CDA Journal - July 2020: Licensure

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ADEA Compendium Objective Structured Clinical Examinations Licensure by Portfolio

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July 2020

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d e pa r t m e n t s

305 The Associate Editor/The Pitter-Patter of CDA 307 Letter to the Editor 309 Impressions 345 RM Matters/Seeking Guidance and Finding Focus in Times of Distraction and Distress

351 Regulatory Compliance/Dispensing or Administering Controlled Substances? Know the Rules

355 Ethics/To Quadrant Dentistry or Not? 356 Tech Trends

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313 A Snapshot of Dental Licensure: California and the United States 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.

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

321 The ADEA Compendium of Clinical Competency Assessments: A Potential Pathway to Licensure This article discusses how the ADEA Compendium can serve as a transformative pathway to licensure.

Steven W. Friedrichsen, DDS

331 The Dental Licensure OSCE: A Modern Licensure Examination for Dentistry This article details the Joint Commission on National Dental Examinations’ development of objective structured clinical examinations (OSCEs) for dentistry.

Anthony J. Ziebert, DDS, MS, and David M. Waldschmidt, PhD

339 Licensure by Portfolio: Our Experience in Prospect and Retrospect In this manuscript, dentists from the Loma Linda University School of Dentistry document their experience conducting licensure-by-portfolio examinations.

Iris Nam, DDS; John Won, DDS, MS; Greg Olson, DDS, MSD; and Edwin L. Christiansen, DDS, PhD

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Journa C A L I F O R N I A

D E N TA L

published by the California Dental Association 1201 K St., 14th Floor Sacramento, CA 95814 800.232.7645 cda.org

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A S S O C I AT I O N

Management Peter A. DuBois Executive Director Carrie E. Gordon Chief Strategy Officer Kristine Allington Chief Marketing Officer Alicia Malaby Communications Director

Editorial

Judee Tippett-Whyte, DDS President-Elect presidentelect@cda.org

Kerry K. Carney, DDS, CDE Editor-in-Chief Kerry.Carney@cda.org

Ariane R. Terlet, DDS Vice President vicepresident@cda.org

Ruchi K. Sahota, DDS, CDE Associate Editor

John L. Blake, DDS Secretary secretary@cda.org Steven J. Kend, DDS Treasurer treasurer@cda.org Debra S. Finney, MS, DDS Speaker of the House speaker@cda.org

Volume 48 Number 7 July 2020

Brian K. Shue, DDS, CDE Associate Editor Gayle Mathe, RDH Senior Editor Andrea LaMattina, CDE Publications Manager Kristi Parker Johnson Senior Communications Specialist

Blake Ellington Tech Trends Editor

Manuscript Submissions

Journal of the California Dental Association Editorial Board

Jack F. Conley, DDS Editor Emeritus

www.editorialmanager. com/jcaldentassoc

Charles N. Bertolami, DDS, DMedSc, Herman Robert Fox dean, NYU College of Dentistry, New York

Robert E. Horseman, DDS Humorist Emeritus

Letters to the Editor

Steven W. Friedrichsen, DDS, professor and dean, Western University of Health Sciences College of Dental Medicine, Pomona, Calif.

Production Randi Taylor Senior Visual Designer

Upcoming Topics August/Health Literacy September/Ethics October/Sugar

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R. Del Brunner, DDS Immediate Past President pastpresident@cda.org

The Journal of the California Dental Association (ISSN 1043–2256) is published monthly by the California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950. The California Dental Association holds the copyright for all articles and artwork published herein.

Mina Habibian, DMD, MSc, PhD, associate professor of clinical dentistry, Herman Ostrow School of Dentistry of USC, Los Angeles Robert Handysides, DDS, dean and associate professor, department of endodontics, Loma Linda University School of Dentistry, Loma Linda, Calif.

Bradley Henson, DDS, PhD , associate dean for research and biomedical sciences and associate professor, Western University of Health Sciences College of Dental Medicine, Pomona, Calif.

Paul Krebsbach, DDS, PhD, dean and professor, section of periodontics, University of California, Los Angeles, School of Dentistry Jayanth Kumar, DDS, MPH, state dental director, Sacramento, Calif.

Lucinda J. Lyon, BSDH, DDS, EdD, associate dean, oral health education, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco Nader A. Nadershahi, DDS, MBA, EdD, dean, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco Francisco Ramos-Gomez, DDS, MS, MPH, professor, section of pediatric dentistry and director, UCLA Center for Children’s Oral Health, University of California, Los Angeles, School of Dentistry Michael Reddy, DMD, DMSc, dean, University of California, San Francisco, School of Dentistry

The Journal of the California Dental Association is published under the supervision of CDA’s editorial staff. Neither the editorial staff, the editor, nor the association are responsible for any expression of opinion or statement of fact, all of which are published solely on the authority of the author whose name is indicated. The association reserves the right to illustrate, reduce, revise or reject any manuscript submitted. Articles are considered for publication on condition that they are contributed solely to the Journal of the California Dental Association. The association does not assume liability for the content of advertisements, nor do advertisements constitute endorsement or approval of advertised products or services.

Avishai Sadan, DMD, dean, Herman Ostrow School of Dentistry of USC, Los Angeles

Copyright 2020 by the California Dental Association. All rights reserved.

Brian J. Swann, DDS, MPH, chief, oral health services, Cambridge Health Alliance; assistant professor, oral health policy and epidemiology, Harvard School of Dental Medicine, Boston

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Harold Slavkin, dean and professor emeritus, division of biomedical sciences, Center for Craniofacial Molecular Biology, Herman Ostrow School of Dentistry of USC, Los Angeles

Richard W. Valachovic, DMD, MPH, president emeritus, American Dental Education Association, Washington, D.C.

Assoc. Editor

C D A J O U R N A L , V O L 4 8 , Nº 7

The Pitter-Patter of CDA Ruchi K. Sahota, DDS, CDE

I

n a convocation address in 1959, President John F. Kennedy noted that in the Mandarin language, the word crisis is a combination of two characters: danger and opportunity. Over 60 years later, the COVID-19 pandemic has applied the brush strokes of this expression all over our world. We saw crisis. We saw danger. But in the days of the lockdown, confusion and ambiguity veiled a sense of opportunity.

I likened the pandemic’s shelter-inplace experience to my maternity leave five years ago. My schedule revolved around my little girl. I did not leave the house. I tried to be focused on resetting my goals for good nutrition and healthy activity. I tried to be productive. I tried to capitalize on the occasion of finally being home for an extended period of time. I tried to sleep. But I did not quite accomplish many of these goals. When I was home with a baby, I did not sleep and was not productive because of night feeding and having a newborn baby. Conversely, I did not sleep during shelter-in-place because of the uncertainty related to what life would be like once we returned to the office. There were so many questions. Which were the correct answers? There were thousands of Facebook posts to sort through. Which were legitimate pieces of information?

There was a great deal of suggestions of what proper PPE would be. Which would be available for us to use?

And when would they be available?

Unfortunately, in contrast to the maternity leave, there was little growth and development in the first few weeks.

Furthermore, this time around, more time did not translate to more sleep.

When COVID-19 kept everyone home, CDA had almost 100 resources to help members understand and navigate this unique time.

Perhaps not all of us can identify with the restive nights with a newborn, but all dentists living in the COVID-19 era can identify with a sense of uncertainty and perhaps anxiety that diffused through our profession.

Yet, there was a pitter-patter of workhorses in the background. Our CDA president teamed up with our state’s dental director to form a workgroup. The workgroup immersed itself in articles and data like predental students immersing themselves in biochemistry, histology and organic chemistry before taking their DAT. The CDA communications team started to build upon its already strong virtual services and resources.

When COVID-19 kept everyone home, CDA had almost 100 resources to help members understand and navigate this unique time. Human resources help was offered. Links explained unemployment forms and questionnaires. In the initial days, cda.org housed FAQs regarding the Small Business Administration loan and the Paycheck Protection Program loan.

CDA offered members guidance on how to communicate with patients during the shutdown and how to manage emergency patients during the shelter-in-place.

Teledentistry resources were highlighted.

Organized dentistry understood that high-quality knowledge was a commodity at the time. CDA understood that disseminating accurate,

timely, useful information was the best way to help its members during this unique time. As Benjamin Franklin said, “An investment in knowledge pays the best interest.” Because in today’s social media era, many commentators from behind a laptop speak as if they are experts when they are not. And though more information and diversity of opinion is not to be chastised, it is fortunate to have a trustworthy resource like cda.org to count on for accurate information.

Throughout the crisis period, the workgroup continued to industriously meet virtually and work continuously.

They worked with the CDC, submitted questions and provided suggestions and considerations. The California Public Health Department (CDPH) guidelines were released. Soon thereafter, CDC guidelines were released.

Meanwhile, our CDA Presents Board of Managers, staff and IT department were working painstakingly as well. A multitude of virtual continuing education courses were offered. Templates to aid best practices in the COVID-19 era of practice were posted online. As they emerged, links to new guidelines from the CDPH, OSHA and CDC were housed in a highlighted banner at the top of cda.org so members would be pointed in the right direction. Virtual membership meetings were organized so dentists could see and hear from leaders JULY 2 0 2 0 305

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ASSOC . EDITOR C D A J O U R N A L , V O L 4 8 , Nº 7

across organized dentistry on the front lines of guiding dentistry through this pandemic.

But the CDA efforts were not just limited to the internet. Staff went above and beyond to advocate for the dental health of Californians and for the dentists who care for them. Daily check-ins with the governor’s office and with the state dental director were imperative. They advocated for simple, clear guidelines from the county public health departments for dentists to begin to see patients again. They advocated for PPE (that authorities had pocketed early on) to be distributed back to dentists.

A “Take Action” button arrived on cda.org and on social media. Clicking the button allowed dentists to advocate for themselves. Clicking the button allowed dentists to communicate with Gov. Gavin Newsom and state legislators.

Clicking the button allowed dentists to remind the politicians that our offices had been closed since March 2020 except for emergencies. Clicking the button allowed dentists to remind politicians that routine care and maintenance of the periodontal health of our patients had been delayed for months. Clicking the button allowed dentists to remind politicians that we needed PPE and financial relief. CDA kept focus on helping dentists succeed.

Volunteer leader dentists across the state and executive directors of dental societies hustled as well. They reached out to county public health departments.

They created communication channels with emergency preparedness so that stockpiled PPE could be distributed to the dentists in the counties’ communities. Whether via emails or via organized PPE pickups, local volunteer leadership extended information, insight and a sense of connection.

And yet amid all of this assistance that was coming from organized dentistry, there were still naysayers proclaiming that 306 JULY

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organized dentistry did not do enough.

In this unique time, perhaps no one could have done “enough.” The Greek philosopher Epictetus said, “He is a wise man who does not grieve for the things which he has not, but rejoices for those which he has.” Will we look back on this unique time and find gratitude for whatever CDA attained and accomplished for the betterment of the dental health of Californians? Time will continue to tell.

As time during the crisis evolved and some danger lifted, we began to look for the brush strokes of opportunity. The old story “When Adversity Knocks” came to mind. In the story, a girl was distressed with life. She did not know what to do, so she went to her father for help. He asked her to bring an egg, two tealeaves and a potato. He put each into its own pot of water on the stove. “Watch,” he said. The water began to boil. After 10 minutes, he asked the girl to remove the items from the water. She peeled the egg, peeled the potato and strained the tea leaves. She looked at her father, bewildered. How were these food items supposed to help her out of anguish? Her father pointed out that each item had been placed in the same situation — boiling water. But each item came out of the water in a different state. The egg was soft before placing it in the pot; now the egg was hard. The potato was hard before; now the potato was soft. And the tea leaves — they changed the water itself. The father then poised the question, “When adversity calls … are you an egg, a potato or tea leaves?” Crisis indeed brings opportunity.

Crisis brings opportunity for perspective. Time will continue to tell how our profession, communities and life in general will evolve after the COVID-19 pandemic. CDA workhorses will continue to pitter-patter in the background and continue to serve our profession as they have for the last 150 years. n

Ruchi K. Sahota, DDS, CDE, practices family dentistry in Fremont, Calif., and serves on the CDA Board of Trustees. She is also a certified dental editor, a consumer advisor for the American Dental Association, past president of the Southern Alameda County Dental Society and a fellow of the American College of Dentists, International College of Dentists and the Pierre Fauchard Academy.

The Journal welcomes letters

We reserve the right to edit all communications. Letters should discuss an item published in the Journal within the last two months or matters of general interest to our readership. Letters must be no more than 500 words and cite no more than five references. No illustrations will be accepted. Letters should be submitted at editorialmanager.com/jcaldentassoc.

By sending the letter, the author certifies that neither the letter nor one with substantially similar content under the writer’s authorship has been published or is being considered for publication elsewhere, and the author acknowledges and agrees that the letter and all rights with regard to the letter become the property of CDA.

Letter

C D A J O U R N A L , V O L 4 8 , Nº 7

Ready To Practice

I

won’t lie. It’s been a tough eight weeks.

Mentally and emotionally. Dentistry got hit really hard by the coronavirus.

My practice will not be the same. I will not be the same. I will have come out stronger and better for this. I’ve learned many good lessons during this time. I’ve learned everyone copes with crisis differently. I learned how I cope.

One thing I should mention: You don’t need to be afraid to go to the dentist.

We have spent countless hours learning about the virus, the disease it causes, how to minimize its impact, what infection control protocol is science based and what is fear based.

We have spent thousands of dollars on equipment, PPE and extra safety measures to protect us and our patients.

There is not a day that goes by where we are not thinking of how else to improve our COVID-19 protocol in our office.

We also spent hours worrying about our staff and patients. Honing our leadership skills to do what we can to be strong leaders at a time of crisis. Hoping to keep our staff on board and hoping our patients will still trust us enough with their safety to want to come back.

In addition, we are small-business owners and had to deal with the panic of watching our practice spiral down and figuring out how to stay solvent for 2020. Many are not financially prepared to be shut down for so many months. We learned about the Paycheck Protection Program (PPP) loan, the Economic Injury Disaster Loan (EIDL) and the circus that ensued. While I’m fortunate that I’m an established practice and will recover, I’m fearful for those who will not survive.

I’ve also learned the importance of community. My tribe has helped me stay sane, grounded and rational. We help each other with information, PPE, support. We are brutally honest and

critical but trusting and supportive.

I am so grateful. We chat constantly throughout the day, every day.

I have not picked up my hobbies, did not practice the piano as I had hoped or improved my photography skills. I have a sourdough starter that I’ve diligently fed for eight weeks with every intention to bake but have only produced one mediocre loaf. My starter has now become three jars … anyone want some? I’ve not cooked or exercised. Oh, and my house is a mess.

And there’s the social aspect of being isolated. We can all relate to that.

But in the end, my practice is as ready as it ever will be. I have done everything I can possibly do that is based on science and facts. My team has been amazingly supportive and is on board and ready (as can be). I am cautious but prepared.

Once I know my practice, my staff and my patients are taken care of, then and only then will I take a step back … make some time to pick up my camera, play some tunes on my piano and work on that sourdough loaf. Until then ... dora lee, dds, mph

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150 YEARS STRONG

CDA. WE’VE BUILT THIS TOGETHER. In 1870, the California Dental Association was founded by 23 visionary dentists.

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1870 2020

Impressions

C D A J O U R N A L , V O L 4 8 , Nº 7

Patients Report Worse Pain With Opioids

“The real-world data from this study reinforces the previously published randomized-controlled trials showing opioids are no better than acetaminophen and nonsteroidal anti-inflammatory drugs for pain after dental extraction.”

— CHAD BRUMMETT, MD

The use of opioids to soothe the pain of an extracted tooth could be drastically reduced or eliminated altogether from dentistry, according to a University of Michigan study published in JAMA Network Open.

For the study, more than 325 dental patients who had teeth pulled were asked to rate their pain and satisfaction within six months of extraction. Roughly half of the study’s patients who had surgical extraction and 39% who had routine extraction were prescribed opioids. Researchers compared the pain and satisfaction of those who used opioids to those who didn’t.

Surprisingly, patients in the opioid group actually reported worse pain than the non-opioid group for both types of extractions “I feel like the most important finding is that patient satisfaction with pain management was no different between the opioid group and non-opioid group, and it didn’t make a difference whether it was surgical or routine extraction,” said study co-author Romesh Nalliah, DDS, clinical professor and associate dean for patient services at the U-M School of Dentistry.

The researchers also found that roughly half of the opioids prescribed remained unused in both surgical and nonsurgical extractions. This could put patients at risk of future misuse of opioids if leftover pills are not disposed of properly.

“The real-world data from this study reinforces the previously published randomized-controlled trials showing opioids are no better than acetaminophen and nonsteroidal anti-inflammatory drugs for pain after dental extraction,” said study co-author Chad Brummett, MD, director of the division of pain research and of clinical research in the department of anesthesiology at Michigan Medicine, U-M’s academic medical center.

Dr. Brummett co-directs the Michigan Opioid Prescribing Engagement Network, or Michigan OPEN, which has developed, tested and shared guidelines for the use of opioids in patients with acute pain from surgery and medical procedures.

“These data support the Michigan OPEN prescribing recommendations calling for no opioids for the majority of patients after dental extractions, including wisdom teeth extraction,” he said.

The results have big implications for both patients and dentists and suggest prescribing practices need an overhaul, the co-authors said.

The American Dental Association suggests limiting opioid prescribing to seven days’ supply, but Dr. Nalliah believes that’s too high.

