Depafiment  of  Health  and Human  Sewices 
OFFICE  OF 
INSPECTOR  GENERAL 
THE  LICENSURE  OF  OUT-OF-STATE 
DENTISTS 
AUGUST  Igg3 
____ ._  OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General  (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department  of Health and Human Services (HHS) 
programs as well as the health and welfare of beneficiaries seined by those programs.  This 
statutory mission is earned  out through a nationwide network of audits, investigations, and 
inspections conducted by three OIG operating components:  the Office of Audit Semites, the 
Office of Investigations, and the Office of Evaluation and Inspections.  The OIG also informs 
the Secretary of HHS of program and management problems and recommends courses to 
correct them. 
OFFICE OF AUDIT  SERVICES 
The OIGS Office of Audit Semites (OAS) provides all auditing services for HHS, either by 
conducting audits with its own audit resources or by overseeing audit work done by others. 
Audits examine the performance of HHS programs and/or its grantees and contractors in 
carrying out their respective responsibilities and are intended to provide independent 
assessments of HHS programs and operations in order to reduce waste, abuse, and 
mismanagement and to promote economy and efficiency throughout  the Department. 
OFFICE OF INVESTIGATIONS 
The OIGS Offke  of Investigations (01) conducts criminal, civil, and administrative 
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of 
unjust enrichment  by providers.  The investigative efforts of 01 lead to criminal convictions, 
administrative sanctions, or civil money penalties.  The 01 also oversees State Medicaid fraud 
control units which investigate and prosecute fraud and patient  abuse in the Medicaid program. 
OFFICE OF EVALUATION  AND  INSPECTIONS 
The OIGS Office of Evaluation and Inspections (OEI) conducts short-term management and 
program evaluations (called inspections) that focus on issues of concern to the Department, 
the Congress, and the public.  The findings and recommendations contained in these inspection 
reports generate  rapid, accurate, and up-to-date  information on the efficiency, vulnerability, 
and effectiveness of departmental  programs. 
This report was prepared  under the direction of Mark R. Yessian, Ph.D., Regional Inspector 
General, and Martha B. Kvaal, Deputy Regional Inspector General, Boston Region, Office of 
Evaluation and Inspections.  Participating in this project were the following people: 
Boston  Headquarters 
Barry McCoy, Lead Analyst  Alan S. Levine 
Ted Wall, Program Analyst 
For additional copies of this repo~  please contact the Boston regional office at 617/565-1050.  Department  of  Health  and Human  Setices 
OFFICE  OF 
INSPECTOR  GENEML 
THE  LICENSURE  OF  OUT-OF-STATE 
DENTISTS 
AUGUST  Igg3 
I  OEI-01-92-~20  EXECUTIVE  SUMMARY

PURPOSE 
To describe  and  assess  State  dental  board  policies  for licensing  dentists  already 
licensed  in another  State. 
BACKGROUND 
Dentists  who  have  a license  in one  State  and  wish to  obtain  one  in another  face  two 
different  paths  to licensure.  In one  group  of States,  they  can get  a license  through  a 
process  called  licensure  by credentials.  It allows for the  granting  of a license  on the 
basis  of established  credentials,  with  no further  examination  requirement.  In the  other 
group  of States,  the  out-of-State  dentists  must  pass  a clinical  examination,  regardless 
of their  experience  and  credentials.  The  examination  is the  same  one  given  to those 
seeking  an initial  dental  license.  It involves  the  use  of a live patient  and  calls for the 
applicant  to find  a willing patient  with the  necessary  oral  problems. 
The  chairman  of the  Subcommittee  on Small  Business  Opportunities  and  Energy  of 
the  House  Committee  on Small  Business  asked  the  Office  of Inspector  General  to 
conduct  an inspection.  He  was concerned  that  the  failure  of many  States  to provide 
licensure  by credentials  might  be  detrimental  to consumers  and  might  impede  access 
to dental  services  for those  living in underserved  rural  or inner-city  areas. 
This report  responds  to his request.  It draws  on a survey  of the  dental  boards  for 50 
States  and  the  District  of Columbia  (hereafter  referred  to as a State),  a review  of the 
professional  literature  and  existing  data  on State  licensure  policies,  and  interviews  with 
representatives  of State  dental  boards  and  national  dental  organizations. 
FINDINGS 
Twenty-nine  States  grant  Iicensure  by credential  an  increase  of  11 since  1987. 
The  29 States  are  concentrated  in the  Northeast  and  Midwest. 
 
The  core  argument  in favor  of Iicensure  by credentials  is that  it facilitates 
	
freedom  of movement  by practicing  dentists. 
Twenty-two  States  do not  grant  licensure  by credentials. 
They  are  concentrated  in the  South  and  West  and  include  six of the  seven 
	
States  leading  the  nation  in population  growth  between  1980 and  1990.  The  core  argument  in opposition  to licensure  by credentials  is that  it fails to 
b 
offer  adequate  assurance  of the  competency  of the  out-of-State  dentists  seeking 
licensure. 
The  clinical  examination  which  22 States  require  of out-of-State  dentists  seeking 
licensure  provides  a check  on the  continued  competency  of practicing  dentists.  But 
these  States  do not  apply  the  requirement  or any similar  assessment  of competency  to 
dentists  already  practicing  within  their  borders. 
The  examina tion  requirement  can  impede  efforts  to recruit  individual  dentists  willing 
to locate  in underserved  areas  within  the  States.  Yet  we found  no da@  nor  any 
studi+  to support  a contention  that  it has much  overall  bearing  on access  to dental 
care  in these  areas. 
CONCLUSION 
Since  1987 dentists  have  come  to enjoy  somewhat  greater  freedom  of movement  as 
more  States  have  established  licensure-by-credentials  policies.  Yet,  within  the 
profession,  controversy  over  the  issue remains  and  may even  have  intensified. 
Our  inquiry  has not  provided  a basis  for supporting  or opposing  licensure  by 
credentials.  It has,  however,  identified  two closely related  issues  that  are  of 
considerable  significance  to dentists  and  the  general  public.  These  are: 
the  minimal  degree  to which  States  currently  assess  the  continued  competency 
	
