LICENSURE

The Pathway to Licensure… A marathon not a sprint!

 

We think that getting into dental school is the hardest part of becoming a dentist, and that often the process is almost automatic after you begin the first day of class. Sadly, that is not the case. Dentistry is a self regulated profession, meaning that a board of dentists supervises the licensure and practice of professionals in our field. Each state has their own Board of Dentistry, and each board has their own rules and regulations regarding applying and getting licensed. Further complicating the process are the different exams required to apply in some states. Don’t worry – we have simplified and condensed the key things you should know!

What is a board exam?

Board exams can refer to two things:

  • The written didactic examinations administered by the ADA’s JCNDE, the NBDE

  • A “clinical licensure exam”

 

The NBDE exam is broken down into two parts, typically taken about a year apart beginning in your second or third year of dental school.

  • NBDE Part I covers information typically taught in the beginning of your dental education such as dental and gross anatomy, microbiology, biochemistry, and more.

  • NBDE Part II covers more “clinical” information such as dental diagnosis, pharmacology, and pathology.

 

Currently, all dental schools in the US prepare their students for the NBDE, and all state boards require passing these exams to obtain licensure. The exams are administered as pass/fail, and the results are reported to the state boards directly.

 

The INBDE, or Integrated National Board Dental Examination, is being developed by the ADA’s JCNDE and is planned to begin replace the NBDE part I/II in 2020 in a phase-out process. For more information, please see the ADA’s website about the INBDE:

https://www.ada.org/en/jcnde/inbde

 

 

“Clinical licensure exams” are where things get a bit more complicated. These exams are typically divided into two portions:

  • Manikin/typodont procedures: Three crown preparations, an endodontic access on a molar, and a full endodontic procedure on a maxillary incisor.

  • Live patient procedures: Peridontal scaling and root planning, full preparation and restoration of a class II as well as a class II carious lesion.

 

States choose which examinations they wish to accept, and the exams are administered by an independent testing agency.

 

So to summarize, there are 4 parts to a typical boards process for most dental students. Two NBDE written exams, a manikin/typodont simulation exam, and a clinical patient exam. You must pass all 4 parts separately to become licensed in most US states.

What is a typical timeline for exams?

1. Get into dental school!

2. Take classes and study.

3. Take your NBDE Part I Written Exam.

4. Hone in your hand skills.

5. Take your particular clinical manikin board exam.

6. Study your diagnosis and treatment options.

7. Take your NBDE Part II Written Exam.

8. Perfect your clinical skills in clinic.

9. Take your clinical patient based examination.

10. Graduate!

11. Apply for licensure in your desired state.

State by state - Policies & boards accepted

Clinical Examinations and State Differences:

District 4 of ASDA includes Georgia, South Carolina, North Carolina, Tennessee, and Virginia. We have outlined the licensure process and requirements for each of the states in our district to serve as a reference, however licensure is an ever changing landscape so please confirm with a state board before proceeding with a license application.

 

Before we start, let's go over a few terms...

Licensure by Credentials: ADA states that issuing a license using a performance record in place of examinations is termed licensure by credentials, and that it is unnecessary for a dentist to take a separate examination for another state if they are already licensed in one state, usually by way of an existing clinical board examination. Currently, 46 states in the US have some form of licensure by credentials for dentists, although the exact terms and times vary. What this means for you as a dental student and new dentist is that once you practice for around 5 years in one state, you will have some sort of portability with your license by applying for another state license without having to go back and take another board examination. This ideology is also known as Reciprocity.

 

PGY-1: [SF1] [KM2] Just like you hear the terms D1 and D4 referring to the first year of dental school and the fourth, PGY stands for post graduate year and the 1 indicates the first year post graduation with your DMD/DDS degree. PGY-1 programs are residency programs and offer training after graduation. Some states (most notably New York) require a PGY-1 to become a licensed dentist after dental school. While some view the PGY-1 as an alternative to a clinical board examination, it is ASDA’s policy (https://www.asdanet.org/index/get-involved/advocate/issues-and-legislative-priorities/Licensure-Reform) that the PGY-1 is not the solution to the clinical patient boards issue. [SF3] There are a few reasons for this, most notably that students are not guaranteed to be competent after graduation so ASDA believes that third party evaluation is necessary (http://onlinedigitalpublishing.com/display_article.php?id=2696402&view=379346). That being said, if you are interested in practicing dentistry outside of District 4 you may hear the term come up and if you are interested in learning more, please read through the articles above.  

 

Canadian OSCE: The Objective Structured Clinical Examination (OSCE) is an alternative exam that tests candidates on a variety of competencies (from local anestheia to oral radiology) through a series of stations.  Stations take one of two forms.  The first type of station requires the candidate to review information such as dental charts and radiographs to answer multiple-choice questions.  The second type requires the candidate to write an acceptable prescription for medications.  While this exam in only in Canada, it is important to know that it exists as an alterative when the topic of licensure reform is presented later.    