“I would estimate we can reduce opioid prescribing to about 10% of what we currently prescribe as a profession,” he said.

Learn more about this study in JAMA Network Open (2020); doi:10.1001/jamanetworkopen.2020.0901.n

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Teeth Serve As ‘Archive of Life’ The parasite Entamoeba gingivalis penetrates the gum tissue, feeding on host cells. (Credit: Schäfer/Charité)

Improving Treatment of Periodontitis For the first time, researchers from Charité – Universitätsmediz n Berlin have shown that a unicellular parasite commonly found in the mouth plays a role in both severe tissue inflammation and tissue destruction. The research was published in the Journal of Dental Research.

The researchers, led by Arne Schäfer, PhD, head of the periodontology research unit at Charité’s Institute of Dental and Craniofacial Sciences, were able to show that oral inflammation is associated with colonization by the oral parasite Entamoeba gingivalis.

The effect of this amoeba is similar to that of Entamoeba histolytica, the parasite responsible for causing amebiasis. Once the parasite has invaded the gingival tissue, it feeds on its cells and causes tissue destruction. According to the researchers’ findings, the two amoebae show similar mechanisms of tissue invasion and elicit a similar immune response in the host.

“E. gingivalis actively contributes to cell destruction inside the gingival tissue and stimulates the same host immune response mechanisms as E. histolytica during its invasion of the intestinal mucosa,” said Dr. Schäfer. “This parasite, which is transmitted by simple droplet infection, is one potential cause of severe oral inflammation.”

Treatment success is often short-lived in patients with periodontitis. This might be due to the high virulence potential of this previously unnoticed, yet extremely common amoeba, according to the study.

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Teeth constitute a permanent and faithful biological archive of the entirety of an individual’s life, from tooth formation to death, according to researchers from NYU’s department of anthropology and College of Dentistry. Their work, published in the journal Scientific Reports, provides new evidence of the impact that events, such as reproduction and imprisonment, have on an organism.

The research team examined nearly 50 human teeth, aged 25 to 69, drawn from a skeletal collection with known medical history and lifestyle data, such as age, illnesses and movement (e.g., from urban to rural environments). Much of this information was obtained from the subjects’ next of kin. They then used a series of imaging techniques that illuminated cementum bands, or rings, and linked each of these bands to different life stages, revealing connections between tooth formation and other occurrences. Cementum begins to form annual layers — similar to a tree’s “rings” — from the time the tooth surfaces in the mouth, according to the study.

Researchers then tested the hypothesis that physiologically impactful events, such as reproduction and menopause in females and incarceration and systemic illnesses in both males and females, leave permanent changes in the microstructure of cementum and that such changes can be accurately timed.

The cementum’s microstructure, visible only through microscopic examination, can reveal the underlying organization of the fibers and particles that make up the material of this part of the tooth.

“Our results make clear that the skeleton is not a static organ, but rather a dynamic one,” said Paola Cerrito, a doctoral candidate and lead author of the paper.

Learn more about this study in Scientific Reports (2020); doi.org/10.1038/s41598-020-62177-7.

Panel A is a longitudinal section of the maxillary second molar of a 35-year-old female who had children at ages 19 and 24. Panel B is a zoomed-in section of panel A. Panel C reveals, at left, the dentine, covered, at right, by the cementum, which presents two distinct darker “rings” that correspond to the two reproductive events.

(Credit: Paola Cerrito) A

“We identified one infectious parasite whose elimination could improve treatment effectiveness and long-term outcomes in patients with gum disease,” said Dr. Schäfer. “Current treatment concepts for periodontitis fail to consider the possibility of infection by this parasite or its successful elimination.”

B

C

A clinical trial is underway to determine the extent to which the elimination of this amoeba might improve treatment outcomes in patients with periodontitis.

Learn more about this study in the Journal of Dental Research (2020); doi. org/10.1177%2F0022034520901738.

C D A J O U R N A L , V O L 4 8 , Nº 7

Immune-Regulating Drug Improves Gum Disease in Mice A drug that has life-extending effects on mice also reverses age-related dental problems in the animals, according to a new study published in eLife. The study suggests that treatments targeting the aging process in the mouth might help periodontal disease in older adults.

Rapamycin is an immune-suppressing drug currently used to prevent organ rejection in transplant recipients. Previous

studies in mice have also suggested that it may have life-extending effects, which has led to interest in studying the drug’s effects in many age-related diseases.

“We hypothesized that biological aging contributes to periodontal disease, and that interventions that delay aging should also delay the progress of this disease,” said lead author Jonathan An, DDS, PhD, acting assistant professor at

AI Model Makes Dentists’ Work Easier Researchers at the Finnish Center for Artificial Intelligence FCAI, Tampere University Hospital, Planmeca and the Alan Turing Institute have developed a new automatized model that accurately and automatically shows the exact location of mandibular canals for dentists to use when planning a dental implant operation, according to a study published in Scientific Reports. The model is based on training and using deep neural networks. Researchers trained the model by using a dataset consisting of 3D cone beam CT (CBCT) scans.

Based on a fully convolutional architecture, the model makes it as fast and data efficient as possible. Research results show this type of deep-learning model can localize the mandibular canals most accurately. It surpasses the statistical shape models, which have thus far been the best automatized method to localize the mandibular canals.

In simple cases — when the patient does not have any special conditions, such as osteoporosis — the new model is as accurate as a human specialist, according to the study.

Using artificial intelligence has another clear advantage, namely the fact that the machine performs the job equally fast and accurately every time. The aim of this research work was not, however, to replace radiologists but to make their job faster and more efficient so they have time to focus on the most complex cases, said Jaskari.

Read more of this study in Scientific Reports (2020); doi.org/ 10.1038/s41598-020-62321-3.

Comparison of the model segmentation. (Credit: Jaskari J, et al. Creative Commons license)

An old mouse before and after rapamycin treatment.

White arrows indicate areas where there is more bone after treatment. (Credit: School of Dentistry, Univerisity of Washington)

the department of oral health sciences at the University of Washington, Seattle.

To find out if rapamycin might slow periodontal disease, researchers added the drug to the food of middle-aged mice for eight weeks and compared their oral health with untreated mice of the same age. Similar to humans, mice also experience bone loss, inflammation and shifts in oral bacteria as they age.

Using a 3D-imaging technique called microcomputed tomography, the research team measured the periodontal bone of the rapamycin-treated and untreated mice.

Results showed that the treated mice had more bone than the untreated mice and had actually grown new bone during the period they received rapamycin.

The work also showed that rapamycin-treated mice had less gum inflammation. Genetic sequencing of the bacteria in their mouths also revealed that the animals had fewer bacteria associated with gum disease and a mix of oral bacteria more similar to that found in healthy young mice.

While rapamycin is already used to treat certain conditions, it can make people more susceptible to infections and may increase their risk of developing diabetes, at least at the higher chronic doses typically taken by organ transplant patients, according to the study.

Read more of this study in eLife (2020); doi:10.7554/eLife.54318.

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dental licensure C D A J O U R N A L , V O L 4 8 , Nº 7

A Snapshot of Dental Licensure: California and the United States Alan L. Felsenfeld, MA, DDS, and Nader A. Nadershahi, DDS, MBA, EdD

a b s t r a c t 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.

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, EdD, is the dean of the University of the Pacific, Arthur A. Dugoni School of Dentistry.

Conflict of Interest Disclosure: None reported.

A

s dentists, we must overcome three major hurdles before we can practice that which we love. The first is getting into dental school. For many years, admission into our schools has been a difficult task reserved only for those with high academic rankings and likely a bit more in the way of outside activities. Today, admission into our dental schools is more competitive than ever with highly qualified and experienced young people interested in the great profession of oral health care.

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 JULY 2 0 2 0 313

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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 314 JULY

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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

“Protection of the public shall be the highest priority for the Dental Board of California in exercising its licensing, regulatory and disciplinary functions.”

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

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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.

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.

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.

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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 316 JULY

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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

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TABLE

Number of California Licenses Issued as Percent of Total Licenses Issued Pathway

2019

2018

2017

WREB

747

877

758

PGY I

124

147

161

2,103

2.86%

Credential 5 years

129

177

181

3,656

4.98%

Credential 0–FQHC

3

11

10

63

0.09%

Credential 0–academic

1

7

4

31

0.04%

Portfolio

4

8

20

80

0.11%

Totals

1,008

1,227

1,134

73,410

Dental board examination

Total issued to date

Percent of all licenses issued

57,087

77.76%

10,390

14.15%

Source: Dental Board of California meeting, November 2019

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.

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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 318 JULY

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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. n

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.

“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

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(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 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.

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The ADEA Compendium of Clinical Competency Assessments: A Potential Pathway to Licensure Steven W. Friedrichsen, DDS

a b s t r a c t The profession of dentistry benefits broadly from a licensure process

that assures the public that the practitioner is prepared to provide contemporary oral health care. The American Dental Education Association Compendium of Clinical Competency Assessments (ADEA Compendium) is being purposely developed as a valid and reliable assessment of clinical competency and gauge of student readiness for practice or entry into advanced dental education. The ADEA Compendium can serve as a transformative pathway to licensure.

AUTHOR Steven W. Friedrichsen, DDS, is a professor and the dean of the Western University of Health Sciences College of Dental Medicine.

He is the chair of the ADEA Compendium of Clinical Competency Assessments work group.

Conflict of Interest Disclosure: The views and opinions expressed are those of the author and do not necessarily reflect those of the American Dental Education Association. The author is one of six who hold the patent and trademark for iFF, a mobile formative feedback application. The commercialization of iFF does not result in financial remuneration for the author.

T

he profession of dentistry would benefit from the increased involvement of practicing dentists and hygienists demonstrating an interest in transforming the dental profession’s licensure processes. The most prevalent licensure pathway involves the use of a single-encounter, procedure-focused, high-stakes, patient-based clinical examination — the licensing exam that most practicing professionals are familiar with. Historically, the most interest in change has come from the dental education community including students preparing for licensure examinations as well as educational program faculty and administration.

This paper points out the value of broad-based support for changes to

licensure for dental professionals, identifies key drivers involved in support of change, highlights selected efforts undertaken within the profession to engage in change and provides a detailed portrait of the American Dental Education Association (ADEA) Compendium of Clinical Competency Assessments (ADEA Compendium), an emerging new assessment and licensure model. The ADEA Compendium has evolved from the collaborative efforts to bring transformative change to the dental licensure process. The ADEA Compendium offers advantages over the existing licensure exams, meshes with changes in dental education assessment and can provide a valid and reliable assessment of readiness for practice.

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Effects of Dental Licensure on the Profession

While the personal immediacy of concerns over the licensure process declines for most dentists and hygienists once they successfully obtain their license, there are compelling reasons for the entire profession to sustain an interest in the dental licensure process and the transformative changes that are needed.1 If dentistry wants to sustain its status as a self-governing profession, be universally regarded as ethically centered and advance changes that reduce increases to the cost of dental education, it will require a broad-based interest in moving to 21st century licensure pathways. The predominant examination process affects the profession as a whole, not just dental education and candidates for licensure.2

Status as a Profession

Dentistry takes great pride in its status as a respected profession. Maintaining dentistry as a profession involves, among other qualities, a significant commitment to self-governance even in an era of increasing external accountability. The privilege of self-governance embodies the responsibility to ensure the public is served by the profession’s providers through a process that includes initial licensure. It is important that the licensure pathway satisfies all entities and is an authentic qualification to practice on behalf of the public.

The current licensure examination process is focused on procedural competency, rather than the full scope of skills required for professional practice. In reviewing licensing board disciplinary actions, Chambers found procedural competence is a less frequent source than practice management and personal issues.3 There are similarities in medicine; Papadakis et al. looked at disciplinary actions by medical 322 JULY

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boards and found a strong statistical association between disciplinary licensure actions for unprofessional behavior and similar prior activity in medical school.4 Incompetence, the physician equivalent of a dentist’s technical errors in this study, were found to be a minor component of disciplinary actions.

Ethics and Professionalism

Much has been written about the value of the ethical foundation of the dental profession. Dentistry’s ethical foundation is buttressed by state dental practice

The current licensure examination process is focused on procedural competency, rather than the full scope of skills required for professional practice. acts, which almost universally prohibit payments and incentives to patients, often require timely and appropriate care, support comprehensive evaluation of patient needs and place the patient’s needs ahead of the practitioner’s interest.

Under the current licensure exam model, most candidates pay patients a substantial amount of money to sit for the examination. Many of the participants are not patients of record. Care can be delayed for months if the patient has an “ideal board lesion” (lesions often no longer recommended for irreversible restoration in contemporary practice) or need just a few more clicks of calculus to qualify as a periodontal patient.5–7 Any one or all of those actions would likely be found to violate the state dental practice act under which the candidates seek to be licensed.

Cost

Many members of the profession are aware and concerned that the cost of dental education programs continues to escalate at an unsustainable rate.

The current examination process incurs significant direct and indirect costs to candidates and schools. Most dental administrators would note that the indirect costs are orders of magnitude higher when faculty and staff time allocated to the various measures preparing for the licensure examinations are considered.

Indirect costs include dedicated curriculum time aligned to and focused on preparation for the examinations, conducting screenings for board patients, providing mock exams to acquaint students with the testing format, closure of the clinic or imposing significant restrictions on the treatment facility to conduct the examination, etc. Transitioning to emerging licensure models can help reduce both direct and indirect costs for students and educational institutions.

Readiness for Practice

It is a logical expectation that a newly licensed dentist or hygienist will have the basic requisite patient care skills needed of an associate, employee or potential owner of a practice. In short, the process for granting a license should indicate a minimum level of competence and readiness for practice.

Many current licensure systems do not offer that minimum assurance because they lack the validity and reliability necessary to accurately evaluate the basic clinical skills.8–11 More importantly, the licensing examinations do not address the broad scope of knowledge, skills and attributes necessary for the practice of dentistry.12,13 Although not frequently articulated, the most accurate evaluation of the readiness of dentists and hygienists primarily resides with

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the educational institutions. No single evaluation at a point in time can match the multiplicity of evaluations, evaluators and variety of methodologies obtained from accredited educational programs.14

Change Drivers

The drivers for change in dentistry have built slowly but appear to have reached a tipping point. The impetus, efforts and rationale for change exceed the stability of the status quo. Key drivers have been an increasingly strident student voice, continuous advances in oral health care, changes in the care delivery model and transformations in dental education that reflect the other drivers of change within the profession.

Student Voice

A significant driver for change is an increasingly active student voice.

The students who are in essence the primary consumers of the licensure exam process have capably pointed out the deficits in the process.15 Their concerns include examination variables that while decisive are not necessarily reflective of the candidate’s clinical skills, the lack of validity and reliability related to evaluation of clinical skills, the cost of the exam and the ethical challenges inherent in patient selection, delay of treatment, payment to patients and even patient procurement services — essentially commoditizing the patient’s treatment needs. The student position opposing the single encounter, patientbased procedural exam resonates with others who have long advocated for changes to the licensure system.1,11,16–18 There are equally strong student concerns related to the interstate portability of their licensure. It is notable that the students believe that retaining an evaluation of psychomotor skills is still a valued component of the licensure process.

Dental education program faculty and administrators recognize the same exam challenges as the candidates as well as the direct and indirect institutional resources required for preparation, execution and follow-up for the licensure examinations.19 To provide students with the best preparation for the exam, many institutions will provide a mock examination process, essentially doubling the time and investment. More importantly, educators recognize that the evaluation of technical skills using a limited number of procedures is not

The student position opposing the single encounter, patient-based procedural exam resonates with others who have long advocated for changes to the licensure system. representative of the complex array of knowledge, skills and attributes required to be competent as a new licensee prepared for contemporary dental practice or entry into advanced dental education programs.2 Moreover, they recognize the time, energy and focus on preparing for and passing the current licensing exam would be better utilized in emphasizing and cultivating other aspects of dentistry within the time constrains of each program’s curriculum.

Advances in Oral Health Care

As the profession has evolved, there are changes in the expectations for newly licensed practitioners that are not reflected in the existing examination process. The single-encounter, patientbased, procedurally oriented examination remains focused on psychomotor skills

and procedure outcomes for minimally complex cases. The minimal or “ideal” lesions and cases most frequently selected for the licensure exam no longer represent the reality of contemporary oral health care. The complexity of care, patient needs and procedures available have expanded and will continue to expand in the future.

Changes in the Practice Model

Today’s graduates need increased licensure portability beyond that typically available under the patchwork of laws governing licensing jurisdictions covering the 50 states, District of Columbia and U.S. territories. Notably, incremental progress has been made in the last decade in the number of states that accept other states’ licensure and broadening of the number of examinations accepted for licensure.

At the same time, there are frequently stipulations requiring a number of years of practice that often hamper individual practitioners’ mobility at the time in their career when it is most needed. Conversely, there is often a limited time period when a state will consider a licensing examination as valid for initial licensure. Both of these time-based stipulations diminish licensure portability and therefore mobility for dental practitioners.

While state licensing laws are well-intended and founded in the need to ensure competent care for the public, their variability and unintended consequences of various stipulations lead to a reduction in mobility and constraint that has drawn significant attention outside dentistry.