of practicing  dentists,  and 
the  questionable  performance  of many  State  dental  boards  in carrying  out  their 
	
enforcement  and  discipline  responsibilities. 
E State  governments  and  dental  organizations,  such as the  American  Association  of 
Dental  Examiners,  the  American  Dental  Association,  the  American  Association  of 
Dental  Schools,  and  the  Association  of State  and  Territorial  Dental  Directors,  focus 
constructively  on these  issues, support  for licensure  by credentials  could  broaden 
considerably.  More  importantly,  the  public  could  receive  increased  protection  for the 
close  to $40 billion  a year  it is spending  on services  provided  by about  145,000 dentists 
across  the  United  States. 
COMMENTS  ON THE  DRAFT  REPORT 
We  received  comments  on the  draft  report  from  the  American  Association  of Dental 
Examiners,  the  American  Dental  Association,  the  American  Association  of Dental 
Schools,  and  The  Association  of State  and  Territorial  Dental  Directors.  In appendix 
C, we present  each  set of comments  in full.  In response  to the  comments,  we have 
made  some  technical  corrections  and  some  updates  in our  data  on States  practices 
concerning  licensure  by credentials. 
ii 
-- TABLE  OF  CONTENTS

PAGE 
=~  s~y 
-mJcrT(IN....  . .. . . . .. . . . . .. . ..  . . . . . . . . . . . . . . . . .. . . . . . . . . ..  I 
mince  . . . . . .. . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..4 
Current  Practices  . . . . . . . . . . 
 
. . . . . . . . . . . . . . . . . . . . . ..O 
. . . . . . ..O  . . . .  4 
.  Rationales  . . . . . . . . . . . . 
. . . . . . . .
. . . . . . . . . . . ..O  . . . . . . . . .OO. . . . . . .  5 
Consequences  . . . . . . . . . . 
 
. . . . . . . .
. . . . . . . . .
. . . . . . . . . . . . . . . . . . . ..O  8
~NcLIJSION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..  II 
~=NTsONTHED~~PORT  . . . . . . . . . . 
. . . . . . .0 . . . . . . . . . . .  12
APPENDI~ 
k	 State  Dental  Board  Authorities  and  Practices  in Granting  Licensure 
by Credentials  to Out-of-State  Candidates:  1987 and  1993  . . . . . . . . . . . . . .  A-1 
B:  Credentialing  Requirements  Imposed  by States  that  Grant  Licensureby 
Credentials,  1993  . . . . . . . . . . . . . . . . . . . . . . 
. . . . . . ...  . . . . . . . . . .
. . . .  B-1
C  Detailed  Comments  on the  Draft  Report  . . . . . . . . . . . . 
. . . . . . ...  . . . . . .  c-1
D:--Endnotes  . . . . . . . . . . 
. . . . . . .. 
. . . . . . ... 
. . . . . . ..  . . . . . . ..  . . . . . . ..  D-I 
  7 
{  1 TABLE 1
/, THE AMERICAN  DENTAL ASSOCIATION AND LICENSURE  BY CREDENTIALS: 
AN HISTORICAL SKETCH 
SIGNIFICANT ACTIONS 
heti~n  Dental-Iation  (ADA)  survey of mem&ship  indicates  that 62 percent  favor licensure

by credentials.

ADA House  of Delegatepsassesa resolution  calling for Stat=  to consider including in their practice

~cts proviSons  for waiving the written  and clinical Iicensure examination  requirements  for candidates

who are licensed in another  State.

4DA  House  passes a resolution  setting forth guidelines for licensure  by credentials.  The resolution

lotes  that  the ADA  believes that an evaluation  of a practicing dentists theoretical  knowledge  and

:linical skill based  upon his performance  record  can provide as much protection  to the public as

vould an evaluation  based  upon examination.

4DA  survey of its membership  show  that 77 percent  favor Iicensure by credentials.

4DA  House  adopts  a resolution  calling for ADA  to appoint  a committee  to study the freedom  of

movement  and Iicensure issues and to report  back to the Housein 1989.  It also calls for ADA  in

cooperation  with the American  Association  for Dental  Examiners  (HE)  to study (1) the

comparability  of clinical examinations  in use for dental  licensure  and (2) the feasibility of identifying

reliable standards  for evaluating  clinical competency.

The committee  to study freedom  of movement  and Iicensure issues sumeys States with and without

[icensure  by credential.  Drawing on the committee  re~rt,  the ADA  House  passes resolutions

extending  the ADAs Iicensure-by-credential  guidelines  for the States, calling for ADA and WE

to study the development  of mutually  acceptable  continuing  com~tence  criteria,  and urging State

boards  of dentistry  to grant  mutual  acceptance  to State or regional clinical iicensure examinations

found  to be comparable.

ADA/AM3E  study produces  Guidelines  for Developing  Dental  Limmure  Clinical Examinations.  It

identifies the minimum  common  core for a clinical Iicensure examination.

Congressman  Bob Livingston (LA) introduces  in the U.S. Houseof Reprewntatives  H.R.  5444 to

require  State  dental  boards  to grant  licensure  by credentials.  No action  taken on bill.