 

State by State Exam Acceptance Overview:

Georgia: CRDTS

South Carolina: CDCA/CITA/ADEX, CRDTS, SRTA

North Carolina: CDCA/CITA/ADEX

Tennessee: CDCA/CITA/ADEX, CRDTS, SRTA, WREB

Virginia: CDCA/CITA/ADEX, CRDTS, SRTA, WREB

 

Georgia ONLY accepts CRDTS, so dentists must have taken that examination to become licensed in Georgia. Georgia does offer Licensure by Credentials, which requires 5 years of active practice in another state and a license in good standing from that state dental board for dentists looking to move to Georgia. Please also note that the Class II in your CRDTS restorative section must NOT be a slot preparation to obtain a Georgia dental license.

Georgia Board of Dentistry: https://gbd.georgia.gov

 

South Carolina accepts the ADEX exam, which is offered by either CDCA or by CITA, along with SRTA and CRDTS. South Carolina does offer Licensure by Credentials, which requires 5 years of active practice in another state and a license in good standing from that state dental board for dentists looking to move to South Carolina.

South Carolina Board of Dentistry: http://www.llr.state.sc.us/POL/Dentistry/

 

North Carolina only accepts the ADEX exam, which is offered by either CDCA or by CITA. North Carolina does offer Licensure by Credentials, which requires 5,000 hours of clinical care not including residency training in another state and a license in good standing from that state dental board for dentists looking to move to North Carolina.

North Carolina Board of Dentistry: http://www.ncdentalboard.org

 

Tennessee accepts ADEX exam, which is offered by either CDCA or by CITA, along with CRDTS, SRTA, and WREB. Tennessee does offer Licensure by Credentials, which requires 5 years of active patient care and/or teaching at an ADA accredited institution in another state and a license in good standing from that state dental board for dentists looking to move to Tennessee. Additionally, Tennessee offers Reciprocity for dentists that taught at an ADA accredited dental school or participated in patient care in another state for 2 years, if they also supply passing board examinations that are “substantially equivalent to the examination required for initial licensure in Tennessee”. Applicants do not have to take the periodontal portion of any live patient exam for licensure in Tennessee.

Tennessee Board of Dentistry: https://www.tn.gov/content/tn/health/health-program-areas/health-professional-boards/dentistry-board.html

 

Virginia accepts the ADEX exam, which is offered by either CDCA or by CITA, along with CRDTS, SRTA, and WREB. Virginia does offer Licensure by Credentials, which requires 5 out of the most recent 6 years of active patient care (>600 hours) in another state and a license in good standing from that state dental board for dentists looking to move to Virginia.

Virginia Board of Dentistry: https://www.dhp.virginia.gov/dentistry/

 [SF1]Is there a reason other alternatives are not mentioned here like the Canadian OCSE or the California portfolio?

 [KM2]I agree that we should at least briefly mention them given that we mention PGY-1

 [SF3]It may be helpful to provide some context here. You could consider citing information from ASDA’s February 2016 Contour article, the 4 misconceptions about ASDA’s stance on licensure reform. I pulled a quote below for you to consider.

 

“PGY-1 gives those students a chance to work on skills that should have been developed earlier. But the same logic that shows a dental student isn’t guaranteed to be competent after four years of school also shows there is no guarantee of competence after five. To protect the public, ASDA believes third- party evaluation is necessary.”

Different clinical licensure exams & testing agencies

Examinations and Testing Agencies:

 

CRDTS – the Central Regional Dental Testing Services offers an examination by the same name in both the traditional and integrated curriculum format. The examination is broken into two portions, manikin and patient based exams. The manikin portion is further broken down into two sections, fixed prosthodontics and endodontics. For fixed prosthodontics, applications must prepare 3 teeth for crowns of varying design (#9 full ceramic, #3 full cast gold, #5 PFM) and the two posterior preps must have common draw. For the endodontics section, applications must perform an access/pulpotomy on a maxillary molar (#14) and a full root canal treatment from access to obturation on a central incisor (#8). The clinical examination is divided into two portions as well, periodontics and restorative. For restorative, a class II and class III lesion must be prepped and restored, and for periodontal scaling and root planing must be successfully completed on a screened group of teeth. For precise information about the examination, please visit the CRDTS website and view the candidate manual. https://crdts.org

CRDTS is administered at Augusta University/Dental College of Georgia in our district. Please check with CRDTS for an exam calendar.