The licensing of dentists and dental hygienists has been cited in recent publications as unnecessarily restrictive and potentially protectionist of the profession rather than the public.20–22 JULY 2 0 2 0 323

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Changes in Dental Education

The dental education assessment and outcomes processes are evolving toward measurements that are reflective of increased understanding and new knowledge about how learning occurs.23,24 Dental education is supportive of migrating the licensure examinations away from high-stakes, procedurefocused assessments and must mirror that same philosophy in their evaluation of student competency as well. As dental schools move closer and closer to true competency-based approaches to student evaluation, there will be a natural evolution toward systematically developing a panel of assessments that view competency globally rather than completing a checklist of procedural examinations. The ADEA Summit on the Future of Assessment in Dental Education (Feb. 6–7, 2019) established the case for continued change in the dental education assessment processes moving away from a preponderance of procedural skill evaluations and toward health outcomes and other “… competencies that are critical for person-centered, team-based care.”25

Dental Profession Change Initiatives

Multiple independent efforts over several decades yielded small and incremental change but neither substantive nor transformative change to the licensure system. The last few years have seen notable attempts at transformative change as well as concerted collaborative efforts. Both the collaborative efforts and the transformative approaches have helped build a momentum that moves toward 21st century licensing practices.

The two notable examples of transformative change were the adoption of the Canadian OSCE for licensure in Minnesota (MN OSCE) and the 324 JULY

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California Hybrid Portfolio Examination (CA Portfolio). Both the CA Portfolio26 and MN OSCE27 serve as case studies in transformative changes in licensure.

In these two states, the dental board, dental association and dental school(s) worked jointly, building mutual trust and cooperation to support the changes.

In addition to the transformative changes at the state level, recent multiple interlacing efforts by national organizations collectively provided significant impetus for changes. The ADEA, the American Dental Association

Both the collaborative efforts and the transformative approaches have helped build a momentum that moves toward 21st century licensing practices.

(ADA), the American Dental Student Association (ASDA) and the American Dental Hygiene Association (ADHA) each played a role in helping to move change forward. Their willingness to work collaboratively toward an analogous goal of transformational change of the licensure process helped accelerate the momentum more than any of the organizations could have accomplished working independently.

The ADEA has supported changes to the licensure process for a number of years and, with the ADEA House of Delegates’ unanimous support of Resolution 5H-2014, established the Task Force on Licensure, which provided a final report to the ADEA House of Delegates in March 2016.28 The task force provided a series of recommendations

that dovetailed with other national initiatives. One of the recommendations led to the workgroup that is developing the ADEA Compendium.

One of the most productive efforts was a joint task force of the ADA, ADEA and ASDA. The three organizations worked collectively and collaboratively from 2015–2019, spanning multiple yearly volunteer leadership transitions.

The consistency of efforts ultimately culminated in support of the Report of the Task Force on Assessment of Readiness for Practice.29 Included in the report was agreement to form the Coalition for the Modernization of Dental Licensure — a national coalition that would expand the base of support for licensure change and sustain valuable momentum.30

ADEA Compendium of Clinical Competency Assessments

The Report of the Task Force on Readiness for Practice proposed modernization of the dental licensure process by outlining three components: 1) completion of a DDS or DMD degree from a university-based program accredited by the Commission on Dental Accreditation (CODA); 2) passing the National Dental Board Examination; and 3) the successful completion of a reliable clinical assessment that does not require single-encounter, procedurebased examinations on patients.

The Task Force on Assessing Readiness for Practice Report specifically includes three examples, any one of which would meet the third licensure component for licensure: an Objectively Structured Clinical Examination (OSCE) including the Dental Licensure OSCE currently being developed by the ADA Department of Testing Services, completion of a CODA-accredited PGY-1 program or completion of a standardized compilation

C D A J O U R N A L , V O L 4 8 , Nº 7

TABLE

Sample Rubric for ADEA Compendium — Preparedness for Patient Care Category Preparedness for patient care

Expectations

Independence modified Chen/Ottawa scales

Accurately applies dental and medical history.

[ ] Hands-on guidance required

Reconfirms procedure/treatment is appropriate to diagnosis or problem.

[ ] Does not meet expectations [ ] Meets expectations

Selected procedure/treatment aligns with patient factors.

[ ] Exceeds expectations

[ ] Attempted independent performance — guidance required [ ] Independent completion

Presentation of procedure/treatment is accurate, clear and concise.

of clinical competency assessments designed to demonstrate psychomotor skills and practice relevant patientcare knowledge, skills and abilities, including the ADEA Compendium currently under development.

The remainder of this paper outlines the development, current status and rationale for adoption of the ADEA Compendium.

ADEA Compendium Development Process

ADEA formed the Compendium of Clinical Competency Assessments Workgroup in January 2018 to develop a clinical competency assessment that was in concert with the recommendations from the ADEA Task Force on Dental Licensure.28 The ADEA Compendium (APPENDIX A ) was also expected to align with collaborative licensure reform efforts of the ADA, ADEA and ASDA. The workgroup (APPENDIX B ) began with four overarching aspirational goals and developed consensus around a group of concepts that were used to frame the development of the clinical competency assessment and implementation process. The four overarching goals provided to the workgroup included developing a clinical competency assessment system and process that: ■ Provides licensure upon graduation.

■ Eliminates the high-stakes, single-encounter, patientbased clinical exam.

■ Increases the portability of initial licensure to all licensing jurisdictions.

[ ] Verbal guidance [ ] Intermittent guidance

Decreases the burden of the licensure process for the students and programs.

With the goals in mind, the workgroup began with discussions that led to consensus on the following framing concepts: ■ All dental education programs already have a curriculum-wide assessment plan to assure that the programs are in compliance with the CODA standards. A small segment or “thin slice” of the overall assessment plan could replicate the areas evaluated on clinical licensing exams (APPENDIX C ). The workgroup initially recommended the six areas of clinical care used by the CA Portfolio as a starting point.

■ As a transformational approach to licensure, key elements of the CA Portfolio aligned with the planned goals for the ADEA Compendium. The use of calibrated faculty, employing a standardized rubric format and a common reporting method as well as the ability to achieve licensure upon graduation were the elements of greatest interest to the workgroup.

■ Strongly support the use of a competency assessment model that builds validity and reliability based upon multiple evaluations over the course of time by multiple evaluators.31 ■ The Association of American Medical Colleges Core Entrustable Professional Activities (EPAs) used by the medical profession ■

Feedback/ corrective action

provide a structured approach to evaluating the preparedness of students to complete activities (procedures) independently.

The EPAs measurement scale of independent performance could be tailored to dentistry and used as a gauge of this component of readiness for practice.32–35 ■ It was logical to start with a prototype rubric that expanded the assessment to include four domains of clinical care for a more authentic representation of the knowledge, skills and attributes expected of a practice-ready student. The four areas were: ● Preparation for patient care. ● Patient and appointment management. ● Procedure. ● Professionalism and communication.

■ An established process and associated mobile application were evaluated that could facilitate rapid data entry and automatic population of a dashboard permitting real-time monitoring of student progress.

The workgroup felt the software and process could be modified for use in the ADEA Compendium.36 The workgroup worked conscientiously over the course of 2018 to refine and build a system of clinical competency assessments that were based on the framing concepts. The workgroup also developed a process for the integration of the ADEA Compendium competency assessments JULY 2 0 2 0 325

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Selected clinical competency areas

Assessment domains Preparation for patient care

n

Periodontics

n

n

Endodontics

n

Restoration of teeth

Patient and appointment management

Replacement of teeth

n

Procedure

n

n

Professionalism and communication

Multiple assessments over time by multiple faculty that meet or exceed program standards

Independence modified Ottawa/Chen Scales 32,33

s

n

s

Oral diagnosis and treatment planning

s

n

Competency model31

Natural progression of learning, leading to repeatedly providing care independently that meets or exceeds expectations

s

Fidelity achieved by providing patient care and virtual patient care FIGURE 1. ADEA Compendium of Clinical Competency Assessments System.

system within dental education programs.

The workgroup balanced the elements of the assessments system with the anticipated integration process to support achieving the original workgroup goals.

In conjunction with their internal development, the workgroup used an iterative process, presenting successive drafts of the assessments system and proposed process to a variety of groups and individuals both inside and outside dental education to obtain feedback and suggestions for improvement. The workgroup also conducted formal focus groups at the ADEA annual session and exhibition in March 2019. Following each review by outside groups as well as the focus groups, the workgroup used the feedback to modify the assessments system and integration process.

ADEA Compendium Assessments System

The ADEA Compendium assessments system was crafted using three foundational evaluation components (APPENDIX D ).

Blended together, the three components provide a comprehensive view of each student’s performance and evaluate their progress throughout the normal learning trajectory toward clinical competence and readiness for practice or entry in advanced dental education programs (FIGURE 1 ).

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The current modified areas of clinical care assessed in the ADEA Compendium include diagnosis and treatment planning, periodontal therapy, endodontic therapy, restoration of teeth and replacement of teeth. For each of those five areas of clinical dentistry, students are evaluated in four domains: preparedness for patient care, patient and appointment management, procedure and professionalism and communication. Student evaluation of each domain includes whether they met or exceeded expectations as well as their level of independence.

The ADEA Compendium assessments system is organized in a format similar to the original rubric. For each clinical area assessed, there are four domains to be evaluated. The TABLE represents one domain of the rubric. The educational program can modify or tailor the criteria to their particular institution. For each of the four domains, the faculty evaluates the student on whether they exceeded, met or did not meet their program’s expectations. A program’s expectations are summarized as the criteria listed under each domain heading.

In addition to evaluation of the encounter as described, the ADEA Compendium assessments system includes a measure of student independence based

on a scale modified from the EPAs. The workgroup modified the Chen and Ottawa independence scales used in the EPAs32 to provide a relevant scale for dental education. Students entering their clinical education would be expected to need guidance, oversight and intervention.

As they progress through their clinical education, the typical learning trajectory leads them toward completion of the patient encounter with lessening faculty intervention, eventually including the ability to independently provide care that meets or exceeds the program’s expectations.

Finally, in the feedback corrective actions column, the faculty assist with the student’s learning, professional growth and formation by providing feedback, corrective action items and comments of either a positive or formative nature.

The ADEA Compendium competency assessments system is designed to allow each program the flexibility to define the elements that contribute to each of the required four domains. Similarly, the program defines the criteria required to meet or exceed their expectations. For the purposes of standardizing the ADEA Compendium, student performance will be reported in the defined categories. As part of the ADEA Compendium integration process, faculty and students will be

C D A J O U R N A L , V O L 4 8 , Nº 7

calibrated on the use of the assessment in the areas of encounter evaluation, the independence scales, recording of evaluations and data submission.

The workgroup supports a definition of competency that is in alignment with the structure of the EPAs. Students should be able to independently perform the procedure at a level that meets or exceeds the institution’s criteria on multiple occasions. Depending upon the individual school’s patient population, some of the areas proposed for the ADEA Compendium may necessitate a blend of patient and simulated procedures to arrive at the multiple independent evaluations.

It is anticipated that the changes in dental disease and demographics will eventually be reflected in changes in the exam components for dental licensure.

ADEA Compendium Integration Process

As indicated earlier, the workgroup engaged in both the process of developing the ADEA Compendium assessments system as well as the adoption and integration process for dental education programs (see F I G U R E 2 at cda.org/ADEA). Internally, the workgroup was assembled with members who understood the complexities of adopting and using new systems in dental education. The workgroup also used the feedback from the iterative development process to refine the utilization process.

A consistent theme in the review of the various drafts by groups outside the workgroup and especially prominent in the ADEA focus groups was the desire to move toward the ADEA Compendium assessments system broadly within their dental education programs. The sentiment expressed was a desire to move toward the ADEA Compendium assessments system for all areas of clinical education and to then simply report the “thin slice”

to third parties who would then use that information for the clinical licensure purposes. The ADEA Summit on the Future of Assessment in Dental Education demonstrated significant alignment with the ADEA Compendium assessments system and utilization process.38 The integration process for the ADEA Compendium is planned to start with programs submitting their assessment plan to a centralized service similar to other centralized academic services. The program’s assessment plan will be reviewed to ensure it meets the criteria for each

Students should be able to independently perform the procedure at a level that meets or exceeds the institution’s criteria on multiple occasions.

clinical area. The program’s assessment plan will also be used to customize those areas of the assessments system in the mobile application for use by the program and establish the centralized data cache for the student outcomes.

Once modified, the faculty, staff and students will be calibrated on the data entry process as well as the elements of the rubric. The ADEA Compendium evaluation could be directly entered into a field on a mobile application and is designed for efficient entry of the evaluation. The entry can be input as an existing institution’s current grading scale or it can be derived from identification of keywords. Keyword utilization assists with automatic development of specific areas for improvement or demonstrated ability.

Feedback has consistently supported one uniform system within an institution rather than a separate one for clinical licensure. The use of a separate database for clinical evaluations assures that student assessment information is discrete from the patient’s electronic health record for legal purposes. The ADEA Compendium is designed to have minimal impact on a program’s criteria for meeting their clinical care expectations and an existing numerical or qualitative measure can be indexed to the ADEA Compendium scale. The role of the faculty is to provide evaluations longitudinally throughout the student’s clinical education program.

The students’ goals throughout the ADEA Compendium integration are well-aligned with an expected learning trajectory. Students learn to consistently provide care that meets or exceeds their program’s expectations in the four domains of the ADEA Compendium with gradually increasing levels of independence. Once the student and faculty are confident of the students’ ability, the students are expected to complete the procedure independently.

Faculty evaluate the procedure at the steps determined by their school to assure that it both meets expectations and that the student is performing independently.

Faculty have the option to intervene if needed and the student would then need to attempt the procedure independently at another time. Competency in a clinical discipline is demonstrated by completing multiple procedures that meet or exceed expectations without the need for faculty intervention.

The students’ outcomes are submitted to the testing agency or licensing body depending upon the state’s rules and regulations. When used for licensure, students who complete the ADEA Compendium, pass the National Board Dental Exam and JULY 2 0 2 0 327

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graduate from a CODA-accredited program would complete other state procedures (jurisprudence, infection control, etc.) and be issued a license.

The ADEA Compendium workgroup anticipates that implementation would include oversight such as approval of faculty as compendium evaluators, recalibration of faculty and periodic evaluation of the school’s records/process.

Oversight measures could be provided from the centralized service or testing agencies or implemented by the states.

Conclusion

The entire profession of dentistry is bolstered by an initial licensure process that authentically represents students’ readiness for practice or for entry into advanced dental education.

The predominant clinical licensure exam process poses significant ethical challenges, incurs extraordinary direct and indirect costs, does not align with changes in dental education or dental practice and does not possess sufficient validity and reliability. Modernization of the clinical licensure process requires transformative changes that should be broadly supported throughout the profession.

The ADEA Compendium is currently under development and could be an instrument of change in the dental licensure process.

The ADEA Compendium is a combination of purposeful design, offers appropriate educational program flexibility, uses evaluation by calibrated faculty and streamlined reporting within a standardized format. As a result, the ADEA Compendium will achieve the following:39 ■ Provide a process of valid and reliable assessment of clinical competency that is completely integrated within the clinical education experience.

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Produce standardized ongoing demonstration of student performance and faculty calibration to achieve clinical competency.

■ Serve as a pathway for licensure upon graduation using accepted, valid and reliable assessments of readiness for practice.

The ADEA Compendium integration process is planned to allow educational programs to integrate with minimal disruption of existing assessment processes. At the same time, the ADEA Compendium is designed to bring maximal value in support of dental education’s role in assessment of student competency while retaining third-party oversight of the process.

There is an established axiom in education that “assessment drives student behavior.” With the ADEA Compendium, students are assessed on the full range of knowledge, skills and aptitudes needed for appropriate patient care, not just the technical skills of a procedure for licensure. The assessments system incentivizes students to learn to provide care independently that meets or exceeds their institution’s criteria.

The ADEA Compendium of Clinical Competency Assessments can serve as a transformative 21st century approach to the clinical licensure process that represents the dental profession’s commitment to the public we serve. n ■

APPENDICES Appendix A. Compendium Definition

compendium plural compendiums or compendia 1: a brief summary of a larger work or of a field of knowledge :abstract a one-volume compendium of the multivol ume original 2a: a list of a number of items

2b: collection, compilation a compendium of folk tales Synonyms album, collectanea, anthology, compilation, florilegium merriam-webster.com

Appendix B ADEA Compendium Workgroup

B. Ellen Byrne, RPh, DDS, PhD, senior associate dean and professor, Virginia Commonwealth School of Dentistry Kim Fenesy, DMD, vice dean, Rutgers School of Dental Medicine Steven W. Friedrichsen, DDS, professor and dean, Western University of Health Sciences College of Dental Medicine, ADEA Compendium Workgroup chair Nicole Kimmes, DDS, associate dean of curriculum inte gration and analytics, University of New England College of Dental Medicine Janet Kinney, RDH, MS, clinical associate professor and director, division of dental hygiene, University of Michigan School of Dentistry David Lazarchik, DMD, associate dean for clinical initiatives and program development, Western University of Health Sciences College of Dental Medicine Timothy J. Treat, DDS, visiting clinical fellow, department of comprehensive care and general dentistry, Indiana University School of Dentistry Ann O’Kelley Wetmore, RDH, BS, MSDH, associate professor, department chair, Eastern Washington University College of Health Science and Public Health Denice Stewart, DDS, MHSA, chief policy officer, American Dental Education Association, ADEA Compendium Workgroup staff liaison

C D A J O U R N A L , V O L 4 8 , Nº 7

Appendix C. CODA Standard 2 Educational Program Critical thinking (Standard 2-9) Self-assessment (Standard 2-10) Biomedical sciences (Standards 2-11, 2-12, 2-13, 2-14) Behavioral sciences (Standards 2-15, 2-16) Practice management and health care systems (Standards 2-17, 2-18, 2-19) Ethics and professionalism (Standard 2-20) Clinical sciences (Standards 2-21, 2-22, 2-23, 2-24, 2-25) Source: American Dental Association Health Policy Institute, 2018–2-19 Survey of Dental Education: Part IV–curriculum.