Congressman  William Jefferson  (LA) introduces  in the U.S. HOUWHR.  2691, a bill to prohibit

discrimination  by the states  on the basis of nonresidency  in the licensing of dental  health  care

professionals.  ADA  House  of Delegates  narrowly votes down a resolution  calling for the ADA  to

actively support  H.R.  269 1.

ADA/&%DE  committee  produces  Guidelines  for Valid and Reliable  Dental  Licensure

Examinations  in order  to further  inform dental  testing agencies concerning  test procedures  that will

comply with professional  testing standards.  The ADA  and AADE  convene  a national  conference  to

address  the document.  Examination  committee  chairs of 20 of the 22 regional and State testing

agencies  make  up the primary audience.

ADA  convenes  a national  conference  on licensure  by credentials.  It draws together  more  than  230

participants  in an effort  to find common  ground.

ADA  House  passes resolutions  on Iicensure by credentials.  Among  them  are ones calling for all

dental jurisdictions  to follow the recommendations  of the Joint  ADA/WE  Guidelines  for Valid

and Refiable  Dental  Licensure  Clinical Examinations,  offering further  elaboration  of ADAs

Guidelines  for Licensure  by Credentials,  and urging State dental  boards  to implement  specialty

licensure  by credentials  and/or  specialty licensure examination  as a top priority.

ADA  House  of Delegates,  by a considerable  margin, votes dow  a resolution  in support  of H.R.

2691.  H.R.  2691 dies with the close of the  102nd U.S. Congress  in 1992.

1  1993  Congressman  Michael McNuky  (NY)  introduces  H.R.  729, parallel  to H.R.  2691 of 1991. 
2 
  In 1992, Congressman  Ron  Wyden,  Chairman,  Subcommittee  on  Small  Business 
Opportunities  and  Energy,  House  Committee  on Small  Business,  began  his own 
investigation  of the  matter.  He  was concerned  that  the  reluctance  of many  States  to 
grant  licensure  by credentials  might  be  detrimental  to consumers  and  might  be 
countering  efforts  to improve  access  to dental  services  in undersexed  rural  or inner-
city areas.  As a result,  he asked  the  Office  of Inspector  General  to conduct  an 
inspection  on the  nature  and  implications  of State  dental  board  policies  in licensing 
out-of-State  dentists.  This  report  responds  to his request  and  follows  up  on a report 
concerning  State  dental  boards  that  we issued  in 1988 (State  Licensure  and  Discipline 
of Dentists,  OAI-01-88-00580).  It describes  the  current  situation  concerning  the 
licensure  of out-of-State  dentists.  It explains  the  primary  rationales  for and  against 
licensure  by credentials.  And  it identifies  some  key factors  relevant  to an 
understanding  of the  consequences  associated  with the  practice  of granting  licensure 
by credentials. 
METHODOLOGY 
In the  report  we drew  on five major  sources  of information.  Each  is identified  briefly 
below. 
A survey  of all State  dental  boards.  We  conducted  a mail  survey  of all State 
dental  boards.  We  sought  information  concerning  board  resources  and 
authorities  and  board  actions  involving licensure,  enforcement,  and  discipline. 
The  professional  literature.  We reviewed  articles  identified  through  a search  of 
the  National  Library  of Medicines  on-line  data  base. 
Existing  data  and  materials  available  from  the  ADA  and  the  American 
Association  of Dental  Examiners  (AADE).  We  reviewed  existing  data  on State 
licensure  policies,  reports  on existing policy positions  of the  organizations,  task 
force  reports,  and  other  internal  documents. 
Personal  interviews.  We interviewed  representatives  of national  dental 
organizations,  regional  testing  agencies  and  State  boards,  and  individual 
dentists.  Our  attendance  at  the  August  1992 ADA  conference  on licensure  by 
credentials  offered  a good  opportunity  to conduct  many  such interviews. 
Focus  group  sessions.  During  the  ADA  and  the  AADE  annual  meetings  in 
October  1992, we conducted  locus  group  sessions  addressing  the  rationales  and 
consequences  of licensure-by-credentials  policies.  One  group  was composed  of 
representatives  of States  granting  licensure  by credentials;  the  other  of 
representatives  of States  that  do not. 
We  conducted  our  review  in accordance  with the  Quality  Standards  for  Inspections 
issued  by the  Presidents  Council  on  Integrity  and  Efficiency. 
3
 FINDINGS

CURRENT  PRACTICES 
Twenty-nine  States  grant  licensure  by credentials,  an  increase  of  11 since  1987. 
The  29 States  are  concentrated  in the  Northeast  and  Midwest. 
 
Twenty-two  of them  grant  lkxmsure  by credentials  to applicants  from  all States; 
	
7 do so only for applicants  fkom States  with similar  practices. 
States  that  provide  licensure  by credentials  requirements  on 
	 still  impose  various 
applicants.  Most  common  are  those  calling for  applicants  to be  in active 
practice,  receive  a favorable  report  from  the  dental  board  in their  former  State, 
and  agree  to a personal  interview. 
In 1909, in a book  on the  history  of dental  surgery,  the  author  noted  that  eight  States 
had  a system  for granting  licensure  by credentials  and  that  in time  such  practice  will 
become  general  throughout  the  country.3  Eighty-four  years  later,  the  practice  has 
increased  but  is still far  from  general.  About  half  of the  States  will grant  a dental 
license  on the  basis  of a licensed  dentists  credentials;  about  half will not  (see 
appendix  A). 
Since  our  review  of dental  Iicensure  practices  in  1987, the  number  of States  that 
exercise  licensure-by-credentials  authority  (on either  a complete  or restricted  basis) 
has increased  by one-half.4  The  growth,  however,  has  reinforced  a long-existing 
geographic  concentration  of such States.  They  remain  heavily  concentrated  in the 
middle  and  northeastern  portions  of the  country  (see  figure  1). 
FIGURE 1: STATE DENTAL BOARDS AND 
UCENSURE BY CREDENTIAL  AUGUST 1993 
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4
 In the  29 States  that  offer  licensure  by credentials,  out-of-State  dentists  seeking  a 
license  do not  automatically  receive  one.  Their  credentials  are  still subject  to review. 
This review  varies  widely among  the  States  in terms  of both  the  type  and  extent  of 
requirements  (see  appendix  B).  One  State  has a particularly  exacting  review  process 
that  calls for applicant  dentists  to submit  a sample  of patient  records  for board  review. 
It reports  denying  licensure  to 5 to  10 percent  of its licensure-by-credentials  applicants. 
Twenty-two  States  do not  grant  licensure  by credentials. 
They  are  concentrated  in the  South  and  West  and  include  six of the  seven 
 
