Questions regarding the ethics of using patients as part of the dental and dental hygiene licensure examination process have plagued our professions for decades. Most national dental and dental hygiene associations have long-standing policies calling for the elimination of the patient-based exam once a viable alternative exists. Over the past several years, valid and reliable alternatives to the patient-based examination have emerged and proven successful. As such, now is the time to permanently eliminate the patient-based examination from state practice acts.
The paramount concern about single-encounter patient-based examinations is that they violate the ethical principles of patient care and the codes of ethics for dentistry and dental hygiene. Additional questions exist about their validity in accurately measuring competency and readiness for practice and their consistency in this measurement. In response to these concerns, three major dental associations, the American Dental Association (ADA), the American Dental Education Association (ADEA), and the American Student Dental Association (ASDA) joined forces in 2018 to create the Task Force on Assessment for Readiness for Practice (TARP). This collaborative effort resulted in the Report of the Task Force on Assessment of Readiness for Practice which advocated for advancements in the licensure process, the elimination of patient-based exams, and greater portability for licensed dentists and dental hygienists across the United States.
The TARP report led to the formation of the Coalition for Modernizing Dental Licensure (CMDL). These three associations were subsequently joined by the American Dental Hygienists’ Association (ADHA) in 2024, and together represent more than four hundred thousand dental professionals. The Coalition now has 130 partner organizations, all supporting the CMDL’s primary goals of adopting valid, reliable, and ethical pathways that demonstrate the professional knowledge and competence needed for licensure and improving access to care and professional mobility by advocating for increased portability of licensure for dentists and dental hygienists.
In 2023, the CMDL commissioned a formal literature review on the ethics of patient-based licensure exams. The literature was scanned for both evidence-based publications and opinion-based articles meeting established criteria. The results published in this issue of the Journal of Dental Hygiene were revealing. From an initial list of over 380 articles, twenty-nine endpoint publications were identified, the first appearing in 1985. An overwhelming majority of these articles expressed concern about patient-based licensure examinations, citing the core ethical principles of beneficence, autonomy, justice, and maleficence. Almost three-quarters of the articles recommended the elimination of patient-based licensure examinations.
Working together, the Coalition has contributed to the significant progress in licensure regulation that has been witnessed over the last five years. These efforts were accelerated, in part, by the COVID-19 pandemic, which made it difficult, if not impossible, for testing agencies to conduct patient-based licensure examinations. As often happens, change and innovation were driven by a combination of good intention, adversity, and necessity. With impressive agility and resolve, state boards responded by approving changes that demonstrated the following: viable alternatives to patient-based assessments exist and are deployable; they are as useful or better than previous methods in assessing the competency of candidates and their readiness for practice; and the long-held assertion that patient-based examinations are irreplaceable even in face of their ethical shortcomings can be finally dismissed. These were all significant breakthroughs in the licensure testing stalemate.
State dental boards across the country are to be commended for their forward-thinking actions. Currently, a majority of states have replaced patient-based examinations with simulated patient examinations or Objective Structured Clinical Examinations (OSCE) formats as pathways to licensure. Some state dental boards have declared these changes permanent while others have not. The state of Connecticut, for example, has removed the requirement to pass a patient-based examination from its dental statutes, replacing it with language prohibiting this method. Other states have taken regulatory steps to no longer require this type of examination. However, relative to dental practice, fourteen states maintain statutes or regulations that recognize patient-based examinations as a legitimate method to attain initial licensure and the state of Delaware retains it as a specific requirement for licensure. Given the evidence of valid and judicious alternative pathways to licensure, the continued recognition of an unprofessional and unreliable approach is confounding at best.
The CMDL believes the time has come to prohibit patient-based examinations for initial dental licensure. Our professions are demanding it and the public deserves it. The CMDL executive committee believes it is time to unequivocally state that “Patient-based licensure exams are unethical and must stop.” Those states that still retain language in their practice acts or regulations that describe the requirement of a patient-based exam should expeditiously remove this unethical anachronism from the story of our great professions.
This guest commentary is appearing in the journals of the four major associations supporting the CMDL and its goals. We ask members of American Dental Hygienists’ Association to actively support an end to patient-based examinations for dental and dental hygiene licensure. Please consider making your opinion known to your state association, your state dental/dental hygiene board or commission, your state’s licensing authority, and elected representatives to your state legislature. Your voice is important.
It’s time.
Signed,
Joseph P. Crowley, DDS
CMDL Executive Committee Chair, ADA appointee
Cecile A. Feldman, DMD, MBA
CMDL Executive Committee, ADEA appointee
JoAnn R. Gurenlian, RDH, MS, PhD, AAFAAOM, FADHA
CMDL Executive Committee, ADHA appointee
Paul R. Logan
CMDL Executive Committee, At-large member
Roderick L. (Monty) MacNeil, DDS, MDentSc
CMDL Executive Committee, ADEA appointee
Kathleen E. Murphy, MSW, PhD, MLIS
CMDL Executive Committee, Public member
Shafa A. Nathani, DMD
CMDL Executive Committee, ASDA appointee
Kirk M. Norbo, DMD
CMDL Executive Committee, ADA appointee
Samarth P. Setru
CMDL Executive Committee, ASDA appointee
Corresponding author:
Joseph P. Crowley, DDS,
CMDL Executive Committee Chair;
info{at}dentallicensure.org
- Copyright © 2024 The American Dental Hygienists’ Association
REFERENCES
- 1.
- 2.