Questions 1a–27a.

Appendix D. ADEA Compendium Foundational Evaluation Components Competence: “… three elements — multiple assessments, over time, with multiple evaluators — provides the best strategy for global assessment of student competence in a valid and reliable manner …”31 Independence: Natural progression of learning leads to independently and repeatedly providing care that meets or exceeds expectations.32 Fidelity: Students performing patient care that is assessed in multiple dimensions in an authentic setting and process as occurs in practice.37 REFERENCES 1. Chambers DW, Dugoni AA, Paisley I. The case against oneshot testing for initial dental licensure. J Calif Dent Assoc 2004 Mar;32(3):243–6, 248–52.

2. Friedland B, Valachovic RW. The regulation of dental licensing: The dark ages? Am J Law Med 1991;17(3):249–70.

3. Chambers DW. Disciplined dental licenses: An empirical study. J Am Col Dent Spring 2018; 852:30–39.

4. Papadakis MA, et al. Disciplinary action by medical boards and prior behavior in medical school. N Engl J Med 2005 Dec 22;353(25):2673–82. doi: 10.1056/NEJMsa052596.

5. Buchanan RN. Problems related to the use of human subjects in clinical evaluation: Responsibility for follow-up care.

J Dent Educ 1991 Dec;55(12):797–801.

6. Ranney RR, Haden NK, Weaver RW, Valachovic RW. A survey of deans and ADEA activities on dental licensure issues.

J Dent Educ 2003 Oct;67(10):1149–1160.

7. Lantzy MJ, Muzzin KB, DeWald JP, Solomon ES, Campbell PR, Mallonee L. The ethics of live patient use in dental hygiene clinical licensure examinations: A national survey. J Dent Educ 2012 Jun;76(6):667–681.

8. Kane MT. The validity of licensure examinations. Am Psychol 1982 Aug;37(8):911–918. doi.org/10.1037/0003066X.37.8.911.

9. Formicola AJ, Lichetenthal R, Schmidt HJ, Myers R. Elevating clinical licensing examinations to professional testing standards. N Y State Dent J 1998; Jan:38–44.

10. Gerrow JD, Murphy HJ, Boyd MA, Scott DA. An analysis of the contribution of a patient-based component to a clinical licensure exam. J Am Dent Assoc 2006 Oct;137(10):1434– 1439. doi: 10.14219/jada.archive.2006.0057.

11. Chambers DW. Board to board consistency in initial dental licensure examinations. J Dent Educ 2011 Oct;75(10):1310– 1315.

12. American Dental Hygienists’ Association. Standards for Clinical Dental Hygiene Practice. Revised June 2016. www. adha.org/resources-docs/2016-Revised-Standards-forClinical-Dental-Hygiene-Practice.pdf.

13. Mohan M, Sundari Ravindran TK. Conceptual framework explaining “preparedness for practice” of dental graduates: A systematic review. J Dent Educ 2018 Nov;82(11):1194– 1202. doi: 10.21815/JDE.018.124.

14. Chambers DW. Boards should be based on multiple tests using patients. J Am Col Dent Spring 2017; 84(2):2–3.

15. American Student Dental Association. White paper: Use of human subjects in clinical licensure examinations. Oct. 31, 2016.

16. Ranney RR, Gunsolley JC, Miller LS, Wood M. The relationship between performance in a dental school and performance on a clinical examination for licensure: A nineyear study. J Am Dent Assoc 2004; 135(8):1146–1153. doi: 10.14219/jada.archive.2004.0374.

17. Bertolami CN. President-Elect’s Address. J Dent Educ 2008; 72(7):758–759.

18. Chambers DW. Portfolios for determining initial licensure competency. J Am Dent Assoc 2004 Feb;135(2):173–184. doi: 10.14219/jada.archive.2004.0149.

19. Abdelkarim A, Sullivan D. Attitudes and perceptions of U.S. dental students and faculty regarding dental licensure. J Dent Educ 2015 Jan;79(1):81–88.

20. Kleiner MM. Reforming occupational licensing policies (discussion paper 2015–01). Washington D.C.: The Hamilton Project, Brookings; 2015.

21. U.S. Department of Treasury Office of Economic Policy, Council of Economic Advisors, U.S. Department of Labor.

Occupational licensing: A framework for policymakers.

Washington, D.C.: U.S. Department of Treasury, U.S. Department of Labor, 2015.

22. Johnson JE, Kleiner MM. Is Occupational Licensing a Barrier to Interstate Migration? (NBER Working Paper No. 24107). Cambridge, Mass.: National Bureau of Economic Research: December 2017.

23. Chambers DW, Glassman P. A primer on competencycased evaluation. J Dent Educ 1997 Aug;61(8):651–66.

24. Von Bergmann H, et al. Designing and implementing a competency-based formative progress assessment system at a

Canadian dental school. J Dent Educ 2018 Jun;82(6):565– 574. doi: 10.21815/JDE.018.063.

25. ADEA Summit on the Future of Dental Assessment in Dental Education. Summary Notes Feb. 6–7, 2019. www. adea.org/ADEA/ADEA_SummitFeb2019.aspx. Accessed Jan. 10, 2020.

26. Dental Board of California. California Hybrid Portfolio Examination for dental licensure. www.dbc.ca.gov/applicants/ licensure_by_portfolio.shtml. Accessed January 2020.

27. Canadian OSCE accepted for licensure in Minnesota. www.ada.org/en/education-careers/licensure/licensuredental-students/licensure-pathways. Accessed January 2020.

28. American Dental Education Association Task Force on Licensure Update on the ADEA Task Force on Licensure’s Recommendations Toward Elimination of the Human Subject/ Patient Component of the Clinical Licensure Exam. January 2016.

29. Report of the Task Force on Assessment of Readiness for Practice. A Joint Task Force of American Dental Association, American Dental Education Association and American Dental Student Association. September 2018. www.dentallicensure. org/~/media/ADA/Education%20and%20Careers/Files/ report_taskforce_assessment_of_readiness_for_practice. pdf?la=en. Accessed November 2019.

30. Coalition for Modernizing Dental Licensure. www. dentallicensure.org/en. Accessed January 2020.

31. Gadbury-Amyot CC, Overman PR. Implementation of portfolios as a programmatic global assessment measure in dental education. J Dent Educ 2018 Jun;82(6):557–564. doi: 10.21815/JDE.018.062.

32. Core Entrustable Professional Activities for Entering Residency. American Association of Medical Colleges 2014.

Washington D.C. www.aamc.org/system/files/c/2/484778epa13toolkit.pdf.

33. Sebok-Syer SS, Chahine S, Watling CJ, Goldszmidt M, Cristancho S, Lingard L. Considering the interdependence of clinical performance: Implications for assessment and entrustment. Med Educ 2018 Apr 19. doi: 10.1111/ medu.13588. [Epub ahead of print].

34. Smith HL, Craig SR, Yost WJ. Examination of entering residents’ self-reported confidence and supervision needs performing AAMC Entrustable Professional Activities. J Grad Med Educ 2018 Aug;10(4):474. doi: 10.4300/ JGME-D-18-00520.1.

35. Strowd RE, McBride A, Goforth J, et al. Educational priorities of students in the entrustable professional activity era. Clin Teach 2018 Aug;15(4):319–324. doi: 10.1111/ tct.12688. Epub 2017 Aug 30.

36. United States Trademark Office. Registration Number 5,782,091; Accepted May 2019.

37. Holmbee ES, Durning SJ, Hawkins RE. Practical guide to the evaluation of clinical competency. 2nd ed. Philadelphia: Elsevier; 2017.

38. Summary — ADEA summit on the future of assessment in dental education. Feb 6–7, 2019. Washington D.C. www. adea.org/ADEA/ADEA_SummitFeb2019.aspx. Accessed January 2020.

39. Stewart DC. Chief Policy Officer, American Dental Education Association personal email communication, Jan. 24, 2020. Washington, D.C. THE AUTHOR, Steven W. Friedrichsen, DDS, can be reached at sfriedrichsen@westernu.edu.

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osce C D A J O U R N A L , V O L 4 8 , Nº 7

The Dental Licensure OSCE: A Modern Licensure Examination for Dentistry Anthony J. Ziebert, DDS, MS, and David M. Waldschmidt, PhD

a b s t r a c t Objective structured clinical examinations (OSCEs) have been used

to assess clinical skills in the health sciences for over 40 years and have a proven track record when used by boards to determine whether a licensure candidate possesses the necessary level of skills to practice. A dental licensure OSCE is being developed by the Joint Commission on National Dental Examinations. Extensive field testing will be conducted to ensure there is validity evidence supporting use of the dental licensure OSCE. Dental boards will be provided the necessary validity evidence supporting use of the DLOSCE to identify candidates who do and do not possess the level of dental clinical skills that are necessary to safely practice.

AUTHORS Anthony J. Ziebert, DDS, MS, received his dental degree from the Georgetown University School of Dentistry and a certificate in general practice from the Veteran’s Administration Hospital in Milwaukee and a MS in prosthodontics from Marquette University. He currently is the senior vice president for education and professional affairs at the American Dental Association and maintains a part-time private practice in Milwaukee limited to prosthodontics.

Conflict of Interest Disclosure: None reported.

David M. Waldschmidt, PhD, is the director of testing services for the American Dental Association and the director of the Joint Commission on National Dental Examinations. He holds a PhD in industrialorganizational psychology and has worked in the professional testing industry for over 20 years. Dr. Waldschmidt has authored papers published in the Journal of Dental Education and the journal Industrial and Organizational Psychology: Perspectives on Science and Practice and presented at many meetings.

Conflict of Interest Disclosure: None reported.

A

n objective structured clinical examination (OSCE) is a type of highstakes examination widely used in the health sciences, including midwifery, occupational therapy, optometry, medicine, physician assistants/associates, physical therapy, radiography, rehabilitation medicine, nursing, pharmacy, podiatry and veterinary medicine.1 Introduced in the 1970s, OSCEs are now part of the U.S. Medical Licensing Examination for all U.S. medical graduates.2 Developed to assess the complex notion of clinical competence in the medical field, the OSCE is a performance-based examination that typically utilizes multiple stations with examinees performing various clinical tasks at each station.3 Test-takers rotate through a set

number of stations, with a time limit to complete the task at each station.

For more complex tasks, time can be extended by yoking adjacent stations together, effectively doubling or tripling the available time. Tasks may include test results interpretation, history taking, physical examination, patient education, order writing and/or other activities. Over time, most medical OSCEs have come to rely on standardized patients (SPs) at many of the stations. SPs are often highly trained actors who will portray a patient with a particular disease or condition, thus affording the evaluator an opportunity to witness the candidate provide a hands-on demonstration of their skills. Candidates can also interview the SP while they perform a physical examination, enabling a highly interactive diagnostic experience.

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The standardized nature of the OSCE is key to its validity and consequently its success as a measurement tool. The use of trained actors serving as standardized patients provides a fair and level playing field for assessment, with little to no variation in the patient serving as the target of candidates’ evaluation.

Candidates face the same tasks and constraints under identical conditions and are evaluated against the same performance criteria. This is in contrast to evaluative work with live patients who — even if they have the same diagnosis — may differ substantially in both subtle and not-so-subtle ways that impact accurate candidate skill measurement. Due to its validity and success, the OSCE method, as used today, has evolved into a flexible testing approach that can incorporate SPs as well as observer ratings, short written tests and other tools to provide a comprehensive clinical evaluation.4 In an OSCE, it is the examinee’s clinical skills and the actions they take when faced with a patient or clinical situation that are assessed. In other words, OSCEs focus on the application of knowledge and skills to practice so that the examinee’s level of competence can be understood.5 OSCEs were introduced in medicine as a replacement for the traditional clinical examination, which had proven to be unsatisfactory for several reasons in the evaluation of medical student skills.6 Over the years and throughout the health-related professions, the OSCE has become not only the gold standard for performance assessment, but also has had the ancillary benefit of impacting student learning and curriculum.7–9 Compared to traditional clinical examinations, OSCEs provide consistent, stable results and represent a valid method of skill evaluation that is rigorous in its measurement of clinical competence, providing strong evidence of content 332 JULY

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validity.10 OSCEs are also flexible and can be used to assess individuals in a range of situations, including undergraduate, graduate, continuing education, licensure and certification.11,12 Finally, OSCEs possess high levels of face validity and are perceived by both students and examiners as being a fair and acceptable tool to assess clinical competence.13 While OSCEs have been used by dental educators for many years as an assessment mechanism,14–16 their potential for use in informing U.S. dental licensure decisions has not been recognized until

OSCEs focus on the application of knowledge and skills to practice so that the examinee’s level of competence can be understood.

recently, despite its use in this capacity in Canada since the 1980s. The National Dental Examining Board (NDEB) of Canada’s OSCE is currently implemented as a multiple-choice examination that utilizes separate stations containing images and physical objects, such as radiographs, photographs and typodonts.17 Over the years, the NDEB of Canada OSCE has accumulated a substantial amount of validity evidence that supports its usage, including published articles and annual technical reports that document the examination’s validity and reliability as it informs licensure decisions.18 In one published article, Gerrow et al. obtained a positive correlation between student performance in the final year of dental school and performance on the OSCE (r = 0.46, p < .001) for examinations

completed between 1995 and 2000. Yearto-year and school-to-school variations in performance were found to be minimal.19 On the basis of such findings, U.S. dental boards have begun to take notice.

Currently, three U.S. dental boards accept a passing grade on the NDEB of Canada OSCE as evidence that a candidate for licensure possesses the level of clinical skills necessary to safely practice: Minnesota, Colorado and Washington.

Minnesota limits the acceptance of Canadian OSCE results to graduates of the University of Minnesota’s dental program.

In 2017, the American Dental Association (ADA) Board of Trustees formed a Dental Licensure OSCE (DLOSCE) steering committee and allocated funding to begin development of a U.S. DLOSCE. DLOSCE development would be overseen by the steering committee, working in close partnership with the ADA’s department of testing services (DTS), which is staffed by a team of examination professionals, many of whom possess advanced degrees in psychometrics, industrial/organizational psychology and related fields. The DTS has a long history of developing valid and reliable high-stakes examinations both for licensure (the National Board Dental Examination (NBDE) Part I and Part II; the Integrated National Board Dental Examination) and dental program admissions (Dental Admission Test and the Advanced Dental Admission Test).20–22 The dental licensure examinations — currently the NBDE Part I and NBDE Part II — have been administered since 1980 under the governance of the Joint Commission on National Dental Examinations (JCNDE). Passing grades on the NBDEs are required by every licensing jurisdiction in the U.S. for candidates to obtain initial licensure. Though requirements vary by state and jurisdiction, all dental

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licensure applicants must meet three basic requirements: education (graduation from a Commission on Dental Accreditation (CODA)-accredited or CODArecognized dental education program), a written examination (NBDE Parts I and II; Integrated National Board Dental Examination starting in August 2020) and a demonstration of clinical competence.

In the past, dental boards understandably relied on the single-encounter, procedure-based clinical examination of a patient as the examination modality to demonstrate the clinical competence of a licensure candidate. There were few proven alternatives. In addition, there were varying points of view regarding the perceived rigor of the CODA accreditation process and corresponding questions concerning the scope and rigor of school-based assessment procedures.

However, thanks to over 25 years of hard work and the adoption and evolution of competency-based education in accredited dental schools, as well as the identification of new, effective pathways for dental clinical assessment, dental boards no longer need to rely on the legacy single-encounter approach for the clinical assessment of licensure candidates. The legacy approach is subject to random error; does not have strong validity evidence; inadequately samples tasks from the domain of clinical dentistry; is not reflective of the broad set of skills and knowledge expected of a dentist; and poses ethical challenges for test-takers, dental schools and the dental profession.23–28 The ADA has recognized many of these shortcomings since the late 1990s, when it adopted policies calling for increased portability of dental licenses through development of a national clinical examination in the same vein as the national board written examinations and when it adopted policies calling for the elimination

of the procedure-based treatment of patients in the clinical examination process.29 In funding the development of an OSCE for dental licensure, the ADA believes that a reliable and valid dental OSCE provides a proven testing modality that dental boards can use with confidence in determining whether a candidate for licensure is competent to practice dentistry. Use of an OSCE enhances dental boards’ ability to screen out incompetent beginning practitioners, enabling boards to better fulfill their duty to protect the public.

Dental boards no longer need to rely on the legacy single-encounter approach for the clinical assessment of licensure candidates.

The purpose of the DLOSCE program is to identify whether a candidate for dental licensure possesses the level of clinical skills that is necessary for the competent practice of dentistry. The program accomplishes this through the use of a valid and reliable examination that has been professionally developed and scored. Successful candidates will have demonstrated the ability to recall important information from the clinical dental sciences and will have applied their skills in an applied, problem-solving context. The DLOSCE will be a national exam with no variation in examination content. This means that content will not be based on the region of the country where it is administered nor on variation of curriculum at different dental schools.

