Licensure Reform

On dental licensure exams, the elephant has had enough

People can’t stop talking about dental licensure. What has been dentistry’s elephant in the room for so long has finally grown tired of being ignored and overlooked and made excuses for.

I took my exam almost one year ago to the day. And if I’m being honest, I haven’t given it too much thought since. But strangely enough, here I am one year later, all the way across the country, and licensing is back on my mind. It’s WREB season here at the University of Washington. Fourth year dental students are taking Western Regional Examining Board exam as I type this. Several of these students are my friends. One of them is my coresident.

Dr. Vaughn

Dr. Vaughn

And so over the past several weeks, I’ve been skimming through patient radiographs. I’ve been having those awkward conversations with patients trying to convince them to be a patient for a desperate future dentist. I’ve been reading excerpts from the WREB manual trying to figure out what these specific people in this specific area of the country are looking for.

In Alabama, I took the Central Regional Dental Testing Service exam, or CRDTS. Which you would think is the same exam just given by a different company. But actually, the exams have varying degrees of differences and nuances.

For CRDTS, we perform the endodontic section on plastic teeth. In WREB, it’s on natural teeth that students must hunt down on their own. In CRDTS, there is a fixed prosth section where you cut three types of crowns on mannequin teeth. In WREB, there is no such section. In CRDTS, the ideal class II lesion that you are supposed to find would likely be rejected in WREB.

This list is just off the top of my head. And what’s funny is that some states accept both of these exams. I can be licensed in the state of Washington just as easily as someone who took WREB.

I’m usually not one to linger, and I could just as easily “let this one go.” But I’m compelled to write on licensure because I’m at a loss for why our profession is at odds over this matter.

We’ve all heard the arguments. The theoretical protection of the public. The walling off of the incompetent. The supremacy of standardization that the exam provides.

These statements of confidence only raise questions. Questions that I, for one, would love answered.

Is our private practice world completely free of incompetence? What about the cases of unethical behavior by licensed dentists? What about those bitewings we’ve all seen that make our brows raise and shake our heads at the questionable work we see staring back at us? Isn’t that work done by a licensed dentist? Someone who has in fact proved his or her competence to the world through passing the licensure exam?

Who never passes the exam? Does anyone?

What type of competence does the exam really measure? Am I a general dentist or am I an operative dentist? Can’t I, as a licensed general dentist, prep crowns? And extract teeth? And perform root canals and treat children and do build-ups and cut flaps and do perio surgeries? In what portion does the licensing exam test these aspects? Is dental school sufficient proof enough for these areas of dentistry but not a class III prep?

“Oh what about the endo portion?” Yes, let’s talk about the endo portion.

“Forget everything you know about doing a root canal.” The exact words my instructor told us when preparing for the endo portion of CRDTS. If you aren’t aware, doing a root canal on a plastic tooth is absolutely nothing like doing a root canal on a person. No sodium hypochlorite. No RC Prep. Push the 10 file all the way out the apex each time so the wax doesn’t collect at the apex.

I’m hearing all of the reaching defenses for this exam, and I’m just not convinced. And I’m not alone.

Not only does ASDA have a formal stance against the use of live patients on exams that can be found here, but so does the ADA (found here). What are we doing to ourselves and our profession when our national organization disagrees with something that continues to happen? Where is the disconnect?

I understand the concerns in keeping our profession a reputable one. I understand the inclination to have more exams and more obstacles and justifying it with buzzwords like “incompetence” and “public safety.”

But we are professionals. And evidence-based practice is very much a part of what we do and who we are. I believe the evidence supporting live patient exams is just not there. We have dental schools. We have vigorous entry processes. We have two National Board Exams. We have two full years of clinical practice under the supervision of experts in the field. To say that none of this matters without a licensing exam is to call everything into question.

Because the fact is, a window in time will tell you nothing about the quality of a dentist. Terrible dentists will pass the exam. Excellent dentists may fail the exam.

And not to mention the overwhelming stress it puts on students. The extra loan we have to take out to afford the $2,500 price tag. Paying patients out of desperation because otherwise they wouldn’t have shown up. Or how about driving two hours round trip to personally pick up my patient the morning of the exam because she could not drive herself.

Patients don’t show up. Lesions are rejected the morning of. And excuse my emotion in this post, but it’s frustrating and disappointing to see this debate continue. I’ve seen classmates cry. I’ve seen mental breakdowns. I’ve seen professors breaking their back and putting in long hours after school guiding their students through this exam because nobody else would.

And worst of all, I’ve seen an apathy from many dentists that is all too familiar. Because a dental student the day before the exam and the day after they passed the exam are, in fact, two very different students. We pass the exam and all we want to do is bury it. Leave it alone. It’s over. And then, slowly, we develop that mentality of “I did it, so can they.”

The new dentist generation is making great strides in moving our profession in the right direction on licensure reform. I’m incredibly excited to see what change comes about once we are in those administrative positions that are making the decisions in our profession.

But until that happens, we need to keep talking. We need to keep pushing for solutions to this chronic problem. We need to show them what we see and what we feel and hope that we can find a middle ground to connect upon. The patient portion of this brutal exam has an expiration date. I believe this to be inevitable. Some states have already made the push to do away with it, and for that I am thankful. But the only way we will see this become a national change is if we keep talking and keep pushing for what we feel is right. I hope you’ll join me in keeping this conversation alive.

Dr. Joe Vaughn is a New Dentist Now guest blogger and a member of the American Dental Association. He grew up in Alabama and recently graduated from The University of Alabama at Birmingham School of Dentistry in 2015. He now lives in Seattle, Washington, where he attends the General Practice Residency at the University of Washington. Two cups of coffee, writing and indie music are everyday occurrences for Joe. Go Seahawks and Roll Tide!

The views expressed in this article are the personal opinions of the author and are not intended to reflect the views, positions or policies of the ADA or the New Dentist Committee.

2 comments

  • There are some good points made here. I do think it’s important that this industry begin to discuss issues of licensure more. Thanks for sharing your thoughts!

  • I completely Agree with the points in this article. Having practiced dentistry for over 10 years, I found myself “back” in the game when I moved to California and had to take the WREB. If you think it is frustrating for new grads, let me tell you that as an experienced dentist, I was even more overwhelmed. I had been out of the school setting for over a decade…..I had no reference point as to what is expected or how to find patients. The costs of the exam aside, the real cost for me would be if I DIDN’T pass. I’m happy to say that I was able to find patients ( my husband drove them and we paid them) through begging and sucking up to several local dentists and I was OK on the other parts as well. I, too, saw people crying and some that had taken the exam over 4 times!!! The entire process was so stressful and there are no resources for reviewing the material if you are out of the dental school setting. I decided to start a prep course for people like myself who are experienced dentists, but I would be happy to see the entire thing eliminated.

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