 

CDCA – the Commission on Dental Competency Assessments administers the ADEX examination in both traditional and Curriculum Integrated Format. The exam is broken into two sections, manikin and patient portions. The manikin portion is further broken down into two sections, fixed prosthodontics and endodontics. For endodontics, access opening on a maxillary molar (#14) must be performed, and a full root canal treatment from access to obturation on a central incisor (#8). For the fixed prosthodontics section, three crown preparations of various designs must be cut (#9 full ceramic, #3 full cast gold, #5 PFM) and the two posterior teeth must be prepped to draw for an FPD. The patient based clinical examination is divided into two sections, periodontal scaling and restorative. For restorative, a class II and class III lesion must be prepped and restored, and for periodontal scaling and root planning must be successfully completed on a screened group of teeth. For precise information about the examination, please visit the CDCA website and view the candidate manual. https://www.cdcaexams.org/dental-exam-manual/

The CDCA ADEX is not currently administered at a school in our district, however you can take it at another school and use those results to seek licensure here in any state that accepts ADEX. Please check with CDCA for an exam calendar.

 

CITA – the Council on Interstate Testing Agencies offers the ADEX examination in the curriculum integrated formats. The exam is broken into two sections, manikin and patient portions. The manikin portion is further broken down into two sections, fixed prosthodontics and endodontics. For endodontics, access opening on a maxillary molar (#14) must be performed, and a full root canal treatment from access to obturation on a central incisor (#8). For the fixed prosthodontics section, three crown preparations of various designs must be cut (#9 full ceramic, #3 full cast gold, #5 PFM) and the two posterior teeth must be prepped to draw for an FPD. The patient based clinical examination is divided into two sections, periodontal scaling and restorative. For restorative, a class II and class III lesion must be prepped and restored, and for periodontal scaling and root planning must be successfully completed on a screened group of teeth. For precise information about the examination, please consult the CITA ADEX candidate manual.

The CITA ADEX is administered at ECU, MUSC, UNC, VCU, Meherry Medical College, and UTHSC in our district. Please check with CITA for an exam calendar.

 

SRTA – The Southern Regional Testing Agency administers an exam by the same name and is available in both curriculum and integrated and traditional formats. The exam is broken into two sections, manikin and patient portions. The manikin portion is further broken down into two sections, fixed prosthodontics and endodontics. For endodontics, access opening on a maxillary molar (#14) must be performed, and a full root canal treatment from access to obturation on a central incisor (#8). For the fixed prosthodontics section, three crown preparations of various designs must be cut (#9 full ceramic, #3 full cast gold/zirconia, #5 PFM) and the two posterior teeth must be prepped to draw for an FPD. The patient based clinical examination is divided into two sections, periodontal scaling and restorative. For restorative, a class II and class III lesion must be prepped and restored, and for periodontal scaling and root planning must be successfully completed on a screened group of teeth. The periodontal section is optional to take, deepening on the requirements of your state board for licensure. For precise information about the examination, please consult the SRTA website and view the candidate manual. https://srta.org/dental/dental-manual/

SRTA is offered at Meherry Medical College, UTHSC, and VCU in our district. Please check with SRTA for an exam calendar.

 

 

WREB – the Western Regional Examining Board offers the WREB exam, which is divided into three sections. The Comprehensive Treatment Planning (CTP) exam is a written case based examination administered through Parametric testing centers (just like NBDE). The cases are patient based, with a chief complaint, medical history, and x-Rays and you must create and submit a treatment plan for each case and answer questions about it. The Endodontic section requires a full root canal treatment from accessing to obturation on a simulated anterior tooth and access of a mandibular first molar simulated tooth. Finally, the operative section requires “up to two restorative procedures on patients to demonstrate competence” and must include a class II restoration for the first, and the second can be a class II or class III. WREB does also offer two additional optional sections that candidates can elect to take if their state board requires them. The periodontal section requires treatment of at least 8 surfaces for scaling and root planing, and the prosthodontic section includes treatment of an anterior full coverage crown, and posterior 3 unit (2 abutment) FPD.

The WREB is not currently administered at a school in our district, however you can take this exam at another school and use those results to seek licensure here in any state that accepts WREB. Please check with WREB for an exam calendar.

why is this so complicated? what can I do?

Why is this information so similar for different exams?

That’s a FANTASTIC question! States used to administer their own board examinations, back when licensure was even less portable than it is today. Then, states began to group together and offer the same exam, and still now more and more states are combining and offering similar exams. This is how testing agencies were created. Ultimately, now, the reason for different acronyms and exams is mostly political. This situation creates headaches for new dentists and dental students to try to figure out which exams to take, much less which states accept which. These exams, which are proven not to be psychometrically valid or reliable, put unnecessary pressure on students and put live patients in the middle of a political battle. Think there could be a better solution? We do too! ASDA feels that an ideal licensure exam will not use human subjects, will be psychometrically valid and reliable, is reflective of the current scope of dental practice, and will be universally accepted. If you feel strongly about these issues, get involved with ASDA and ADA advocacy, and advocate for dental licensure reform. Reach out to your chapter or district leadership, and we will be happy to help you get involved! You can also read the ASDA white paper on clinical licensure reform to learn what alternatives to the current system can be and be informed the next time the topic comes up! https://www.asdanet.org/docs/advocate/asda_white-paper_licensure_web_final.pdf?sfvrsn=6[SF5]