States  leading  the  nation  in population  growth  between  1980 and  1990. 
In  19 of these  States,  the  dental  board  has  no authority  to provide  licensure  by 
	
credentials;  in 3 it has the  authority  but  does  not  exercise  it. 
The  22 States  that  do not  grant  Iicensure  by credentials  represented  the  major  growth 
areas  of the  country  in the  1980s.  Collectively,  their  population  grew by 19 percent 
from  1980 to  1990 while  that  of the  other  29 States  grew by 5 percent.  Included 
among  the  22 are  6 of the  7 States  with  the  largest  population  increases  during  the 
decade:  California,  Florida,  Georgia,  Arizona,  Virginia,  and  North  Carolina. 
hong  the  States  that  do not  grant  Iicensure  by credentials,  there  are  some  signs of 
change.  Whereas  in 1987 only one  had  the  authority  to engage  in such practice  (see 
appendix  A), by 1993 three  had  such authority.  In others  there  is active  inquiry  into 
the  matter  that  could  well result  in some  liberalizing  changes. 
Yet  in these  22 States,  the  entry-level  clinical  examination  remains  as a major  gateway 
to licensure,  even  for dentists  who have  specialty  practices  and/or  have  many  years  of 
experience.  Eleven  of these  States  devise  and  conduct  their  own examinations;  the 
other  11 typically  rely upon  1 of the  4 regional  dental  testing  services.5 
RATIONALES 
The  core  argument  in favor  of Iicensure  by credentials  is that  it facilitates  freedom  of 
movement  by practicing  dentists.  Supporting  arguments  are  that  it: 
presents  minimal  risk because  of the  disciplinary  action  clearinghouses  run  by 
	
the  National  Practitioner  Data  Bank  (NPDB)  and  AAD~  and 
rests  on a base  of positive  experiences  in States  granting  licensure  by 
	
credentials. 
To  practicing  dentists  living in a highly mobile  American  society,  licensure  by 
credentials  makes  good  sense.  It facilitates  their  freedom  of movement  from  one 
State  to another.  Whatever  their  motives  for moving--be  it to live in a better  climate, 
establish  a more  lucrative  practice,  accommodate  a spouse  who has an attractive 
5  employment  opportunity,  accept  a teaching  position  at  a university,  or work  in a clinic

in an underserved  area--the  availability  of licensure  by credentials  makes  it easier  and

more  possible  for them  to move  than  if they  had  to pass  an entry-level  examination  in

general  dentistry.

Dentists  recognize  that  the  examination  requirement  is not  an  impenetrable  barrier  to

licensure  and  that  most  applicants  pass  the  examination.b  Yet  they  raise  concerns

about  it.  Most  prominent  among  them  is the  cost and  inconvenience  associated  with

taking  the  examination  and  finding  patients  who will be  part  of the  examination.

Another  concern  is the  relevance  of the  examination  for experienced  dentists  who  are

specialists  in fields  such  as periodontics  or orthodontics.  Still another  is that  the

examination  requirement  might  have  more  to do with  reducing  competition  to dentists

already  practicing  in highly desirable  States  than  with  assuring  appropriate

qualifications  of out-of-State  dentists!

In response  to those  who  argue  that  licensure-by-credentials  States  will be vulnerable

to bad apples  who  move  from  State  to State,  proponents  point  to the  establishment

and  operation  of the  national  clearinghouses  on disciplinary  actions  run  by NPDB  and

AADE.  Between  them  the  clearinghouses  provide  all State  boards  with  access  to the

names  of dentists  disciplined  by other  State  boards,  professional  associations,  or

hospitals.

For  example,  in a letter  to Congressman  John  Dingell  (MI),  one  dentist  stressed  the

significance  of the  NPDB  and  concluded:  There  is no longer  a need  to restrict  the

movement  of all dental  health  care  professionals  because  this national  clearinghouse

of information  detects  the  few who  try to move  around  for unprofessional  reasons.9

To  further  their  case,  proponents  also point  to the  experiences  of those  States  that

have  granted  licensure  by credentials  for a number  of years.  If the  practice  were

harmful  to the  public,  would  these  States  continue  to practice  it, they  ask.  Before

1987, one  State  did rescind  its licensure-by-credentials  practice,  largely  because  of

concerns  about  a few dentists  who  had  been  licensed  by this route  and  who it later

found  had  been  disciplined  in another  State.  But  it has since  reestablished  the

practice  and  reports  no subsequent  problems.  Similarly,  representatives  from  other

States  that  engage  in the  practice  reported  to us that  they have  had  no bad

experiences  and  expressed  confidence  in their  own credentials  review  process  as a way

of weeding  out  problem  cases.

