Skeptic Turned Supporter: Why I Now Accept the Non-patient Licensure Exam

Skeptic Turned Supporter:

Why I Now Accept the Non-patient Licensure Exam

By David F. Boden, DDS, M.S., FDA President

The debate between patient-based and non-patient-based dental licensure exams has been one of the most controversial topics in dentistry. Many of you know that I do not avoid controversy when principles are involved, and I was right in the middle of this one. Nevertheless, as professionals we should be open to changing our minds when facts lead our way. Let me guide you down my path toward change with a little history.

What is the Purpose of a Licensure Exam?

The sole purpose of licensure by the state is to ensure grantees are as safe as possible to treat Floridians by:

p being at least minimally competent.

p having met certain didactic and clinical standards tested by standardized examination.

p having no criminal record.

Does the Florida Clinical Examination Require a Patient?

For now, yes. The only examination accepted by Florida statute is the American Dental Licensing Examination (ADEX) as administered by the Commission on Dental Competency Assessments (CDCA). The same statute requires certain clinical procedures prescribing certain restorations and periodontal procedures be “on a live patient.” As a state law and not a rule, this is not amendable by the Florida Board of Dentistry (BOD).

Is this Going to Change?

Short answer, likely … probably this year. Again, this is not under control of the Florida Dental Association (FDA) or even the BOD, but each can make recommendations. Bills have been introduced into the Florida Legislature to change the statute to an examination developed by ADEX that does not require a “live patient.”

So, why the change?

History

Dental licensure examination has been required since the enactment of the first Florida dental law by the state dental legislature in 1887 at the behest of the Florida State Dental Society. There has been a long history of legislation affecting the Dental Practice Act, but in general, the requirement of examination by the Board of Dental Examiners has continued.

In 2011, Things Changed

The Florida examination, administered by the Northeast Regional Board (NERB) became nearly identical to the examination given by ADEX in other states. There was a potential lawsuit by a dentist in Illinois who had taken the ADEX exam in Illinois claiming unnecessary restraint of trade by Florida.

After much negotiation with the FDA, the BOD and the Florida Legislature, the statute was changed to today’s iteration. Florida joined the 46 states using ADEX, gained a seat on the ADEX

Board and the Florida examination became the ADEX exam. Candidates could now take the ADEX anywhere it was offered, providing all the modules were included.

Worries regarding a flood of dentists relocating to Florida became unfounded, as only nine dentists reportedly took immediate advantage of the change.

In 2020, Everything Changed

Due to the COVID-19 pandemic, the governor ordered practices and universities closed, eliminating the possibility of administering a patient-based examination.

The race was already on to develop a non-patient-based exam due to a push from the American Dental Association (ADA) House of Delegates to eliminate patient-based exams since 2018.

Canada was using an Objective Structured Competency Examination (OSCE), which I observed, for many years. But they had less than a dozen schools with highly standardized national curricula, whereas the U.S. had, at that time, more than 60 schools with widely differing curricula, varied teaching methods and an accreditation standard that had to encompass all those variations.

The ADA accelerated its own version of this type of exam, called the Dental Licensure Objective Structured Clinical Examination (DLOSCE) that did not require patients or mannikins. I was able to observe parts of the development of the ADA DLOSCE while a member of the ADA Council on Dental Education and Licensure, but full observation of it was shrouded in secrecy and almost all permission for observation was denied.

Meanwhile, the CDCA (the successor to the NERB) already had an OSCE examination and was concluding a three-year development of a mannikin operative dentistry tooth model, called Compedont™. I also was able to observe this and noted a very close resemblance to enamel, dentin and caries textures and hardness; there were several variations of the test lesions. DLOSCE and CDCA Compedont™ were both offered to boards of dentistry throughout the country. DLOSCE, a very elegantly constructed examination, gained a handful of states. The CDCA’s OSCE and Compedont™ had the advantage of existing massive market penetration and rapidly gained large acceptance.

A Crisis Answered

Because the patient-based examination in Florida was required by statute, the only option was for the governor to proclaim an emergency order temporarilysetting aside the words “live patient” in the statute and permitting the BOD to administer a non-patient-based examination. This was done with the FDA’s support. It was extended several times, permitting dental candidates to gain licenses during a health crisis.

The Florida BOD only accepted the CDCA Compedont™ model because they wanted a manikin module, and the statutes already required the ADEX examination as administered by the CDCA.

The Case for a Change

All dentists are surgeons, using mental, somatosensory and manual skills to a high degree to perform microsurgical procedures in a difficult environment. William J. Geis, considered the founder of modern dental education, wrote the famous landmark Geis Report for the ADA in 1926:

“… but even if he knew all about dentistry and yet were unable to do effectually its essential tasks, the award to him of a license, the board’s certificate of professional proficiency and acceptability as a practitioner, would be indefensible.”

The variations of Compedont™ caries force candidates to make clinical decisions more typical in practice, rather than minimal carious lesions sought in patients for examinations. t

The CDCA’s OSCE and Compedont™ had the advantage of existing massive market penetration and rapidly gained large acceptance.

The non-patient-based CDCA Compedont™ exam has now been administered by ADEX several times by dental schools in Florida and throughout the country. The feedback by student candidates, some at the institution where I teach (Nova Southeastern University College of Dental Medicine), has been positive, but more telling are the comments from some of the candidates who have taken both the patient-based and this examination. In each case, the candidates said the new examination was significantly more challenging due to the tooth caries variations.

The actual patient-based examination itself has been studied and declared ethical several times by the ADA Council on Ethics, Bylaws and Judicial Affairs. As past chair, I oversaw one of these debates. However, the lack of patient contact eliminates the truly unethical temptations for pre-examination patient brokering by candidates as well as patient extortion of candidates.

My Change

I was truly a vociferous skeptic to the end regarding the efficacy and validity of a non-patient examination. I had many debates. Early proponents were highly emotional but had few facts to back their arguments. However, we now have data from three iterations of this exam right here in Florida in addition to the exams given in other states and can make factbased decisions. The conclusion is that the ADEX/CDCA OSCE/ Compedont™ examination psychometrics demonstrated at the very least an equivalency to the current patient-based examination that could not be denied. It is with this knowledge that the FDA Board of Trustees and the FDA House of Delegates support the change to the non-patient-based examination for our state of Florida, and support the bills recently filed with the Florida Legislature.

Although you, our member readers, may not have seen this data, it is compelling, and it is my hope that you trust that your FDA delegates and officers have debated this decision at great length and reached a strong consensus. If you would like additional information, I am always happy to speak with you. Or you can reach out to FDA Director of Third Party Payer and Professional Affairs Casey Stoutamire. My email is dboden@ bot.floridadental.org and Ms. Stoutamire can be reached at cstoutamire@floridadental.org or 850.350.7202.

Let it be known that, once again, you can be proud Florida and the FDA lead the way.

Photos:

Courtesy of CDCA-WREB

Sources:

https://floridasdentistry.gov/licensing/dentist/#tab-statutes-rules

https://floridasdentistry.gov/licensing/

High Fidelity Restorative Compedont™ Human Tooth Simulation, Clinical Performance and Psychometric Statistical Evaluation, A Non-Patient Alternative (Presentation by Dr. Guy Shampaine, CDCA, presented to the FDA House of Delegates Jan. 23, 2021)

“One Hundred Years of Dentistry in Florida,” Dr. Robert Thoburn

Private communications, ADA CDEL, ADA CEBJA, The National Dental Examining Board of Canada, and of course, Dr. James Antoon