The freedom to practice wherever

Oct. 1, 1997
Licensure laws restrict movement of dentists, even though the original reasons for the laws are obsolete.

Licensure laws restrict movement of dentists, even though the original reasons for the laws are obsolete.

Roger P. Rupp, DDS, MS

Before the opening of the first dental school in Baltimore (1840), most dental practitioners had various levels of training. Almost all prominent dentists were medical doctors who had chosen dentistry rather than medical practice as their vocation. Others who practiced dentistry were the local blacksmith and the barber. Most entered practice with no basis in either the scientific method or academic discipline. Some were preceptors, others acquired limited opportunities for professional education or clinical training and others simply assumed the title of "dentist." In fact, many of these individuals were totally incompetent and had little or no native skill in the art and science of dental practice.

There was a lack of uniform educational standards for dental training institutions. The licensure process at this time made sense. Regulation of practitioners offered some assurance to the public that certain individuals met minimal competency standards. State boards originally were designed to weed out the poorly trained from proprietary schools or low-quality preceptorships.

The licensing of dentists is and has been a responsibility of individual states. Some version of the current state board licensure system has been in effect for over 150 years.

Licensure first began in the dental profession in Alabama in 1841. In 1868, Ohio, Kentucky and New York also adopted legal restrictions to the practice of dentistry, which later extended to the other states in the nation. In 1883, six state boards joined to form the National Association of Dental Examiners. By 1907, all states had regulations governing the admission to dental practice.

Times have changed, but the examination process continues as if we were still in the time of apprenticeships; as if the only real test of dental knowledge and skills lies in performing a few common restorative and periodontal procedures under very stressful and artificial conditions. There are those who would limit the state responsibility to testing candidate`s knowledge of state laws and regulations as they relate to the practice of dentistry.

Today, these laws hamper the free movement of dentists and are anachronisms in an era of national standards and practices. The technology in dentistry is changing rapidly. The institution of examining and licensing boards may have been adequate in a time of societal and professional stability.

In this time of rapid change, however, this system may not just be inadequate, but also risky. It has been said the entry-level examinations may deter innovation in dental education. Licensure examinations vary from state to state and region to region. According to a special report commissioned by the ADA House of Delegates from the Council on Dental Education in 1990, clinical examinations for licensure are not comparable. There is no obvious pattern of success or failure that is consistent with the academic records of United States dental-school graduates, their schools of origin or the quality of their graduate work.

There appears to be no relationship between a student`s class ranking in dental school and whether he or she can successfully pass a licensure examination. The test frequently fails some of the more qualified candidates. A candidate for licensure may be an outstanding clinician and still face the prospect of failing the exam due to unforeseen and uncontrollable incidents. Weak candidates often pass their licensure examinations on the first try, while honors graduates sometimes require two or three attempts. They sometimes fail because of patient problems or other circumstances beyond their control.

Essentially, all candidates pass the examinations eventually, usually without additional training or experience. The clinical examinations are unlikely to identify and weed out the unqualified or incompetent practitioners. A study published in 1992 suggested that the current mechanism of entry-level exams provided less than consistent processes and outcomes. Clinical boards revisit, in a superficial and unpredictable way, skills and knowledge that all U.S. dental schools already teach and examine in a far more comprehensive manner.

General exam for specialists

A rather overt inconsistency is the requirement for specialists to pass a general dental-board examination that has little or nothing to do with their specialty. For example, an orthodontist who has practiced orthodontics exclusively for 20 years in one jurisdiction may be asked to do a gold casting and perio treatment in the entry-level, minimal-competency examination of another jurisdiction before being licensed. An examination of two or three clinical procedures, along with a written test, is open to enormous sampling bias and cannot provide (and never has provided) an assurance of competency. There is no proof that these board examinations serve any public good, and certainly there is anecdotal evidence to suggest that they harm competent young graduates. There also may be harm to the patient.

The process of treating patients during the usual board examination requires practices that normally would be deemed substandard or unacceptable if followed routinely by a private practitioner. For example, any dentist who keeps patients under rubber dam for extended periods required by the examining process could well be accused of malpractice. A dentist treating patients in this manner in private practice would likely soon have no patients.