Two States  we contacted  had  actually  reviewed  the  number  of disciplinary  actions  they

had  taken  against  dentists  to whom  they  had  granted  Iicensure  by credentials.  One

State  found  that  of 59 dentists  issued  a license  in this way since  1974, only  1 was

subsequently  disciplined.  The  other  reported  that  of 171 dentists  licensed  by

credentials  in the  last  10 years,  only  1 had  a complaint  lodged  against  him. This

represented  less than  one-half  of  1 percent  of all complaints  lodged  during  this period.

6
 Ihe core  argument  in opposition  to lictmsure  by credentials  is that  it fails to offer 
adequate  assurance  of the  competency  of out-of-State  dentists  seeking  licensure. 
Supporting  arguments  are  that: 
the  NPDB  and  AADE  clearinghouses  have  limited  information  and  can not 
	
compensate  for the  inadequate  enforcement  efforts  of some  State  dental 
boar(ky  and 
the  clinical  licensure  examination  requirement  is a vital  safety  valve,  especially 
	
for States  to which  large  numbers  of dentists  seek  to move. 
From  the  opponents  camp  comes  the  message  that  what  licensure-by-credentials

advocates  are  seeking  is licensure  by convenience,  without  regard  for  a boards

obligations  to protect  the  residents  of its State.  In that  context,  they  cite  two

fundamental  bases  for their  contention  that  licensure  by credentials  fails to provide

adequate  protection.

One  is that  some  of the  out-of-State  applicants  may not  be  sufficiently  competent,

This reservation  rests  largely  on perceived  variations  in the  quality  of dental  schools

and  their  graduates.  Indeed,  a committee  formed  by the  ADA  to study  freedom  of

movement  and  licensure  issues  reported  in  1989 that  these  perceived  variations  were  a

primary  reason  why five States  surveyed  opposed  licensure  by credentials.l  The

reservation  about  out-of-State  dentists,  however,  involves  more  than  dental  schools;  it

also extends  to  dental  boards  and  to their  capacity  and  readiness  to identify  and  then

respond  to incompetent  and/or  unprofessional  dentists.  Dental  board  officials we met

with doubted  the  adequacy  of the  enforcement  efforts  of many  State  boards  and  even

the  willingness  of some  boards  to strengthen  these  efforts.ll

The  other  fundamental  basis  offered  for opposing  licensure  by credentials  is that,  in

itself, it is not  a credible  basis  for granting  licensure.  The  argument  is that  the

credentials  available  for review,  the  lack of any disciplinary  action,  the  receipt  of a

supportive  letter  from  a board  or character  witness,  the  conduct  of a personal

interview,  and  the  like simply fail to offer  adequate  assurance  of the  competency  of a

dentist.  A dental  board  owes the  residents  of its State  greater  assurance  than  such

factors  provide.

In this context,  the  fact  that  the  NPDB  and  AADE  clearinghouses  offer  a source  of

information  about  disciplined  dentists  presents  little  assurance.  The  latter,  they  point

out,  does  not  receive  reports  from  a number  of States  and  the  former  does  not  include

any disciplinary  actions  taken  prior  to October  1990.  Even  more  significant,  they  add,

is that  both  of these  clearinghouses  identify  only those  individuals  who  have  had

formal  action  taken  against  them.  That  a dentists  name  does  not  appear  in either

clearinghouse  is no assurance  that  he or she  is competent;  nor  does  it preclude  the

possibility  that  the  dentist  is under  investigation.

7
 Thus,  the  opponents  of licensure  by credentials  hold  to the  argument  that  a clinical 
examination  provides  a minimum  necessary  check  to impose  on any dentist  wishing  to 
practice  in a State.  Many  of them  will grant  that  the  examination  itself  is not  a sure 
measure  of competence  and  that  better  mechanisms  can  probably  be  developed.  Yet, 
even  as it is, they  assert  it provides  better  protection  than  that  offered  through 
Iicensure-by-credentials  reviews.  For  example,  one  dental  board  member  told  of a 
dental  school  dean  who on paper  had  excellent  credentials  and  would  have  easily 
passed  a Iicensure-by-credentials  review,  but  failed  the  boards  clinical  examination 
three  times. 
Further,  representatives  from  States  facing  a major  influx of out-of-State  applicants  for 
licensure  say that  they  have  a particularly  compelling  need  to go beyond  a case-by-
case review  of a candidates  qualifications  and  rely upon  a standardized  examination  to 
help  them  assess  a candidates  capacity  to practice  dentistry.  For  dental  board  officials 
from  California,  which  had  1,294 dental  licensure  applicants  in 1991 or from  Florida, 
which  had  631, the  positive  experiences  of Iowa (70 applicants),  Minnesota  (93),  or 
other  States  which  have  much  smaller  number  of applicants  (and  can  more  readily 
give each  candidate  individual  attention)  seem  of little  relevance.12  It is not,  they 
note,  a matter  of keeping  out  the  competition,  but  giving their  residents  the  assurance 
that  licensed  dentists  are  sufficiently  competent  to practice.13 
CONSEQUENCES 
It is reasonable  to ask what  if any notable  consequences  are  associated  with the 
practice  of granting  licensure  by credentials.  We addressed  that  question  as part  of 
the  rationale  offered  by those  favoring  licensure  by credentials.  They  cite  the  results 
as positive,  with  no particular  dangers  presented  to their  States  residents. 
We gave  more  attention,  however,  to any consequences  associated  with the  practice  of 
not granting  licensure  by credentials--that  is, of requiring  all out-of-State  applicants  to 
take  a clinical  examination.  We  did that  because  the  controversy  concerning  licensure 
by credentials  has  focused  on the  possibly  negative  effects  caused  by the  22 States 
falling in the  latter  category.  Our  inquiry  in this regard  was not  a comprehensive 
assessment  of the  many  possible  consequences.  At a general  level,  however,  it 
surfaced  two central  findings  that  are  pertinent  to further  discussions  of the  pros  and 
cons of licensure  by credentials. 
The  clinical  examin ation  which  22 States  require  of out-of-State  dentists  seeking 
licensure  provides  a check  on the  continued  competency  of practicing  dentists.  But 
these  States  do not  apply  the  requirement  or any similar  assessment  of competency  to 
dentists  already  practicing  within  their  borders. 
Dentistry  is often  referred  to as one  of the  last cottage  industries.14  The  relevance 
of this analogy  is indicated  by the  fact  that  69 percent  of dentists  practice  alone  and 
that  89 percent  practice  alone  or with  1 other  dentist.]s  Thus,  dentists  tend  to have 
8
 relatively  little  day-to-day  contact  with  colleagues,  other  health  care  professionals,  or

