CDA support the elimination of human subjects/ patients in the clinical licensure examination process with the exception of alternative methods of licensure examinations that are carried out within the dental schools’ curricula, and be it further

Resolved, that CDA support the concept of a national clinical licensure exam, and be it further

Resolved, that CDA approve the components of the “ADA report of the task force on the role of patient-based examinations (2002),”** as well as the “characteristics of an ideal national clinical licensure exam”*** as objectives for an ideal national clinical licensure exam.

“ADA REPORT OF THE TASK FORCE ON THE ROLE OF PATIENT-BASED EXAMINATIONS (2002): An ideal clinical licensure examination process should:

■ 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.

■ 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.

“CHARACTERISTICS OF AN IDEAL NATIONAL CLINICAL LICENSURE EXAM”

■ 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.

Excerpt from ADA Current Policies

Eliminating Use of Patients in Board Examinations (Trans.2005:336; 2013:351)

Resolved, that dental students providing patient care under the direct and/or indirect supervision of qualified faculty is an essential method of learning clinical skills including the ability to manage the anxieties, fears, reflexes and other emotions related to dental treatment, and be it further

Resolved, that the Association recognizes that ethical considerations, including those identified in the ADA Council on Ethics, Bylaws and Judicial Affairs statement entitled Ethical Considerations When Using Patients in the Examination Process (Annual Reports and Resolutions 2008:103), may arise from the use of patients in the clinical licensure examination process, even though the clinical examination process is itself ethical, and be it further

Resolved, that the ADA supports the elimination of patients in the clinical licensure examination process with the exception of the curriculum integrated format, as defined by the ADA, within dental schools, and be it further

Resolved, that the Association encourages all states to adopt methodologies for licensure that are consistent with this policy.

Definition of Curriculum Integrated Format (Trans.2007:389)

Resolved, that the American Dental Association adopt the following definition:

Curriculum Integrated Format: An initial clinical licensure process that provides candidates an opportunity to successfully complete an independent “third party” clinical assessment prior to graduation from a dental education program accredited by the ADA Commission on Dental Accreditation.

If such a process includes patient care as part of the assessment, it should be performed by candidates on patients of record, whenever possible, within an appropriately sequenced treatment plan. The competencies assessed by the clinical examining agency should be selected components of current dental education program curricula.

All portions of this assessment are available at multiple times within each institution during dental school to ensure that patient care is accomplished within an appropriate treatment plan and to allow candidates to remediate and retake any portions of the assessment which they have not successfully completed.

Excerpt from ADEA Policy Statements:

Recommendations and Guidelines for Academic Dental Institutions (With changes approved by the 2015 ADEA House of Delegates) III. Licensure and Certification

A. Goals. ADEA supports achievement of the following goals for dentists and dental hygienists who are students or graduates of accredited programs and have successfully completed the National Board Dental Examination or the National Board Dental Hygiene Examination: freedom in geographic mobility; elimination of those licensure and regulatory barriers that restrict access to care; elimination of the use of patients in clinical examinations; and high reliability of any licensure examination process and content as well as predictive validity of information used by licensing authorities to make licensing decisions.

B. Live Patient Examination. By the year 2015, the live patient exam for dental licensure should be eliminated, and all states should offer methods of licensure in dentistry that include advanced education of at least one year, portfolio assessment, and/ or other nonlive patient-based methods and include independent third-party assessment.

Excerpt from ASDA Initial Licensure Pathways (revised 1998, 2001, 2002, 2005, 2013, 2016) Policy Number: L-1 Policy Category:

Licensure ASDA understands alternatives that are preferable to the current process exist, however the Association believes an ideal licensure exam:

■ Does not use human subjects in a live clinical testing scenario

■ Is psychometrically valid and reliable in its assessment

■ Is reflective of the scope of current dental practice

■ Is universally accepted The American Student Dental Association (ASDA) believes demonstration of both kinesthetic and clinical decision-making competence is necessary to obtain initial dental licensure. ASDA believes this should be demonstrated through the following:

■ Manikin-based kinesthetic assessment,

■ A non-patient based Objective Structured Clinical Examination (OSCE) Submission of a portfolio of comprehensive patient care.

Additional CDA resources

LINKS TO RESOURCES IN THE FULL ISSUE OF THE JOURNAL

Licensure and Continuing Education

CDA Journal July 2017: Ignorance is no excuse: understand the limits of licensure

CDA Journal July 2019: The cost of not practicing safely: Perspectives in the legal profession

REFERENCES

1. Gies WJ. Dental education in the United States and Canada: A report to the Carnegie Foundation for the advancement of teaching. New York: Carnegie Foundation; 1926.

2. Dental Board of California Sunset Review Report 2014. www.dbc.ca.gov/about_us/meetings/materials/draft_ sunset.pdf.

3. Business and Professions Code § 1601.2.

4. Business and Professions Code § 1635.5.

5. Business and Professions Code § 1635.5.

6. Business and Professions Code § 1634.1.

7. Business and Professions Code § 1634.1(c). 8. Business and Professions Code §1632.1 et seq.

.9. American Board of Dental Examiners. adexexams.org.

10. Business and Professions Code § 1632(c)(2)(B).

11. History of WREB. wreb.org/about-us.

12. The Commission on Dental Competency Assessments. www.cdcaexams.org/.

13. Central Regional Dental Testing. www.crdts.org/.

14. Southern Regional Testing Agency. srta.org.

15. Council of Interstate Testing Agencies. www.citaexam.com/.

16. American Dental Association. Coalition focused on dental licensure reform holds inaugural meeting. https:// www.ada.org/en/publications/ada-news/2019-archive/ october/coalition-focused-on-dental-licensure-reform-holdsinaugural-meeting.

THE CORRESPONDING AUTHOR, Alan L. Felsenfeld, MA, DDS, can be reached at felsenfeld814@gmail.com.

AUTHORS

Alan L. Felsenfeld, MA, DDS, is a member of the Dental Board of California. He was a professor of oral and maxillofacial surgery at the University of California, Los Angeles, School of Dentistry and the California Dental Association liaison to the dental board. Conflict of Interest Disclosure: None reported.

Nader Nadershahi, DDS, MBA, is the dean of the University of the Pacific, Arthur A. Dugoni School of Dentistry. Conflict of Interest Disclosure: None reported.