DLOSCE development is informed by the

Standards for Educational and Psychological Testing30 that provides considerations for developing, implementing and evaluating examinations. The standards were developed by the American Educational Research Association (AERA), American Psychological Association (APA) and the National Council on Measurement in Education (NCME) and provide considerations for developing, implementing and evaluating tests. The standards and industry best practices help guide DLOSCE development activities as the DLOSCE is designed, constructed and implemented. In developing the DLOSCE, the focus is on validity. Validity concerns the evidence that supports the interpretation and use of examination results relative to its intended purpose.

Validity is the most important and most fundamental consideration in developing and evaluating tests.30 A validity argument lays out the evidence in support of a specific interpretation of a test score (Standard 1.0). The standards indicate that clear articulation of each intended test score interpretation for a specified use should be set forth and appropriate validity evidence in support of each intended interpretation should be provided.30 In testing, reliability refers to the consistency and precision of scores across replications of a testing procedure.30 Standard 2.0 states that, “Appropriate evidence of reliability/precision should be provided for the interpretation for each intended score use.”30 Reliability is reduced by random error, which can be caused by such things as fluctuations in candidate attention or memory, momentary distractions present in the testing environment and inconsistencies in examiner ratings. Evidence of high-score reliability strengthens a validity argument.

Reliability is necessary for validity, but caution is warranted when placed in assessment situations where one is forced JULY 2 0 2 0 333

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to choose between maximizing validity or maximizing reliability. Validity remains the focal, fundamental consideration.

Development of the DLOSCE is being overseen by the DLOSCE steering committee, which is composed of general practitioners in private practice; educators with experience teaching comprehensive, general dentistry in dental school clinics; current state dental board members; and consultants with experience in developing an OSCE for licensure purposes. The steering committee was charged with the following: ■ Identify and establish the content domain and test specifications for the examination through utilization of a practice analysis.

■ Establish the general structure for the examination (number of stations) and permissible item formats.

■ Identify and contract with key vendors (e.g., technology, administration) in support of the examination.

■ Identify and establish test construction team (TCT) structure based on the content domain and test specifications.

■ Call for TCT member applications and appoint members to the TCTs. TCT members develop the test questions for the examination.

■ Administer and interpret the results of the DLOSCE field tests.

■ Develop the candidate guide.

■ Identify the appropriate governance structure for DLOSCE administration.

The steering committee has held regular, face-to-face meetings since 2017 and has made significant progress in all areas of its charge, in addition to completely fulfilling its charge in several areas. The establishment of the DLOSCE content domain and test specifications 334 JULY

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represented a key early accomplishment.

This occurred through the formation of a subject-matter expert panel that carefully considered the appropriate role of a modern dental clinical licensure examination and the areas of content that must be considered to safely protect the public. The panel considered data from multiple relevant sources and, most importantly, the results of a 2016 dental practice analysis involving over 2,500 entry-level general dentists practicing throughout the U.S. and its jurisdictions.

As highlighted by the Standards for

Taken as a whole, the DLOSCE test constructor pool includes more than 170 subject-matter experts, including general dentists and specialists.

Educational and Psychological Testing, practice analysis plays a vital role in properly establishing the content domain of a high-stakes licensure examination.

Practice analyses for licensure purposes in the health sciences — including dentistry — involve soliciting ratings from practicing entry-level professionals concerning the tasks performed and the frequency and criticality of those tasks to patient care. This in turn is used to understand and identify the knowledge, skills, abilities and other characteristics (KSAOs) that are required to perform those tasks. The information obtained from this exercise for the DLOSCE was used by subject-matter experts to determine the number of items that would be devoted to each area of competency.

This in turn informed the structure and

expertise-related composition of TCTs charged with the task of developing and reviewing examination content.

The judgment of subject-matter experts was critical to each step in this process to help ensure that the examination properly reflected the breadth and complexity of clinical dental skills required for safe entry-level practice.

DLOSCE questions are focused exclusively on the clinical tasks a dentist performs while providing direct, chairside treatment to patients. Based on the aforementioned test specifications, topic areas included in the DLOSCE are as follows: restorative dentistry, prosthodontics, periodontics, oral surgery, endodontics, orthodontics, prescription writing, medical emergencies, oral pathology, pain control and temporomandibular dysfunction.

Diagnosis, treatment planning and occlusion are assessed across the topic areas listed above. The examination includes questions involving each of the following patient types: pediatric, geriatric, special needs and medically complex. DLOSCE questions can include one or more correct answers, one or more critical errors and response options that are unscored (neither contributing nor deducting from the points awarded for the question).

Answering questions correctly without missing points due to a critical error requires depth and breadth of clinical judgment with emphasis on clinical application and synthesis of clinical knowledge (as opposed to simple recall).

The steering committee established a separate DLOSCE working committee comprised of subject-matter experts to guide and facilitate the test question development process. Calls for test constructor applications for the DLOSCE were quite successful. Taken as a whole, the DLOSCE test constructor pool

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includes more than 170 subject-matter experts, including general dentists and specialists, who the DLOSCE steering and working committees can draw upon to develop and review DLOSCE questions and stimulus materials. The first series of DLOSCE TCT meetings took place between February and November 2019 resulting in the development of several hundred potential examination questions. In addition to the development and review work occurring within each DLOSCE TCT, each DLOSCE question is also separately reviewed by a panel of general dentists to help confirm and ensure clinical relevance and the appropriateness of the content in service to the examination purpose.

In designing the DLOSCE, the steering committee considered various question types, measurement methodologies and presentation formats as well as administration vendors who would be capable of presenting this information accurately and efficiently to candidates. The committee determined that the DLOSCE would best and most accurately evaluate candidate skills when implemented as a computer-administered examination, and it selected a test administration vendor accordingly.

The committee considered various technologies and determined that 3D representations have developed to the point where 3D models accompanied by software enabling the candidate to rotate, move and enlarge the models can provide an interactive experience of such high fidelity that the candidate experience closely mirrors the experience of the practicing entry-level dentist. This realization represents an advancement of the OSCE methodology beyond its current focus on stations and physical materials.

Utilization of 3D interactive models to modernize dental licensure represents an important advancement not only to the

OSCE methodology itself, but also to the evaluation of dental candidate clinical skills within the dental licensure process.

In considering the DLOSCE, a common question concerns the difference between the DLOSCE and the Integrated National Board Dental Examination (INBDE). Both of these examinations are computer administered, both assess clinical skills (e.g., diagnosis and treatment planning, oral health management) and there is certainly overlap in the tested topics. However, despite surface similarities, closer inspection reveals

The committee determined that the DLOSCE would best and most accurately evaluate candidate skills when implemented as a computeradministered examination. the presence of key differences. As indicated previously, the DLOSCE focuses exclusively on the clinical tasks a dentist performs while providing direct, chairside treatment to patients. This narrow focus includes microjudgments, the recognition of errors in treatment and knowledge of success criteria. In contrast, the INBDE focuses on cognitive skills and the biomedical underpinnings of clinical decisions. The INBDE has a broader focus that includes practice and professional considerations, evidencebased dentistry, understanding research and patient oral health care education.

The INBDE also evaluates candidate understanding of the reasoning behind decisions (e.g., mechanisms of action and the reasons why certain clinical outcomes are anticipated). An example of the

difference between the examinations can be illustrated with questions related to the topic of pharmacology. For the INBDE, pharmacology questions require in-depth knowledge of microbiology, pharmacokinetics and pathology as foundational knowledge areas. For the DLOSCE, a candidate would simply be asked to write a prescription for the appropriate drug based on the clinical situation presented in the question.

A related question concerns the difference between the Advanced Dental Admission Test (ADAT) and both the DLOSCE and INBDE. Once again, while each of these examinations is computer administered and there is some overlap in clinical science topics, these examinations are fundamentally different. The ADAT is a norm-referenced examination designed to help advanced dental education program directors understand applicants’ likelihood of success in advanced dental education programs and to give these directors the ability to rank order applicants based on their potential for success. On the other hand, the DLOSCE and INBDE are criterion-referenced examinations designed to help dental boards determine whether a candidate for licensure possesses the level of clinical skills that is necessary to practice safely.

The norm-referenced methods for interpreting ADAT results — where applicant performance is considered relative to the performance of others — stands in sharp contrast to the criterionreferenced methods for interpreting DLOSCE and INBDE results where candidate performance is interpreted relative to specific skill requirements established through standard activities involving subject-matter expert review of a content domain. In accordance with these principles, for the ADAT, JULY 2 0 2 0 335

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education programs and applicants receive quantitative scale scores that facilitate applicant comparison. Scale scores range from 200 to 800 with a target mean of 500 and a target standard deviation of 100. In contrast, DLOSCE and INBDE performance is simply reported as “pass” or “fail,” with the corresponding standard determined by a panel of subject-matter experts charged with the task of reviewing test content relative to a domain to identify the level of clinical skills required to safely practice. This panel is composed of a representative group of dental board members, general practitioners (both entry level and more experienced) and clinical dental educators. In accordance with the purposes of these two examinations, test-takers whose performance meets or exceeds the established standard are simplify notified that they have passed the examination (i.e., no additional performance information is reported to these individuals). Individuals whose performance falls short of the standard are informed that they have failed the examination. These individuals are in turn provided with additional performance information to help them understand the areas where remediation would be beneficial. Lastly, there are test scales that are exclusive to the ADAT, including biomedical sciences (anatomic sciences, biochemistry, physiology, microbiology and pathology) and data (research interpretation and evidence-based dentistry). In comparison, DLOSCE topics relate exclusively to clinical decision-making.

With regard to the INBDE, biomedical science questions are presented in an applied clinical context, whereas for the ADAT, biomedical science questions are presented in a pure format (not integrated). In other words, the 336 JULY

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emphasis on the ADAT rests with the test-taker’s discrete knowledge of biomedical and clinical science concepts. In contrast, the INBDE emphasizes clinical relevance and whether candidates can appropriately integrate foundational knowledge areas and clinical content areas to make appropriate treatment decisions.

As indicated previously, an important charge of the DLOSCE steering committee involved the identification of a suitable governing body for the examination program. For the first few

The JCNDE released the DLOSCE for use by dental boards to determine a licensure candidate’s competence as a safe, beginning practitioner in June 2020. years of DLOSCE development, the DLOSCE steering committee operated as a committee of the ADA Board of Trustees. During this time, in accordance with the aforementioned charge, the steering committee carefully and thoughtfully considered issues involving DLOSCE governance. Licensure examination programs involve a public trust that requires the examinations be administered and decisions made in a consistent manner that is as free from bias and conflict of interest as possible.

Similarly, confidentiality protections and due process must be afforded to candidates seeking licensure. Given the preceding, the steering committee determined that governance by a commission would be most appropriate. Through the promulgation of policies and procedures

in accordance with the ADA bylaws’ mandated duties, a commission endeavors to protect the public and conduct its activities with integrity in a manner befitting its charge. Commissions have mechanisms in place to guard against any particular community of interest having an undue influence on decisions and program administration. In considering these issues further, the steering committee concluded that the Joint Commission on National Dental Examinations would represent an ideal choice to administer the DLOSCE, as the Joint Commission is a wellrespected and trusted agency that has been developing and administering written licensure examinations that are accepted by all U.S. licensure jurisdictions since 1990. This led to a conversation between the steering committee and the JCNDE during which both parties recognized the merits of this line of thought. In December 2019, the ADA Board of Trustees received a corresponding report from the steering committee and formally made the decision to assign governance of the DLOSCE to the JCNDE, maintaining the makeup of the DLOSCE steering committee for continuity purposes and placing it as a committee of the JCNDE. The steering committee will be sunset once field test results provide strong evidence that the examination is valid and reliable and once the steering committee has successfully fulfilled its charge. At that time, the oversight, administration and continued development of the DLOSCE will be fully integrated into the standard organizational structure of the JCNDE. The JCNDE released the DLOSCE for use by dental boards to determine a licensure candidate’s competence as a safe, beginning practitioner in June 2020.

In conclusion, OSCEs have been used to assess clinical skills in the health sciences for over 40 years. OSCEs have a proven track record when used by

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boards to determine whether a licensure candidate possesses the necessary level of skills to safely practice at an entry level.

DLOSCE development activities are guided by the Standards for Educational and Psychological Testing and industry best practices (i.e., releasing annual technical reports with reliability and validity evidence for the examinations) and implemented by a professional staff operating under the oversight of a commission of the ADA (JCNDE) with strong protections in place to help reduce conflicts of interest. The JCNDE pursues DLOSCE activities through a DLOSCE steering committee with a clearly defined charge. DLOSCE development efforts involve a working committee and a substantial number of highly educated and trained dental subject-matter experts. There will be extensive field testing of the DLOSCE to provide dental boards with the necessary validity evidence supporting use of the DLOSCE to identify candidates who do and do not possess the level of dental clinical skills that are necessary to safely practice. The standardized nature of the DLOSCE is key to its validity. The DLOSCE format addresses many of the shortcomings of current legacy single-encounter, procedurebased clinical examinations involving varied patients and advances the OSCE methodology through utilization of sophisticated 3D models with high fidelity. Administration of the DLOSCE by the Joint Commission on National Dental Examinations, an agency with a long track record of providing valid and reliable licensure examinations to all U.S. licensing jurisdictions, provides further confidence to dental boards that the DLOSCE will serve as a strong tool that can be confidently used by boards to understand candidate clinical skills and protect the public health. n

REFERENCES 1. OSCE. Objective structured clinical examination. www. oscehome.com/What_is_Objective-Structured-ClinicalExamination_OSCE.html.

2. Federation of State Medical Boards (FSMB) and National Board of Medical Examiners NBME). USMLE Bulletin of Information. 2019. www.usmle.org/pdfs/ bulletin/2020bulletin.pdf.

3. Harden RM, Lilley P, Patrício M. The Definitive Guide to the OSCE. Edinburgh: Elsevier; 2016:A1.

4. Turner JL, Dankoski ME. Objective structured clinical exams: A critical review. Fam Med 2008 Sep;40(8):574–8. PMID: 18988044.

5. Harden RM, Lilley P, Patrício M. The Definitive Guide to the OSCE. Edinburgh: Elsevier; 2016:A7.

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7. Harden RM, Lilley P, Patrício M. The Definitive Guide to the OSCE. Edinburgh: Elsevier; 2016:A33.

8. Conto LB, Durand MT, Wolff, ACD, et al. Formative assessment scores in tutorial sessions correlates with OSCE and progress testing scores in a PBL medical curriculum.

Med Educ Online 2019 Dec;24(1):1560862. doi: 10.1080/10872981.2018.1560862.

9. Kumar V, Gadbury-Amyot CC. Predoctoral curricular revision for dental interpretation competence based on OSCE results. J Dent Educ 2019 Oct;83(10):1233–1239. doi: 10.21815/ JDE.019.112. Epub 2019 Jun 10.

10. Goh HS, Zhang H, Lee CN, Wu XV, Wang W. Value of nursing objective structured clinical examinations: A scoping review. Nurse Educ 2019 Oct;44(5):E1–E6. doi: 10.1097/ NNE.0000000000000620.

11. Dong T, Swygert KA, Durning SJ, et al. Validity evidence for medical school OSCEs: Associations with USMLE step assessments. Teach Learn Med 2014;26(4):379–86. doi: 10.1080/10401334.2014.960294.

12. Warner DO, Isaak RS, Peterson-Layne C, et al.

Development of an objective structured clinical examination as a component of assessment for initial board certification in anesthesiology. Anesth Analg 2020 Jan;130(1):258–264. doi: 10.1213/ANE.0000000000004496.

13. Bousicot KAM, Roberts TE, Burdick WP. Structured assessments of clinical competence. In: Swanwick T, ed.

Understanding Medical Education Evidence, Theory and Practice. 2nd ed. Chichester, U.K.: John Wiley and Sons; 2014:246–258.

14. Graham R, Zubiaurre Bitzer LA, Anderson OR. Reliability and predictive validity of a comprehensive preclinical OSCE in dental education. J Dent Educ 2013 Feb;77(2):161–7.

15. Pack SE, Anderson NK, Karimbux NY. OSCE and case presentations as active assessments of dental student performance. J Dent Educ 2016 Mar;80(3):334–338.

16. Zartman RR, McWhorter AG, Seal NS, Boone WJ. Using OSCE-based evaluation: Curricular impact over time. J Dent Educ 2002 Dec;66(12):1323–1330.

17. The National Dental Examining Board of Canada. OSCE. 2019. ndeb-bned.ca/en/accredited/osce-examination.

18. The National Dental Examining Board of Canada.

Technical Report: Objective Structured Clinical Examination. 2019. ndeb-bned.ca/sites/ndeb/files/pdf/ TechnicalManuals/2018/acj_2018_technical_report_ approved091419.pdf.

19. Gerrow JD, Murphy HJ, Boyd MA, Scott DA. Concurrent validity of written and OSCE components of the Canadian dental certification examinations. J Dent Educ 2003 Aug;67(8):896-901.

20. Joint Commission on National Dental Examination. 2018 Technical Report National Board Dental Examinations. www. ada.org/~/media/JCNDE/pdfs/NBDE_Technical_Rpt. pdf?la=en.

21. American Dental Association. Dental Admission Test (DAT) Validity Study 2014–2016 Data. www.ada.org/~/media/ ADA/Education%20and%20Careers/Files/dat_validity_study. pdf?la=en.

22. American Dental Association. The Advanced Dental Admission Test (ADAT) Program Update for 2019. www. ada.org/~/media/ADA/Education%20and%20Careers/ Files/2019_ADEA_ADAT_Program_Update.pdf?la=en.