with hospitals.lb

Dentists  also  tend  to have  little  if any exposure  to quality  assurance  reviews  once  they

receive  their  initial  dental  license.1  Few, for instance,  are  exposed  to  the  kind  of

ongoing  oversight  which  hospitals  and  the  Medicare-funded  Peer  Review

Organizations  conduct  on the  hospital-based  medical  practice  of physicians.18

Among  the  51 States,  30 require  some  continuing  education  courses  as a condition  of

dental  Iicensure,  but  none  calls for any assessment  of what  a dentist  actually  learned

from  a course.lg

Thus,  the  clinical  examination  that  22 States  require  of out-of-State  dentists  seeking

licensure  represents  the  most  significant  quality  assurance  check  that  licensed  dentists

are  likely to face  in their  entire  career.  Whatever  the  examinations  limitations  as a

competency  assessment  tool,  it affords  some  basis for  determining  a dentists  current

clinical  knowledge  and  skill.zo

Notwithstanding  the  quality  assurance  benefits  associated  with the  clinical  examination

requirement,  the  fact  remains  that  the  22 States  imposing  it on licensed  out-of-State

dentists  seeking  licensure  apply  it selectively.  They  require  these  out-of-State

applicants  to take  it regardless  of their  credentials  or the  nature  of their  practice,  but

they  impose  no similar  requirement  on the  much  larger  number  of dentists  already

practicing  in their  own States.  As in all other  States,  licensed  dentists  practicing  in

these  States  are  not  subject  to any ongoing  State-imposed  assessment  of their

competency.  In  11 of the  22 States  that  do not  grant  licensure  by credentials,  dentists

do not  even  have  the  minimal  State-imposed  obligation  of attending  continuing

education  courses.21

Some  representatives  of these  States  defend  this inequity  on the  grounds  that  their

own licensees  have  already  passed  the  clinical  examination  they  require  out-of-State

applicants  to take.  Yet,  when  questioned,  they  acknowledge  that  could  have  been  as

many  as 30 to  40 years  ago and  offers  insufficient  basis  for assuming  current

competency.

Thus,  however  much  a clinical  examination  may help  ensure  a certain  minimum  level

of competency,  the  selective  manner  in which  these  States  use  it makes  them

vulnerable  to the  charge  that  it is intended  to reduce  competition  more  than  to protect

patients.  One  educator  who has  studied  this issue described  this  situation  as imposing

a secondary  burden  on out-of-State  competitors  that  does  not  exist for in-State

commercial  interests.  He  adds:

State  licensing  bodies  would  be  hard  pressed  to maintain  that  they  are

ensuring  the  safety  and  health  of in-state  residents  and  not  establishing  a

barrier  to commercial  interests  when  in-state  practitioners  may maintain

Iicensure  for a lifetime  without  some  system  of retesting  and/or

continuing  education.22

9  The  examination  which  22 States  require  of out-of-State  dentists  seeking  licensure  can 
impede  efforts  to recruit  individual  dentists  willing to locate  in underserved  areas 
within  the  States.  Yet  we found  no  da@  nor  any studies,  to support  a ccmtention  that 
it has much  overall  bearing  on access  to dental  care  in these  areas. 
Another  concern  associated  with  the  clinical  examination  requirement  for out-of-State 
dentists  is that  it might  serve  to hinder  efforts  to improve  access  to dental  services  in 
underserved  areas.  There  are  data  that  lend  some  support  to this concern.  Among 
the  22 States,  16 have  dentist-to-population  ratios  below  the  national  average  of 57.5 
per  100,000 population.  Further,  while  the  22 States  account  for 36 percent  of the 
licensed  dentists  in the  United  States,  they  account  for 54 percent  of the  771 dental 
shortage  areas  and  55 percent  of the  423 shortage  areas  with  20 percent  or more  of 
the  population  below  the  poverty  level.n 
A State  requirement  that  licensed  out-of-State  dentists  take  and  pass  a clinical 
examination  as a condition  of licensure  clearly  does  not  facilitate  the  movement  of 
such dentists  to  shortage  areas  in these  States,  nor  does  it encourage  the  retention  of 
National  Health  Services  Corps  dentists  who work  in undersexed  areas  in these  States 
and  do not  have  a State  license.  Indeed,  we have  been  informed  of individual  cases  of 
these  kinds. 
Yet  we found  no data,  nor  any studies,  to indicate  that  licensure-by-credentials  policies 
have  much  overall  bearing  on the  access  to dental  semices  in underserved  areas.  If 
dentists  enjoyed  complete  freedom  of movement,  it is not  at  all clear  that  many  more 
would  work  in undersexed  areas  than  is now the  case.  Representatives  from  most  of 
the  States  we covered  in our  focus groups--whether  or not  they  grant  Iicensure  by 
credentials--reported  significant  difficulties  in having  dentists  work  in underserved 
areas,  even  in those  underserved  areas  where  they  have  the  opportunity  to make  a 
substantial  income. 
10

