My View: Advocating for ethical licensure exams

The Coalition for Modernizing Dental Licensure, founded in October 2018, was created to address long-standing concerns with the dental licensure process. Supported by the American Dental Association, American Dental Education Association and American Student Dental Association, the coalition builds on the work of the Task Force on Assessment of Readiness for Practice. The task force published a report that raised awareness about the ethical and patient safety issues inherent in the current licensure system, particularly surrounding single-encounter, procedure-based patient examinations.

The coalition has made significant strides in expanding its influence since its founding in 2018. With over 130 partners — including state dental and dental hygiene associations, dental schools, hygiene programs, specialty associations and national and nonprofit organizations — the coalition has grown into a powerful force advocating for change in dental licensure.

One of the primary goals outlined in the coalition’s 2021-24 strategic plan was to eliminate single-encounter, procedure-based patient examinations for dental and dental hygiene licensure in all states and jurisdictions and advocate for the adoption of valid, reliable and ethical licensure pathways. The 2021-24 strategic plan emphasized the importance of raising awareness among both professionals and the public about the ethical challenges and patient safety risks posed by single-encounter, procedure-based exams.

Research shows ethical issues

To bolster its advocacy, two of the coalition’s executive committee members conducted a comprehensive literature review, highlighting the long-standing ethical issues with the single- encounter patient-based licensure model. This research serves as a critical resource for those within the profession, further underlining the necessity of modernizing the licensure process and moving away from outdated, unethical, patient-based examinations. The coalition hopes that these findings will continue to influence dental professionals, educators and legislators to adopt safer and more ethical licensure practices.

The literature review revealed several longstanding ethical concerns regarding patient-based examinations for dental licensure. Ethical concerns about the use of patient-based exams have been documented since as early as 1985, reflecting widespread recognition within the dental community of the risks involved.

These ethical challenges underscore the fundamental issues with using patients in high-stakes, single-encounter exams, which can compromise both the quality of care and the integrity of the examination process. They include:

• Recruitment and consent.

• Stress of candidate may affect ethical decision-making.

• Use of patients to identify incompetence and substandard treatment.

• Performance of irreversible dental surgical procedures.

• Provision of clinical procedures out of optimal sequence.

• Treatment procedures that are exam specific and yet inconsistent with current standards

of clinical care.

• Gaps in the provision of follow-up care.

The coalition believes that patient-based exams are unethical and should be eliminated. Their removal from the dental licensure process is not only a professional imperative but also necessary for the safety of patients. The coalition urges the remaining states to reform their statutes and regulations, expeditiously eliminating this outdated and unethical requirement.

The road ahead

Despite substantial progress, with 36 states no longer requiring patient-based exams, 14 states still have statutory or regulatory provisions requiring a single-encounter, procedure-based patient examination for licensure, and one state still requires a single-encounter patient-based examination.

With its new strategic plan for 2024-27, the coalition remains committed to modernizing dental licensure. This plan includes:

• Advocating for valid, reliable and ethical pathways to licensure.

• Supporting licensure portability through the Dentist and Dental Hygienist Compact.

• Strengthening the coalition’s sustainability by expanding partnerships and collaborations.

The coalition’s ongoing efforts reflect its dedication to ensuring that the licensure process evolves in a way that serves both the profession and the public. Its vision is a licensure process that is safe, ethical and aligned with current clinical and educational standards. 

Joseph P. Crowley, D.D.S., is chair of the Coalition for Modernizing Dental Licensure Executive Committee and served as ADA president from 2016-17.

REFERENCE

1. MacNeil, R.L. & Murphy, K.E. A Review of the Ethics of Patient-Based Licensure Examinations. American Dental Hygienists’ Association. August 2024, 98 (4) 37-49.