23. Ranney RR, Wood M, Gunsolley JC. Works in progress: A comparison of dental school experiences between passing and failing NERB candidates, 2001. J Dent Educ 2003 Mar;67(3):311–316.

24. Ranney RR, Gunsolley JC, Miller LS, Wood M. The relationship between performance in a dental school and performance on a clinical examination for licensure: A nineyear study. J Am Dent Assoc 2004 Aug;135(8):1146–1153. doi: 10.14219/jada.archive.2004.0374.

25. Ranney RR. What the available evidence on clinical licensure exams shows. J Evid Based Dent Pract 2006 Mar;6(1):148–154. doi: 10.1016/j.jebdp.2005.12.012.

26. Chambers DW. Board-to-board consistency in initial dental licensure examinations. J Dent Educ 2011 Oct;75(10):1310– 1315.

27. Friedrichsen SW. Moving toward 21st-century clinical licensure examinations in dentistry. J Dent Educ 2016 June;80(6):639–640.

28. American Dental Association. Ethical considerations when using patients in the examination process. www.ada.org/~/ media/ADA/Education%20and%20Careers/Files/ethicalconsiderations-when-using-patients-in-the-examination-process. pdf.

29. American Dental Association. Comprehensive Policy on Dental Licensure. www.ada.org/~/media/ADA/Member%20 Center/Members/current_policies.pdf?la=en.

30. American Educational Research Association, American Psychological Association, National Council on Measurement in Education and Joint Committee on Standards for Educational and Psychological Testing. Standards for Educational and Psychological Testing. Washington, D.C.: 2014:11,23,33,42.

THE CORRESPONDING AUTHOR, Anthony J. Ziebert, DDS, MS, can be reached at zieberta@ada.org.

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licensure by portfolio C D A J O U R N A L , V O L 4 8 , Nº 7

Licensure by Portfolio: Our Experience in Prospect and Retrospect Iris Nam, DDS; John Won, DDS, MS; Greg Olson, DDS, MSD; and Edwin L. Christiansen, DDS, PhD

a b s t r a c t Loma Linda University School of Dentistry’s pathway to California

licensure by portfolio began in 2016 with eight candidates. Designated faculty were calibrated to assess and guide candidates. Portfolios substantiating clinical accomplishments were required as were clinical experience and successful completion of the California Portfolio Examination. Participation demanded organizational skills, commitment and motivation. Four students transferred out and four students completed the program. Postportfolio surveys confirmed the greatest challenge was finding appropriate competency cases.

AUTHORS Iris Nam, DDS, is an assistant professor, division of general dentistry, at the Loma Linda University School of Dentistry.

Conflict of Interest Disclosure: None reported.

Greg Olson, DDS, MSc, is professor and chair, pediatric dentistry, at the University of Texas Health Science Center at Houston.

Conflict of Interest Disclosure: None reported.

John Won, DDS, MS, is an assistant professor and head, division of general dentistry, at the Loma Linda University School of Dentistry. He is a fellow of the American College of Prosthodontics.

Conflict of Interest Disclosure: None reported.

Edwin L. Christiansen, DDS, PhD, retired from Loma Linda University in December 2019. He was a professor in the school of dentistry and an adjunct professor in the school of medicine.

Conflict of Interest Disclosure: None reported.

T

he Commission on Dental Accreditation stipulates that qualification for dental licensure in the U.S. requires that a candidate successfully matriculate from an accredited dental school, pass parts I and II of the National Board Dental Examination and demonstrate clinical competency in a live-patient examination administered and overseen by a state or regional testing agency.1 In lieu of clinical licensure examination, certain states mandate or permit one postgraduate-year residency from an accredited institution. Postgraduate-year residencies are mandated in Delaware and New York but are optional in Minnesota, California, Colorado, Ohio and Washington.1 The Curriculum Integrated Format also leads to licensure and is available through examining agencies collaborating with participating dental schools.2

Pathways to California Licensure

California has four pathways open to qualified dentists: licensure by credential, by residency, Western Regional Examination Board (WREB) exam and licensure by portfolio (LP).

Licensure by credential is available only to practicing dentists licensed in another state. A minimum of 5,000 hours of active clinical practice are required over a period of five consecutive years during the seven years immediately preceding application.3 Two years of maximum credit is allowed for a completed residency.

Unfulfilled clinical years may be met by contracting to teach or practice in a setting specified by the California Business and Professions Code.3 Licensure candidates are required to prove nonfailure of the California licensure exam or the WREB clinical exam within the five-year period immediately preceding application.3 JULY 2 0 2 0 339

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TABLE

Itemized Cost of California Dental Licensure Licensure pathway

Application

Miscellaneous

Licensure by credential

$525

Initial licensing fee may be applicable

$525

Licensure by residency

$800

Law and ethics exam fee: $125

$925

Licensure by WREB

$400

Law and ethics exam fee: $125

Licensure by portfolio

$400

Law and ethics exam fee: $125

Following receipt of candidates’ application and proof of eligibility, a license may be issued within two weeks.3 Licensure by residency requires a minimum of 12 months in a general practice residency or advanced education in a general dentistry program.4 Also required are passing the California Law and Ethics Exam and fingerprinting.4 The WREB is the most common option selected by candidates for licensure. A common thread of requirements exists for most pathways to licensure: graduation from an accredited dental school, passing National Dental Board examinations, passing WREB exams, passing tests of dental law and ethics and undergoing required fingerprinting.5 Fees for WREB may vary with the chosen test site in any given year.6 Enrollees for LP build portfolios to substantiate efforts and accomplishments throughout their dental education.

Students’ expanding portfolios are subject to evaluation by designated faculty in accordance with guidelines established by the Dental Board of California.

Standardized minimum clinical experience and successful completion of the California Portfolio Examination are required and cover seven competencies in six clinical domains. The remaining requirements are the same as the WREB.6 A summary of comparative costs for all licensure pathways is shown in the TABLE .

Strengths and Challenges of Licensure

by Portfolio

Challenging the LP pathway may represent the most significant and comprehensive evaluation of a student’s clinical skills during their dental education.7 It is assumed that by requiring a measured minimum of clinical experiences, as 340 JULY

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Exam cost

Total

WREB exam fee: $2,560–$3,320

well as demonstrated competencies in each domain, there is a strongly perceived probability that candidates will have been prepared and qualified to treat patients within the boundaries of established standards of care.

Seven competency examinations administered to LP pathway participants cover more areas of dental expertise than a single comprehensive clinical dental board examination. Additionally, it is anticipated the LP path will broaden traditional dental foundations of didactic and clinical skills by providing more opportunities for assessment and improvement. Presumably, the cost of a dental education may be lowered if one factors out traditional, relatively high testing fees.

Drawbacks to Loma Linda’s LP offering were anticipated, chief of which appeared to be the cost in time, effort and money. Each cost challenged the administration’s decision to develop, refine and implement a new curricular path, one requiring testing by competent faculty examiners (CFEs) who underwent specialized training and calibration. Loma Linda was well aware that the LP option would place unique demands on an already robust curriculum and require significant investments of time and resources.

Though the LP guidelines provided by the Dental Board of California are clear and detailed, each participating school is tasked with implementing the LP program in harmony with its unique circumstances and resources.

Calibrating CFEs is one example of the challenges that faced the program organizer and faculty. From students’ perspectives, participation demanded

$3,575–$3,845 $4,525

greater than average organizational skill sets, undivided commitment and unflagging motivation, the lack of which may result in some electing to return to a traditional route of graduation and licensure (e.g., WREB).8,9

Progress or Problem?

Discontent with clinical testing has been growing for more than 20 years.

Now a few administrators, faculty and students are calling for the elimination of live-patient testing.10 Countering this argument, other voices remind dentistry of the norm that has dictated policy for decades – that operative competency testing on live patients represents an assessment of students’ graduation-readiness, serving as a rite-of-passage [emphasis added].

Recently, the American Student Dental Association (ASDA) published a position paper against [writers’ emphasis] live-patient testing: “Members of the ASDA … stand firm in our conviction that the practice of using human subjects in clinical licensing examinations is flawed and unethical”11 [citation modified].

Considering current curricular debate, Loma Linda, moving thoughtfully and cautiously, determined that LP provides a viable option to live-patient testing.12

The Loma Linda Experience

Loma Linda embraces a philosophy and tradition of preparing graduates to be best positioned for service learning. Our faculty strives to enable students to pass licensure examinations in pursuance of productive careers serving as oral health care providers at all levels of society. Thus, with these guiding principles, we moved forward.

C D A J O U R N A L , V O L 4 8 , Nº 7

Loma Linda’s Response Methodology

Immediately following the official decision to incorporate LP into the curriculum, a search was set in motion for a faculty member to organize and coordinate the process. The coordinator’s first steps were to review relevant published materials and open a channel of communication with the Dental Board of California — an action that proved essential throughout the process. Loma Linda’s LP program coordinator communicated with licensing specialists in the dental licensing and examinations department at the Dental Board of California, receiving assistance and guidance on “building” the program.

Licensing specialists, available by phone and email, were prompt to provide valuable oversight of the logistical and technical requirements of the process. Materials developed by California dental schools in conjunction with the dental board were particularly helpful for us as we outlined the methodology for calibrating participating LP faculty. Detailed information was provided describing the process of having our portfolio graders approved by the dental board.

Moreover, licensing specialists visited our campus for direct, interactive Q&A sessions.

Upon agreement of the plan for our infant LP program, we moved ahead.

Identifying and recruiting faculty competency graders was the next step. To our advantage, competency examinations preexisted the LP project in the divisions of general dentistry, endodontics and periodontics, which smoothed the intramural transition to LP to metrics in these departments. It was decided to retain existing examination and grading protocols (each with unique features) within qualifying departments.

Faculty examiners were calibrated in accordance with published guidelines of the California Portfolio Examination.13

Calibration exercises were conducted within the division of general dentistry in the sections of operative dentistry and removable prosthodontics. Guidelines were given to faculty competency graders for review ahead of meetings that followed.

Grading rubrics were scrutinized to assure faculty were “reading from the same page” and grasped the core requirement of each step. After intradepartmental calibrations, all three departments met to review the specific details of administering and grading competency examinations.

A list of graders and their credentialing

Our faculty strives to enable students to pass licensure examinations in pursuance of productive careers serving as oral health care providers at all levels of society. information was submitted to the dental board from the Office of the Dean. After approval, competency examination graders met regularly to review issues and updates.

Eight candidates joined the LP program when it launched in 2016.

Their identities were submitted to the dental board and each was assigned an ID number. The project coordinator met with the candidates on several occasions to review program details and requirements and collect information on issues and challenges. The coordinator served by establishing protocols of the competency examination, guiding candidates and faculty as needed, leading out in faculty calibration and serving as a liaison between LP candidates and grading faculty members.

Shortly after the project launched, candidates began challenging the

California Portfolio Exam. Delay of testing was believed to be due to difficulties encountered in identifying patients who met the specific testing parameters.

Parallel with establishing the program, a redundant record was organized by creating subfolders for graders, candidates and calibration. Google Docs was chosen for its versatility and live document status, which was readily edited and shared among approved users. In addition to electronic documentation, the entire document was hard copied for storage at a secure site in the division of general dentistry — a precaution to ensure against electronic failure.

Challenges

By far, time spent grading was the greatest challenge facing LP faculty.

It is estimated that faculty examiners spent 30 hours’ grading time per candidate during the entire program.

For the LP candidates, their greatest challenge was timely identification of appropriate treatment cases for portfolio competency examinations.

Because school policy does not allow students to directly select patients from the general pool, some candidates had difficulty finding appropriate cases.

Outcomes

The LP program commenced with eight candidates, each in the first quarter of their senior year. They were unable to begin taking competency examinations until the second quarter as most of the first quarter was consumed by organization and preparation. Though all eight candidates underwent examination, two chose to leave the program in the third quarter, opting for the approaching WREB examination.

Both candidates were scheduled to report for military service shortly after graduation and stated they could not afford to risk having to remain beyond graduation to JULY 2 0 2 0 341

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complete remaining LP requirements. Two additional candidates opted out in favor of the WREB because of their uncertainty of finding the required number of competency cases. In the end, four candidates finished the program and submitted completed portfolios to the dental board for licensure.

In postexperience surveys, all candidates confirmed that their biggest challenge was the difficulty finding appropriate competency cases in a timely manner but added that the minimum-clinicalexperience requirement posed no challenge.

■

■

■

LP Strengths, Weaknesses and Lessons Learned

Important lessons were learned during our efforts to implement the LP pathway at Loma Linda: ■ Students’ familiarity with the process was helpful.

■ Having an existing, robust competency-based clinical curriculum accelerated the most difficult aspect — reliable and valid measurement. Not needing to reinvent the method for grading the portfolio competency exams was a significant bonus.

■ Competency exam graders selected for portfolio grading were more easily calibrated. Scoring results showed excellent agreement.

■ The patient pool was sufficiently diverse and plentiful to provide necessary clinical experiences, though a few candidates expressed concern about finding necessary procedures in a timely manner, which may have exaggerated students’ anxiety.

■ Ten to 12 months (minimum) is a reasonable period for completing one’s portfolio.

■ We believe that having two or three additional months would have allowed students to complete their portfolio.

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■

Valuable time was spent instituting rather than implementing the LP program.

Though competency-based examinations and faculty calibration existed prior to launching LP, interdepartmental calibration required more time to develop.

Relative compartmentalization of specialties and departments created significant barriers to the flow of information and communication.

Another symptom of “compartmentalization” was suboptimal communication and recordkeeping. Such issues were managed with interdepartmental meetings.

One way to improve competency grading and record-keeping is by centralization of faculty calibration results and LP student grading, rather than by division; this should be implemented.

Looking Ahead

Administration and LP faculty were pleased when the first four students graduated. Having collected data pertaining to increased demands of time and effort imposed on an (already) overworked faculty, we are aware that more efficient, collaborative efforts are crucial for recruiting and accommodating LP candidates.

Valuable lessons and insights were gained over the course of initiating the LP pathway. Most students agreed the process was rigorous but reported less stress during competency assessments.

Another benefit was the opportunity afforded faculty to reinforce our unique core values regarding patientcentered care — values we espouse.

Conclusion

Debating the format and the existence of dental board examinations seemingly dominates discussions on dental licensure.

Throughout the U.S., a menu of licensure options is being weighed: some for acceptance, while others, traditional and historical, may be rejected. The debate is caught, for now, in the evolving ratiocinations of curricular specialists, educational psychologists and philosophers.

Though the future of dental licensure may be turbulent, Loma Linda remains certain that the interests of students, patients and faculty are best served by greater personal investment and professional fulfillment offered by licensure by portfolio. n REFERENCES 1. American Dental Association. State licensure for U.S. dentists. www.ada.org/en/education-careers/licensure/state-dentallicensure-for-us-dentists.

2. American Dental Association. Licensure pathways. www.ada. org/en/education-careers/licensure/licensure-dental-students/ licensure-pathways.

3. Dental Board of California. Licensure by credential. www.dbc. ca.gov/applicants/licensure_by_credential.shtml.

4. Dental Board of California. Licensure by residency. www.dbc. ca.gov/applicants/licensure_by_residency.shtml.

5. Dental Board of California. Application for licensure based on passing the WREB examination — general information and updates. www.dbc.ca.gov/applicants/wreb_exam.shtml.

6. Western Regional Examining Board. Dental exam schedule. wreb.org/dental-candidates/dental-exam-schedule/.

7. Gadbury-Amyot CC, McCracken MS, Woldt JL, Brennan RL. Validity and reliability of portfolio assessment of student competence in two dental school populations: A four-year study.

J Dent Educ 2014 May;78(5):657–667. doi: 10.1002/j.00220337.2014.78.5.tb05718.x.

8. Davis MH, Ponnamperuma GG, Ker JS. Student perceptions of a portfolio assessment process. Med Educ 2009 Jan;43(1):89– 98. doi: 10.1111/j.1365-2923.2008.03250.x.

9. Spicuzza FJ. An evaluation of portfolio assessment: A student perspective. Assessment Update 1996 Nov–Dec;10(2):4–13. doi.org/10.1002/au.3650080604.

10. Elliot C. The debate on the elimination of live patients in clinical licensure examination. www.thefreelibrary.com/ The+debate+ on+the+elimination+of+live+patients+in+clinical+li censure...-a0179977425.

11. American Student Dental Association. Use of human subjects in clinical licensure examinations. www.asdanet.org/docs/ advocate/issues/asda_white-paper_licensure_web_final. pdf?sfvrsn=a0a868dd_18.

12. COMIRA. Alternative pathways for initial licensure for general dentists, submitted to the Office of Professional Examination Services California Department of Consumer Affairs. Feb. 9, 2009. www.dbc.ca.gov/formspubs/pub_portfolio_final.pdf.

13. Dental Board of California. Portfolio examination candidate handbook. www.dbc.ca.gov/formspubs/portfolio_handbook.pdf.

THE CORRESPONDING AUTHOR, Iris Nam, DDS, can be reached at inam@llu.edu.

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RM Matters

C D A J O U R N A L , V O L 4 8 , Nº 7

Seeking Guidance and Finding Focus in Times of Distraction and Distress TDIC Risk Management Staff

D

entists are experts at building resilience — from the grit needed to graduate from dental school to the patience that comes with practicing compassionate care, especially during times of hardship.