  CONCLUSION

Since  1987 dentists  have  come  to enjoy somewhat  easier  freedom  of movement  across 
the  United  States  as more  States  have  established  Iicensure-by-credentials  policies. 
Yet  within  the  profession,  the  controversy  has continued  and  perhaps  even  intensified. 
The  core  of that  controversy  focuses  on the  restrictive  practices  of a few large  sunbelt 
States  and  perhaps  three  to five others  to which significant  numbers  of dentists  might 
wish to move. 
The  ongoing  operation  of the  NPDB  and  AADE  clearinghouses,  the  slow but  clear 
movement  toward  a standardized  clinical  licensure  examination  acceptable  to all 
States,U  and  the  continuing  pressure  exerted  by many  dentists  could  lead  to wider 
adoption  of licensure  by credentials  in the  years  ahead.  Such  direction  would 
obviously  contribute  to the  interstate  mobility  of dentists;  its consequence  for the 
public  at large  is less clear. 
Our  inquiry  has  not  provided  a basis  for supporting  one  side  or the  other  in the 
controversy  concerning  licensure  by credentials.  In examining  the  arguments  for  and 
against  it, however,  we have  identified  two closely related  issues  that  are  of major 
significance  to dentists  and  the  general  public.  These  are: 
the  minimal  degree  to which  States  currently  assess  the  continued  competency 
	
of practicing  dentists,  and 
the  questionable  performance  of many  State  dental  boards  in carrying  out  their 
	
enforcement  and  discipline  responsibilities. 
If State  governments  and  dental  organizations,  such as the  American  Association  of 
Dental  Examiners,  the  American  D>ntal  Association,  the  American  Association  of 
Dental  Schools,  and  The  Association  of State  and  Territorial  Dental  Directors,  focus 
constructively  on these  issues, the  support  for licensure  by credentials  could  broaden 
considerably.  More  importantly,  the  public  could  receive  increased  protection  for the 
close  to $40 billion  a year25Itis spending  on services  provided  by about  145,000 
dentists  across  the  United  States.2G 
11
 COMMENTS  ON  THE  DRAFT  REPORT

We  received  comments  on the  draft  report  from  the  American  Association  of Dental 
Examiners  (AADE),  the  American  Dental  Association  (ADA),  the  American 
Association  of Dental  Schools  (AADS),  and  The  Association  of State  and  Territorial 
Dental  Directors  (ASTDD).  In appendix  C, we present  each  set of comments  in full. 
The  AADE  agrees  with our  concluding  observations  about  the  minimal  attention  given 
to continued  competency  and  the  questionable  performance  of boards  in carrying  out 
their  enforcement  responsibilities.  It asked  for  any additional  information  we could 
provide  on continued  competency  to facilitate  its own efforts  in that  area.  We  have 
followed  up with AADE  to provide  such information. 
The  ADA  provided  some  updated  information  on licensure  by credentials  policies  of 
the  States  and  indicated  it would  alter  some  of our  observations  on which  States 
engage  in the  practice.  It agreed  with  our  conclusion  about  continued  competency, 
but  suggested  we report  the  importance  of continuing  education  as a mechanism  to 
address  such  competency.  Finally,  it reviewed  its position  and  actions  concerning 
licensure  by credentials. 
On  the  basis  of ADAs  information  and  follow up conversations  with  representatives 
from  Texas  and  Arkansas,  we have  added  them  to the  group  of States  that  is now fully 
exercising  the  authority.  But, as figure  1 indicates,  it remains  that  this group  is 
concentrated  in the  middle  and  northeastern  portions  of the  country  and  still does  not 
include  6 of the  7 States  with the  largest  population  increases  during  the  1980s 
(California,  Florida,  Georgia,  Arizona,  Virginia,  and  North  Carolina). 
In regard  to continuing  education  (CE),  we agree,  as ADA  suggests,  that  mandated 
CE  is important  to consider  among  the  array  of approaches  that  are  relevant  to 
continued  competency.  Yet,  we also  point  out  that,  its overall  value  in this regard 
remains  questionable.  27  In a proposal  seeking  funding  for computer-based  patient 
simulations,  the  major  national  dental  organizations,  including  ADA  note:  It is 
widely agreed  that  a major  weakness  in mandatory  continuing  education  requirements 
is that  frequently  there  is little  relationship  between  the  continuing  education  activity 
and  the  professional  development  needs  of the  individual.%  The  ASTDD,  in its 
comments  on this report,  reinforces  this point  by noting:  Many practitioners  take 
courses  they  like, rather  than  courses  they need.  Assessment  of what  a dentist  actually 
learned  from  a course  (e.g. knowledge),  does  not  necessarily  translate  into  changes  in 
practice  or attitude. 
The  AADS  offered  some  technical  suggestions,  cited  two recent  articles  in the Journal 
of the Amencan Dental  Association  (JADA)  that  were  relevant  to our  discussion,  and 
urged  that  we more  fully address  antitrust  issues,  We  made  corrections  that  addressed 
their  technical  suggestions,  referenced  one  of the  articles  at an  appropriate  point  in 
12
 our  text,  and  did not  address  the  antitrust  implications  - mainly  because  they would 
call for judgments  by the  Federal  Trade  Commission. 
The  ASTDDS president  urged  that  State  public  health  dental  programs  be more 
closely tied  in with  State  licensing  and  credentialing  efforts,  emphasized  its concern 
about  insufficient  access  to oral  health  services,  expressed  its support  for periodic 
assessment  of the  competency  of dentists,  and  suggested  that  it is time  to move  toward 
a national  clinical  licensure  examination  for dentists.  He  did not  call for any changes 
in our  draft  report. 
13
 APPENDIX  A