Many requirements for licensure

Some contend that the manipulation of board examinations for political or economic motives was, and still is, very frequent. The Joint Commission on Accreditation has accredited dental schools. A degree in dentistry is offered only to those who have completed the requirements of an accredited institution. Occasionally, substandard students graduate.

The dental school must recognize the deficiency and offer remediation. It should be the responsibility of dental schools to determine and certify graduates as technically proficient. School-accreditation authorities should be responsible for ensuring that the schools meet this responsibility. The failure rate on recent entry-level, minimal-competency clinical exams given by the NorthEastern Regional Board (NERB has 25 dental schools in its region) was 37 percent in 1991, 38 percent in 1992 and 46.20 percent in 1993. That same year, the overall failure rate for all candidates was 44.25 percent. The results of the regional board examinations for 1994 showed failure rates for regions reaching as high as 40 percent or more. Virtually all who fail board examinations ultimately pass. No other profession has so many requirements for licensure.

Organized medicine in the United States has long since abandoned the "practical board exam." Instead, the medical profession relies on a variety of alternative, standardized national qualifying exams, with written science and clinical-problem questions. Once qualified, a physician may be licensed in another state simply by presenting his or her credentials and current recommendations, as well as hospital and malpractice claim records, etc.

A physician can become licensed to practice in any of the 50 states and the District of Columbia without separate examination. Dentistry is the only learned profession that perpetuates the myth that a clinical demonstration is essential to determine competence prior to licensure. No other health-care profession requires an examination of clinical skills. No other profession imposes geographic restrictions on where you can practice. The United States is the only developed country that imposes geographic restrictions on the practice of general dentistry.

There are many in our profession who feel that clinically examining graduates of schools accredited by the Commission on Dental Accreditation is not central to the task of protecting the public. Educators continue to challenge the premise that entry-level licensure protects the public. The American Association of Dental Schools House of Delegates recommends elimination of state and regional entry-level, clinical-licensure examinations for graduates of accredited schools who have successfully passed the National Board Examinations. The current process is enormously costly in terms of time, money and resources. The cost to the licensure candidates is considerable, ranging between $1,070 to $1,150. This cost does not take into consideration taking the examination at a distant site with the attendant costs of airfare and lodging for the candidate and the patients. The costs to the University of Missouri at Kansas City School of Dentistry for licensure exams hosted at that institution in one year were $245,741.66.

Licensure exam is anachronistic

The current system of examination for licensure is anachronistic, unfair and serves no useful purpose. These examinations are unlikely to identify and weed out the unqualified or incompetent practitioners. Dental-licensure examinations have been criticized for being invalid, unreliable and heavily patient- oriented and clinically-oriented. The bottom line is that the board exams do not measure what they have been established to measure - clinical competence.

Dental boards in 33 states have statutory authority to grant licenses to dentists who are licensed in another jurisdiction without further theoretical or clinical examination. This license recognition system is variously referred to as licensure by credentials, licensure by endorsement or licensure by criteria or reciprocity. Twenty-nine of the 33 dental boards that have been given statutory authority to grant a license by credentials actually do so. Twenty-two of these states grant licensure by credential to applicants from all states. Seven do so only for applicants from states with similar practices. A few states have chosen not to exercise their statutory authority. Currently, 35 dental-licensing jurisdictions accept one or more regional clinical examinations for initial licensure. The American Dental Association has been on record since the early 1970s as supporting licensure by credentials. In the last four years, that policy has been strengthened considerably.

There was a point in time when the clinical licensure process, as it now exists in the United States, was necessary. That point in time has now passed. It is time for the profession of dentistry to accept the graduates of accredited schools as qualified for licensure without further examination. It also is time for licensure by credentials and/reciprocity to become the law of the land.

References available upon request.

U.S. licensure restrictions

States that accept and process applications for licensure based on a dentist`s credentials received in other jurisdictions:

Alaska, Arkansas, Connecticut, District of Columbia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nebraska, New Hampshire, New Jersey, New York, North Dakota, Ohio, Oklahoma, Pennsylvania, South Dakota, Texas, Washington, Wisconsin, Wyoming

States that can grant a license by credentials only to licensees of states with similar reciprocal practices:

District of Columbia, Iowa, Kentucky, New Jersey, Oklahoma, Pennsylvania, Wyoming

States that have statutory authority to grant licensure by credentials, but do not exercise it:

Georgia, South Carolina, Virginia