Our current circumstances, however, are creating new challenges for even the most seasoned dental professionals. The combination of clinical concerns, business uncertainties and economic pressures can lead to overwhelming feelings of anger, fear, disillusion and grief.

Through organized dentistry, members are connected to a network of their peers as well as specialized experts who can share empathetic, objective guidance. Dentists aren’t alone during times of distraction and distress. Through the California Dental Association, members have access to expertise and resources from Practice Support specialists on regulatory compliance, employment practices, dental benefit plans and practice management. And, regardless whether members are policyholders with The Dentists Insurance Company, they also have access to no-cost guidance from TDIC’s Risk Management Advice Line. These experienced analysts provide education, support and advice by phone to dentists to assist them with managing concerning situations.

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have created additional concerns and more dentists are calling seeking guidance for new, emotional and high-stakes practice challenges.

A recent caller shared that he had not been able to obtain the required PPE to safely reopen his practice. He told the Risk Management analyst that he’d been feeling frustrated and psychologically strained as he faced the real possibly of losing his business,

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RM MAT TERS C D A J O U R N A L , V O L 4 8 , Nº 7

stating that he may be forced to close his doors through the end of the year.

The analyst offered recommendations to support the dentist in making clearminded decisions while navigating this pain and fear. The analyst encouraged him to continue to check in with his furloughed employees and to be open with them about the lack of PPE and the reasons for the temporary closure. If he laid off employees now, he could contact them when the market conditions change to see if they are available to come back to work. The dentist was hopeful to secure PPE and reopen

at the beginning of next year. The objective guidance helped him refocus his efforts and plan his next steps.

In another call to the Risk Management Advice Line, a practice had received a request for employment records from an attorney. The office had closed temporarily in mid-March, at which time all eight employees were furloughed. The practice resumed patient care at the end of May; however, due to sporadic patient flow and unpredictable income, she was only able to afford to bring back four of the eight furloughed employees.

The plan was to eventually call the

remaining four employees back to work once business picked up and the practice resumed full operations.

Upon learning that other employees had been called back to work, one of the employees who had not been asked to return contacted an attorney. The employee alleged that she was not asked to return because the other staff members who were called back were younger and represented the image that the practice wanted to promote.

The attorney alleged that his client was discriminated against due to her age and that other employees were provided with preferential treatment.

The practice owner and her spouse expressed their frustration about the overall impact of the unexpected office closure, which was now even more stressful because of a potential employment claim. During the conversation, the practice owner was emotionally overcome, expressing her fear of losing the business that is the only source of their income. She shared that this uncertainty and stress was causing her to have sleepless nights, a lack of appetite and the inability to focus on how to get herself out of the situation and survive. After listening attentively, the analyst acknowledged that fear and anxiety about the current pandemic and its effects on the dentist and her business can be overwhelming.

She advised her to take a step back and to focus first and foremost on her own well-being. She also offered a referral to an employment attorney for guidance on how to best respond to the attorney’s request for the employee’s file. In addition, the analyst shared tips on how to effectively communicate with employees and stay in touch with the employees who are not yet back at work.

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RM MAT TERS C D A J O U R N A L , V O L 4 8 , Nº 7

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While these are just a few of the calls received, the underlying stress of COVID-19 is impacting the emotional well-being of countless dentists. It’s also contributing to stressful home and work environments in which challenges can quickly escalate into crises.

As shared in the May RM Matters article, open communication can help strengthen employee-employer bonds. As employers, dentists are charged with being authentic, positive, consistent and concise.

In this complicated climate, it’s more important than ever to communicate clearly and often.

And, in keeping with the analyst’s recommendation, it’s crucial that practice leaders step back and take care of their own well-being.

Mindful, forward-thinking decisions come from a place of calm, care and concentration. If there’s a lack of sleep, sustenance or focus, decisions are made from a place of desperation and practice risks increase.

Here are a few coping strategies: ■ Focus on what you can control. As described in a recent American Dental Association article, there’s a battle going on in our brains between fear and contentment.

The fight-or-flight reflex is kicking in, which increases our heart rate, constricts or dilates blood vessels, shuts down our stomachs and get us ready to physically address the threat.

But we also have a rational part of our brains that can help us understand that our body’s automatic responses aren’t always the appropriate ones, and we can find a thoughtful resolution to problems.

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Stay connected. In times of isolation, we can manifest negative thoughts or let unhealthy thoughts spiral. Pursue face-to-face conversations with family, colleagues and peers — even if digitally — and reach out to the support system within organized dentistry. Also make a conscious effort to engage in activity and get outdoors each day. In addition to the health benefits, sunlight and exercise can help improve our moods. Consistent routines can positively affect our mental state amid disruption in other aspects of life and work.

■ Know that you’re not alone.

Your peers in dentistry are experiencing the same crisis and, like you, are navigating complex emotions. Those feelings of anger, grief, disillusionment and fear are likely shared by your peers — and there are no easy answers. Don’t hesitate to seek support for financial, emotional and social well-being through your dental community and professional organizations.

As the profession continues to respond to and recover from the impacts of the pandemic — clinical, financial, social and emotional, care for your own well-being along with your patients and dental team. And remember there are people and programs that can provide trusted guidance and help you focus on positive outcomes. n ■

TDIC’s Risk Management Advice Line is a benefit of CDA membership.

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Well-Being Resources Connect with trusted national and state organizations that are dedicated to supporting your emotional health during times of hardship. Share these resources with your family or dental team members who may benefit from tools to navigate stress and anxiety.

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6177 SALINAS During Great Recession, Salinas dentists did well as Salinas Valley is one of California’s most productive agricultural regions and is the engine driving this area’s economy. As such, Salinas shall bounce back quickly from Covid Hangover. Under-performing practice collected $935,000 in 2019. 5-days of Hygiene.

Housed in beautiful 6-op suite. Condo optional purchase. Great platform to bring in specialists.

6176 SANTA CRUZ Delta PPO practice seeks Successor skilled in placing implants.

Last 2-years averaged $1,180,000 in collections and $735,000 in Available Profits. $480,000 invested in technology to make this possible. 4-days of Hygiene. Full Price $675,000.

6174 HUMBOLDT COUNTY’S UNIVERSITY COMMUNITY – ARCATA Special area to raise one’s family and enjoy quality of life benefits. Best location, great foundation, dedicated Team. Seller works 3-day week by choice. 2019 collected $360,000. Before reducing schedule, collected $420,000 in 2018. Beautiful Victorian building is optional purchase. Practice wants to be full-time. Full Price $50,000.

6173 SAN FRANCISCO – OUT-OF-NETWORK 2019 collected $1,300,000.

Available Profits of $420,000. 6-ops. 8-days of Hygiene. 1,500+ active patients.

Contract with specialists to perform referred work in-house and take to next level.

6172 SAN FRANCISCO’S EAST BAY – OUT-OF-NETWORK 2019 collected $850,000 with Profits of $430,000. 4-days of Hygiene. Requires skilled, easy temperament and great communicator as Successor. Seller shall work-back to assist in transition.

6171 SANTA ROSA Great DNA in long-established practice. Strong patient foundation per 6+ day Hygiene Schedule. 2019 collected $990,000 with Available Profits of $338,000. Great Team. Practice has rebounded! Full price $213,750.

6170 MANTECA / RIPON AREA 2019’s revenues totaled $860,000 with Available Profits of $352,000. 5-days of Hygiene. Refers endo, most OS and implant placements. Extensive patient base. Successor should contract with specialists to perform referred work. Facility perfect for making this a full-service practice. Full price $450,000.

6167 DOWNTOWN PALO ALTO – OUT-OF-NETWORK Perfect for skilled Dentist seeking strong patient relationships and insurance independency! 2019 topped $800,000 on Owner’s 3-day week with 5-days of Hygiene. Office has been completely upgraded and charting is paperless.

6165 ROSEVILLE ORTHO – OUT-OF-NETWORK Stanford Ranch. $455,000 invested in build-out, furnishings, computers and equipment. 3-chair Bay. Digital Pan with Ceph. Averages 3 New Patients per month. Full Price $125,000.

6164 SAN FRANCISCO’S UNION STREET – OUT-OF-NETWORK Highly regarded as evidenced by 9-days of Hygiene per week. Collections topped $2 Million each last 3-years with Profits averaging $1 Million. Paperless. 3D Cone Beam.

6163 LAKEPORT Attractive option to practicing in competitive areas in expensive housing markets. 6-op facility completely networked. Great main street location. 2019 collected $969,000.

6158 FORTUNA Relaxed lifestyle in Humboldt’s Banana Belt, adjacent to Ferndale.

Perfect for Dentist seeking small town living. 2019 collected $379,000. 6-weeks off.

6147 CENTRAL MARIN COUNTY - “OUT-OF-NETWORK” Recent year collected $2.2 Million with Seller taking 8-weeks off. 11-days per week of Hygiene produced $1+ Million. $700,000+ in profits. Best location and fantastic staff. Seller available for long transition.

Great Time to Think about Change. Not doing the Type of Dentistry You would like to do? Look to Tom Fitterer & PPS to plan your future.

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BAKERSFIELD AREA Small city. Seller built 4,500 sq.ft. beautiful home for $450,000. (Cost $1.5 million in OC.) Built Hi Identity Dental building 7-Adec ops.

3,000 sq.ft. next to Health Center for 1.200,000. Established 32-years grossing $1 Million. Buy all at Bank Appraisal. Only 5 Dentists serving this 40,000 market area patients.

BEAUMONT AREA 8,000 new homes to be built 5 minutes away. Retiring DDS established 1988. 1,550 sq.ft. 3-ops. Rent $1,650. Average Gross $365,000.

BEAUMONT/ BANNING Senior DDS Grossing $250,000. 1-op. Rent $960. Take home $200,000.

EAST LOS ANGELES 60 years old. 3-ops. Rent $1,600. Part-time Senior Grossing $285,000 in 2-days. Do $500,000 on 3.5 days. Hi visibility. Bargain at $195,000.

HEMET - HISPANIC AREA Includes Dental Building. Established 50-years.

Absentee Seller. This is a neglected practice. Beautiful 5-op office. Open part-time.

Will do $500,000 first year. $1 Million in 3-years like one prior owner. Pay Mortgage that never increases. Part-time Seller will transition. Upgraded Cerec. $250,000 buys practice. Small down buys building. Historic location. Live in apt if you like during week, live on beach on weekends.

GP INNOVATOR Gross $1,700,000. Net over $1 Million. Nothing fancy, low tech dentistry. Full Price $1,500,000.

INLAND EMPIRE - UNION PRACTICE Gross $550,000 2.5 days by choice. Net $350,000. 5-ops.

INTERSECTION OF 210 / 57 Hi identity. 25-years old. Unbelievable state-of-art.

10-ops, new everything. Recent $500,000 renovation. Cone beam, Cerec, lasers.

Grossing $1,100,000. Seller has 2-practices, cannot do both justice. This is a $2,000,000 location.

LA HABRA Huge shopping center. Well maintained. PT Seller will stay. 6 ops.

LAGUNA WOODS Grossing $800,000 part-time. Should gross $1,000,000.

MARINA DEL REY Take home $1 Million Net. HMO checks $5-to-8,000/month.

Resume required ORANGE COUNTY Established 1970. Near Chapman / Tustin intersection.

Grossing $400,000. Merge or Grow PALM DESERT Hi identity. Established 2007. Terrific one girl staff. Mostly Hispanic. Low overhead. Rent $1,600. Gross near $300,000. Semi-retire on 2-or-3 days. 4-ops, 2-equipped.

PALM SPRINGS AREA $1,500,000 includes specialists. Grow to $2,000,000+. 8ops. Best buy.

PALOS VERDES TO LAX 50-to-70,000 autos pass daily. Across street from major retailers with Hi Identity. High Tech Adec like-new, 6-ops, no expense spared. $5,000 HMO checks pays 56% of cost to buy. Within 36-months Buyer will net $50,000 a month. After 5-years, Net of $1,000,000 per year is achievable goal.

REDONDO BEACH Semi-retire. Work 2-to-3 days, low overhead. Established 20years. 2-ops. Super staff. Rent $1,550. Seller refers a lot. Full Price $118,000.

SAN DIEGO GROUP 4-office DSO grossing $3.7 Million.

SOUTH BAY OPPORTUNITY For talented GP to Net $50,000/month.

TEMECULA SHOPPING CENTER High visibility. 5-ops. Grossing $40-to-50,000 month. Absentee owned. Hands on owner will double first year. Bargain.

THOUSAND OAKS Classic practice. Established 42-years. One Partner willing to work back 3-to-5 years. Grossing $1 Million. Refers lots to Specialists. 5-ops. Owners own 25% of Building housing 4 Dentists including Ortho. Great for Specialist or GP. TORRANCE Established 1984. 10,000 charts.

UPLAND Established 38-years. 3-ops. Grossing $330,000. 2000 active patients

• Lee Skarin and Associates has been serving the dental profession since 1959.

• Kurt Skarin has over 30 years experience in dental practice sales.

• We have sold more practices than any broker in the state within • • • •

the last 12 months.

Our experienced practice appraisals are backed with credentials unequaled among dental practice brokers.

We provide in-house legal counsel to advise you in all aspects of the sale and purchase, including the tax consequences of the sale.

Excellent financing is available, in most cases for 100% of the purchase price.

With a reputation for experienced, conscientious, and ethical performance, we give our clients personal attention in all aspects of the purchase.

With scores of Buyers, profiles of their practice interests and financial ability, Lee Skarin & Associates is able to find the right buyer for your practice.

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Experience the difference. Call Lee Skarin and Associates for responses to all of your questions - No obligation!

Visit our website for current listings: www.LeeSkarinandAssociates.com Dental Practice Brokers CA DRE #00863149

805.777.7707 818.991.6552 800.752.7461

Regulatory Compliance

C D A J O U R N A L , V O L 4 8 , Nº 7

Dispensing or Administering Controlled Substances?

Know the Rules CDA Practice Support

A

dentist who dispenses or administers controlled substances must comply with federal and state laws for their storage and must maintain required documentation.

There are limits on drug dispensing, and their containers must be childproofed and labeled with specific information.

Storage and Record-Keeping

A dentist must store controlled substances in a locked cabinet or drawer with limited access. It is recommended to document who has had access to the key or combination. A log of drugs must be kept and maintained for three years.

An inventory of controlled substances must be taken at least once every two years.

The inventory record may be handwritten, typewritten or on a printed form. It should be maintained at the practice for at least two years from the date that the inventory was conducted. Each inventory record must contain the following information: ■ Date of inventory and whether the inventory was taken at the beginning or close of business.

■ Names of controlled substances.

■ Each finished form of the substances (e.g., 100 mg tablet).

■ The number of dosage units of each finished form in the commercial container (e.g., 100-tablet bottle).

■ The number of commercial containers of each finished form (e.g., four 100-tablet bottles).

■ Disposition of the controlled substances.

Controlled substance samples provided by pharmaceutical companies must be included in the inventory record.

Dispensing Controlled Substances

Prior to dispensing, a dentist must offer to give a written prescription to the patient that the patient may elect to have filled by the dentist or by any pharmacy. The patient must be provided with a written disclosure that he or she has a choice between obtaining the prescription from the dentist or obtaining the prescription at a pharmacy of the patient’s choice.

No more than a 72-hour supply of a Schedule II controlled substance may be dispensed to one patient in accordance with normal use. Schedule II controlled substances may not be dispensed at free or nonprofit clinics.

Containers and Labels

When dispensing controlled substances to a patient, a dentist must: ■ Use a childproof container.

■ Label the container as described below.

■ Display on the container a notice that states “Caution. Opioid. Risk of overdose and addiction.”

■ Inform the patient orally or in writing of possible side effects of the drug.

Label requirements are intended to provide patients with easy-to-read labels. The following elements must be printed in at least 12-point sans-serif typeface, listed in the following order and clustered into one area of the label that comprises at least 50% of the label: ■ Patient’s name.

■ Drug name and strength.

■ Directions for use.

■ Purpose or condition for which the drug is prescribed.

This part of the label also must be highlighted in bold typeface or color or have blank space to set off the above items.

The remaining required elements of the label must be printed so as not to interfere with the legibility of the four elements listed above. The remaining required elements are: ■ Prescriber’s name and address.

■ Date medication was dispensed.

■ Quantity of medication dispensed.

■ Expiration date of the effectiveness of the medication dispensed.

■ Physical description of the dispensed medication, including its color, shape and identification code that appears on the tablets or capsules.

If a drug may impair a user’s ability to operate a vehicle or vessel or poses a substantial risk if consumed with alcohol, the container of the drug must have a written label indicating that the drug may impair a user’s ability to operate a vehicle or vessel or that the drug poses a substantial risk to the person consuming the drug when taken in combination with alcohol.

Upon the request of a patient or patient’s representative, a dentist who dispenses must provide translated directions for use on the prescription container, label or on a supplemental document. (An example of directions for use is “Take one pill at bedtime.”) The English-language version of the directions for use must also appear on the container or label (not on a supplemental document). The California Board of Pharmacy has translated directions online at pharmacy.ca.gov/publications/ translations.shtml in Chinese, Korean, Russian, Spanish and Vietnamese. A JULY 2 0 2 0 351

J U LY 2 0 2 0 REGULATORY COMPLIANCE C D A J O U R N A L , V O L 4 8 , Nº 7

dentist may provide their own translated directions for use or can use the translations made available from the board of pharmacy. The prescriber dispenser is not obligated to provide translated directions for use beyond the languages that the board has made available or beyond the directions that the board has made available in translated form.

When applicable, directions for use must use one of the 16 directions listed in Section 1707.5 of Title 16 of the California Code of Regulations. The one likely to be used by dental practices is:“If you have pain, take __ (insert appropriate

dosage form — pill, caplet, capsule or tablet) at a time. Wait at least __ hours before taking again. Do not take more than __ (appropriate dosage form) in one day.”

Reporting Theft or Loss of Drugs

The theft or loss of controlled substances from a prescriber’s premises must be reported to local law enforcement and to the Drug Enforcement Agency (DEA) within one business day of discovering the theft or loss. Report the theft or loss to the DEA using Form 106, which is available at deadiversion.usdoj. gov/21cfr_reports/theft/index.html.

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352 JULY

2020

Dispose of out-of-date, damaged or otherwise unusable or unwanted controlled substances, including samples, by transferring them to an entity that is authorized to receive such materials. These entities are referred to as “reverse distributors.” Contact your local DEA field office (apps. deadiversion.usdoj.gov/contactDea/spring/ fullSearch?execution=e1s1) for a list of authorized reverse distributors. Schedule II controlled substances should be transferred via the DEA Form 222, while Schedule III, IV and V compounds may be transferred via invoice. Maintain copies of the records documenting the transfer and disposal of controlled substances for two years. Very small quantities of a controlled substance may be disposed through participating community pharmacies and local law enforcement agencies. Dentists can encourage patients to properly dispose of their unused or expired controlled substances through their local pharmacy or take-back event sponsored by local law enforcement. n REFERENCES A Practitioner’s Manual, 2006 edition, U.S. Drug Enforcement Administration. www.deadiversion.usdoj.gov/pubs/index.html.

California Health and Safety Code §11158 and 11165.3, Business and Professions Code §§4076 – 4078, 4081, 4170 – 4172, 4184 and 16 CCR §1707.5.

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Disposal of Controlled Substances

Regulatory Compliance appears monthly and features resources about laws that impact dental practices. Visit cda.org/ practicesupport for more than 600 practice support resources, including practice management, employment practices, dental benefit plans and regulatory compliance.

CARROLL &COMPANY 4408 SONOMA COUNTY Beautiful 2,100 sq. ft., 6 op practice, 4 doctor-days & 3 hygiene days per week. Average gross receipts $1M+.

Asking $590K. 23-year perio practice, also ideal for GP; loyal, seasoned staff and great location.

4407 SAN MATEO GP Exceptional 5-operatory San Mateo practice in popular health provider neighborhood generating significant daily business draw. Beautiful 2,200 sq. ft. seller-owned facility, handsomely equipped to highest standards. Average GR $1.4M, average overhead 61%. Seasoned and loyal staff. Seller willing to help for a smooth transition.

4381 SOUTH SF GP 23 year practice close to Kaiser Hospital; phenomenal shopping and residential mix area. 4 op facility with new/ G recently upgraded equipment.

DIN Great location in desirable N PEwilling to help for smooth transition of the neighborhood. Owner practice. Average gross receipts approximately $250K with average 60% overhead. Asking $170K. 4359 SANTA CRUZ GP 30+ years of goodwill within walking distance of the beach! Located in a well-known, attractive, single story professional building with ample parking, good visibility and easy access. 2 doctor days/week, 2G hygiene days/week, 380 active patients DIN N with approx. 10 new P patients/mo.

3 fully equipped ops in 850 sq. ft.

E Average GR $250K with adj. net of $135K. Asking price $150K. 4394 SANTA CRUZ GP Retiring seller offering 33+ years of goodwill in stunning 1,534 sq. ft. facility with 4 fully-equipped ops. Pristine leasehold improvements/gorgeous cabinetry make this a mustsee! Prime corner location with dedicated parking lot, situated in one of the most desirable areas of Santa Cruz, close to shoreline and tourist attractions. 2019 GR $887K with adj. net of $353K. 1,500+ active patients with average of 19 new patients/month. Seller works 3+ days/ week with 5+ days of hygiene. Asking $729K. 4405 LOS GATOS GP 30 year practice in beautiful modern, office and desireable location with two 5 G year options to extend lease. 3.5 average D7IN doctor days per week and average hygiene days per week. $1.2M N PEwith 56% average overhead. Seller transitioning average gross receipts into retirement. Practice has great upside potential for a buyer. Asking $986K. 4382 MONTEREY COUNTY GP Established practice in Monterey County, California Coast. Multiple ops can expand, approx. 900 active patients, 4 days of hygiene per week. Ideal for a mature, experienced dentist for this adult-focused practice in an Extraordinary location. Periodontal emphasis with communicative technology in each operatory for multiple crown and implant restorative procedures. Loyal, committed staff will remain through transition. Future opportunity to purchase office building.

4351 SEBASTOPOL AREA GP & BLDG. Beautiful, modern practice in seller-owned building (available for purchase); 3 fully-equipped ops, room for a 4th. Pristine equipment including digital X-ray, most purchased 2016-2018. 2019 GR annualized at $679K+ with adj. net of $210K. Average 3.5 doctor days/week and 4 hygiene days/week. 800 active patients, all fee-for-service. 70+ years of goodwill = longstanding, loyal patient base in scenic vineyard country. Asking $305K for practice, $425K for building. Owner/doctor willing to help for smooth transition.

carroll.company

dental@carrollandco.info

“Matching the Right Dentist to the Right Practice” 4399 SAN JOSE GP Well established, East San Jose neighborhood practice. Smooth running practice with seasoned and loyal employees.

Approx. 2,000 active patients and 12-13 new patients per month. 1,860 sq. ft. office with 6 fully equipped ops. Over $1,300,000 avg. gross receipts. Asking $977K. 4366 SONOMA COUNTY GP Fabulous practice and location in a stellar ING North Bay town. Beautiful, D well-appointed office with 4 ops in 1,425 sq.

N GR $786K with average adj. net of E ft. Last two years’ average P $341K. Asking price $450K. Seller will help for smooth transition.

4392 SAN JOSE GP Offering 40+ years of goodwill. Excellent location in beautiful bldg on well-traveled thoroughfare. 6+ ops in 1,882 sq. ft.

Lots of natural light with views of the eastern foothills. 1,800 active patients. 8 hygiene days/wk. Average GR $900K with adj. net of $295K. Terrific upside potential. Asking $621K. Owners will help for smooth transition.

4387 SF GP 50 year Nob HIll neighborhood practice with approximately 1,000 active patients. Almost no Delta Premier patients. Average GR $600K. Seller transitioning into retirement. Asking $315K. 4362 MARIN COUNTY GP 36 years of goodwill, Seller-owned 1,550 square foot facility with 5 fully-equipped ops. Prime position in charming town; desirable area known for temperate weather, easy, outdoor living and natural beauty. No Delta Premier patients. Excellent reputation and word-of-mouth referrals. Retiring seller will help for smooth transition. Average Gross Receipts last 2 yrs is $450K. Asking $248K for the practice. Bldg condo is available for purchase.

4360 SALINAS GP Seller transitioning into retirement and offering wellestablished practice located near downtown Salinas and Salinas Valley Memorial Hospital. Average Gross Receipts $250K. Asking $133K. 4389 SALINAS GP Stable, 2400+ patient base. Seasoned and dedicated staff. Practice with an emphasis on Restorative treatment. 4 doctor days & 5 hygiene days per week. Average GR $910K. Asking $670k. Retiring owner.

4375 LOS GATOS DENTAL FACILITY Unique opportunity in highly desirable area! Seller offering two full suites of state-of-the-art equipment and modern, 2-operatory facility including furniture, fixtures and leasehold assets in medical office building adjacent to Los Gatos Community Hospital. Asking $250K. UPCOMING: Redwood Shores GP $1.2M+ avg. GR, Palo Alto GP $1.4M+ avg. GR, Redwood City GP $1M+ avg. GR, Morgan Hill GP $1.1M+ avg.GR.

Mike Carroll

Pamela Carroll-Gardiner

Mary McEvoy Carroll

CalRE# - 00777682

(650) 362-7004

(650) 362-7007

Call us today at (855) 337-4337

or visit www.integritypracticesales.com

A Professional Team Dedicated to Your Success

Bill Kimball, DDS Broker / Partner (619) 933-6225 DRE# 01921421

Darren Hulstine Broker / Partner (805) 878-0633 DRE# 01899816

Trevor Kimball, PhD President (805) 748-7439 DRE# 02078646

Brian Flanagan Northern California (707) 898-0842 DRE# 01947466

Ken Skeate Southern California (805) 338-5850 DRE# 00885612

Tim Miller Southern California (714) 272-8408 DRE# 02107070

“Integrity Practice Sale’s customer care,

reliability, and knowledge about the rapidly changing dental practice sales market is the highest anyone could expect to find.”

- R. Adames, DDS

Call us today at (855) 337-4337 and approach your sale with confidence.

Visit www.integritypracticesales.com to see all our dental practices for sale.

NEW! San Diego: $1,090,000 | 7 ops

NEW! Ventura: $550,000 | 3 ops

NEW! Chula Vista: $415,000 | 5 ops

Ojai: $350,000 | 4 ops Ventura: $475,000 | 6 ops Ventura Turnkey: $110,000 | 3 ops

NEW! Vista: $100,000 + RE | 3 ops Palm Springs: $325,000 | 4 ops South Bay + RE: $649,000 | 6 ops NEW! Los Alamitos: $1,650,000 | 7 ops West Covina: $95,000 | charts Diamond Bar: $370,000 | 6 ops NEW! Los Angeles: $200,000 | 6 ops Glendale: $400,000 | 4 ops Agoura Hills: $225,000 | 3 ops NEW! Beverly Hills: $270,000 | 3 ops Newhall: $250,000 | 5 ops Valencia: $600,000 | 5 ops Thousand Oaks: $85,000 | 3 ops Westchester: $600,000 | 4 ops Camarillo: $275,000 | 5 ops

DRE #01911548

Santa Barbara County: $270,000 | 3 ops Santa Barbara + RE: $1,040,000 | 4 ops N. San Luis Obispo County: $1,500,000 | 6 ops San Luis Obispo: $865,000 | 3 ops Central Coast: $454,000 | 5 ops Central Coast: $548,000 | 4 ops Central Coast: $390,000 | 3 ops Central Coast Endo: $750,000 | 5 ops San Luis Obispo County: $650,000 | 4 ops NEW! Monterey Peninsula : $379,000 | 3 ops Carmel: $419,000 | 4 ops San Jose: $200,000 | 4 ops

San Francisco: $1,057,000 | 4 ops NEW! Santa Rosa Area: $379,000 | 4 ops San Anselmo: $200,000 | 2 ops Bakersfield: $185,000 | 4 ops Bakersfield: $350,000 | 4 ops Porterville: $1,099,000 | 12 ops Bakersfield: $275,000 | 3 ops Fresno: $860,000 | 4 ops Folsom: $330,000 | 6 ops NEW! Sacramento: $534,000 | 4 ops Sacramento: $420,000 | 4 ops NEW! Vacaville: $650,000 | 4 ops Rancho Cordova: $215,000 | 4 ops Shasta County: $135,000 | 5 ops S. Lake Tahoe: $215,000 | 3 ops California City: $350,000 | 6 ops

Broker-Partners: Darren Hulstine and Bill Kimball, DDS

Ethics

C D A J O U R N A L , V O L 4 8 , Nº 7

To Quadrant Dentistry or Not? Paul Hsiao, DDS, MPH, JD

H

ow is quadrant dentistry an ethical issue? Well, is it ethical to complete one filling at a time when there are also cavities on multiple teeth in the same quadrant? When recommending treatment plans, we should at least consider whether consolidating treatment into quadrants is feasible so we can be efficient with our and our patients’ time.

With quadrant dentistry, we are not traumatizing the patient’s tissues and muscles as often. Furthermore, many patients don’t have the luxury of taking multiple days off from work for themselves or for their kids in order to have procedures extended over a significant amount of time. For example, if the patient needed 12 fillings and the fillings were completed in 12 visits, there could be challenges with transportation, school and work, not to mention motivation to keep coming back.

Additionally, why give three nerve blocks over three visits when one visit and one nerve block can take care

of the same three teeth? Aside from reduced trauma and trips to the office, consolidating treatment can result in fewer missed appointments because there is a higher probability of missed or broken appointments with more trips. Countless social media, practice management, phone calling, emails, postcards and software are aimed at decreasing no-show rates.

If we can decrease the number of visits simply by performing quadrant dentistry, there’s potential for increased revenue because of less money and resources wasted in reminders. Moreover, fewer visits means setting up and breaking down the room fewer times. Resources spent on three visits could be condensed into one visit with less excess trash created from sterilization pouches, sharps, barriers, gowns, masks, suction tips, etc.

The ultimate ethical principle as a dental professional is to serve our patients and promote high standards.

If a treatment plan includes multiple treatments in close proximity, discuss

with the patient the pros and cons of having the treatment completed in one visit versus multiple visits. Multiple visits may be preferable for a variety of reasons (patient preference, length of treatment, medical condition, cost); however, patients will often appreciate the choice of consolidating treatment.

We owe it to society to address carious lesions more quickly than addressing one filling a time and one month apart. The general public relies on us to perform to the best of our abilities, but we should also be efficient and effective with our time. CDA’s Code of Ethics section 5 states that “dentists have the obligation to advance their knowledge and keep their skills freshened by continuing education throughout their professional lives.” Therefore, quadrant dentistry seems like a logical choice for both the profession and the patients. n Paul Hsiao, DDS, MPH, JD, is a general dentist practicing in Fresno, Calif. He served on the CDA Judicial Council.

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Tech Trends

C D A J O U R N A L , V O L 4 8 , Nº 7

A look into the latest dental and general technology on the market

Apple Magic Keyboard (for iPad Pro; $299, Apple) Think Dirty (Free, Think Dirty Inc.) Apple has long advertised that its iPad Pro series of tablets can replace traditional desktop and notebook computer devices. While its specifications do support that claim in regard to processing power and other features such as Face ID and touchscreen capability, users have not considered it as a substitute for the original computer. One of the major factors hindering this shift was the lack of trackpad accessory support, which Apple addressed with the release of the latest version of iPadOS. Most recently, Apple has released the Magic Keyboard for iPad Pro, further closing the gap by matching both keyboard and trackpad experiences from its MacBook series for the tablet.

The Magic Keyboard attaches to the back of the iPad Pro using powerful magnets and has a cantilever mechanism that suspends the tablet in midair, giving it a floating appearance with an adjustable viewing angle. It is able to do this because the keyboard base is very heavy and the viewing angle range is limited, allowing basic physics to do its work. The combined weight is nearly equivalent to that of a similarly sized MacBook Air. Although this keyboard acts as a cover for front and back protection, it is unable to fold back on itself and be used in portrait mode like the Smart Keyboard Folio. A USB-C port at the hinge provides passthrough charging, leaving the iPad Pro USB-C port available for connecting other accessories. The keyboard is backlit and full sized and brings back the scissor-switch mechanism for its keys. The typing experience is pleasant and near identical to Apple desktop or notebook keyboards, but lacks a row of function keys. The trackpad is highly responsive throughout, has a physical click mechanism and brings the same multitouch gestures found in MacBooks to the iPad. With the trackpad, users can use two- or three-finger gestures to swipe between apps, switch apps, scroll, go to the home screen and right click. The latest iPadOS with trackpad support also introduces a new contextual cursor experience. Unlike a mouse cursor, which is always present on the screen, the cursor in iPadOS appears as a translucent circle when in use, disappears when not in use and transforms into buttons, text and app icons to highlight its focus.

— Hubert Chan, DDS

356 JULY

2020

Think Dirty is a mobile application that utilizes artificial intelligence (AI) to evaluate ingredient lists of beauty and personal care products.

After evaluation, the app assigns a product a single score on its “Dirty Meter,” which is a 0–10 scale that rates the toxicity of the ingredients based on publicly available information. Among the nearly 1.6 million products reviewed by the AI, many are oral hygiene products like mouthwashes, toothpastes, whitening strips and floss.

Think Dirty is a Toronto-based company that launched its app in 2013. The purpose was to educate and empower consumers regarding the environmental impact of cosmetics on health. The app has been made with the average consumer in mind: Users can quickly search for products (or even scan their barcodes), evaluate their “Dirty Meter,” then choose to like, review or add a product to their personal list. Links to affiliated partners like Amazon are present so products can be purchased with minimal effort.

While the concept of analyzing ingredients according to potential harm is sound, leveraging AI for the execution can be hit or miss.

Ingredient lists are often incomplete. For example, ACT Anticavity Fluoride Rinse does not have fluoride or any of its derivatives listed as an ingredient. The rating of ingredients is suspect — while ethyl alcohol is rated as a “Clean” ingredient, titanium dioxide is listed as a “Dirty” ingredient. The “Dirty Meter” itself addresses toxicity but leaves out efficacy. There is a “Clean” toothpaste that contains no cariostatic agent, but has goji berry and pomegranate extract, both supremely acidic and sugary. Think Dirty emphasizes that its app is an educational tool to empower consumers, not a replacement for professional or medical guidance. As consumers become more sophisticated thanks to apps like Think Dirty, dental practitioners need to be aware of how their patients arrive at their conclusions and be ready to support their recommendations with evidencebased science.

— Alexander Lee, DMD

Would you like to write about technology?

Dentists interested in contributing to this section should contact Andrea LaMattina, CDE, at andrea.lamattina@cda.org.

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