!SIATDEE NTAL  BOARD  AUTHORITIEASNDPRACIK33IN GRANTING 
LICENSUREBYCREDENTIALTSO  OUT@F-STATCEANDIDA=  1987AND1993
BOARD  ~  AUTHORITY  TO GRANT  LICENSURE 
BY CREDENTIALS 
BOARD  HAS 
~ 
BOARDEX  ERCISEIST*S  BOARDHASNOT 
AUTHORITY 
AUTHORITY  EXERCISED ITS  TO GRANT 
AUTHORITY 
LICENSURE 
BY 
BOARD  BOARD 
CREDENTIALS 
AUTl+ORITY  AUTHORITY 
EXTENDTSO   LIMITETDO

CANDIDATES CANDIDATES

FROMALL  FROM STATES

STATES  WITHSIMILAR

PRACTICES

STATE  1987  1993  1987  1993
 1987  1993  1987  1993 
AL
 x x 
AK  x
 x 
Az
 x x 
AR  x
 x 
CA
 x x 
co
 x x 
CT  x
 x 
DE
 x x 
DC  x x

FL
 x x 
GA
 x x 
HI
 x x 
ID
 x x 
IL  x
 x 
IN  x x

IA x  x

Ks  x x

KY  x
 x 
IA  x
 x 
ME  x x

A-1
 ~ATE DENTALBOARDAUTHOIUTIEASNDPRACIKESINGRANTING 
IKENSUREBYCREDENTIAL~S   OUT~F~ATE  Cu4NDB3ATE1k9 87AND1993
BOARD  ~  AUTHORITY  TO  GRANT  LICENSURE 
BY CREDENTIALS 
BOARD  HAS 
~ 
BOARDEX  ERCISEISTS  BOARDHASNOT 
AUTHORITY 
AUTHORITY  EXERCISED ITS  TO GRANT 
AUTHORITY 
LICENSURE 
BY 
BOARD  BOARD 
CREDENTIALS 
AUTHORITY  AUTHORITY 
EXTENDTSO   LIMITETDO 
CANDIDATES CANDIDATES 
FROMALL  FROMSTATES 
STATES  WITHSIMILAR 
PRACTICES

STATE  1987  1993  1987  1993
 1987  1993  1  1987  !  1993

MD  x x

MA  x x

MI  x x

MN  x x

, 
MS
 x x

MO  x x

MT
 x x

NE  x x

Nv
 x x

NH  x x

NJ  x
 x

NM
 x x

NY  x x

NC
 X1X

ND  x
 x

OH  x
 I  xl

OK  x x

OR
 x x

PA  x x

RI  x
 x

I

Sc
 x x

SD  x
 x

TN  x
 x

A-2
 ~ATE DENTALBOARDAUTHORITIEASNDPRACIXESINGRANTING 
LICENSUREBYCREDENTIALTOOUT~F-SIATECANDIDA~:  1987AND1993 
BOARD  ~  AUTHORITY  TO  GRANT  LICENSURE 
BY CREDENTIALS 
I  BOARD  HAS 
~ 
BOARDE XERCISEIST*S  BOARDHASNOT 
AUTHORITY 
AUTHORITY  EXERCISEIDTS 
TO  GRANT 
AUTHORITY 
I  LICENSURE 
BY 
BOARD  BOARD 
CREDENTIALS 
AUTHORITY  AUTHORITY 
EXTENDTSO   LIMITETDO
CANDIDATES CANDIDATES 
FROMALL  FROMSTATES 
STATES  WITHSIMIL/iR
I  PFLKTICES 
STATE  1987  1993  1987  1993  1987  1993  1987  I  1993 
m
 x 
UT

VT
 x  lx 
VA
 lx  x  I 
WA
 x  x I 
w
 X1X 
1 
WI
 x 
WY
 x  I  +--
TOTALS
 11 
........... ........... 
Sourctx  American  Dental  Association  ADA  News, Juiy 8, 1987 and  October  5, 1992  Updated  throu& 
August  1993  by Ofice  of Inspector  General  telephone  contacts  with ADA  and Stare boards. 
  We sou@  dam porn  the individual  Stoles  on how ojkn  they acmal(y  ererctied  their licensure-Qy-credemials 
atuhor@  in Fiscal  Year 1991.  However,  most  of the States were unable  to provide  us with the akta. 
A-3
 APPENDIX  B

CREDENTIAUNG  REQUREMmnS  IMPOSED  BY STATES THAT GRANT 
LICENSURE  BY CRED ENTIALs,  1993 
NUMBER  OF 
REQUIREMENT  STATES 
REOUIRING 
Active practice within former  State immediately  24 
preceding  application 
Board  in former  State must attest  that the  20 
subject  was in legal and reputable  practice  (no 
unresolved  complaint,  review procedure,  or 
disciplinary proceeding,  and license has not 
been  revoked) 
Must  be personally interviewed  14 
Affidavits or letters  from practicing dentists  8 
regarding  moral character 
Good  moral character  6 
Physicians statement  of physical and mental  3 
health 
Intends  to establish  mactice  2 
Source:  American  Dental  Association, Repro  of the  Division  of Education: 
Dental Licensure, April 1992. 
B-1
 APPENDIX  C

DETAILED  COMMENTS  ON THE  DRAFT  REPORT 
In this appendix,  we present  the  complete  comments  on the  draft  report  received  from 
the  American  Association  of Dental  Examiners  (AADE),  the  American  Dental 
Association  (ADA),  the  American  Association  of Dental  Schools  (AADS),  and  The 
Association  of State  and  Territorial  Dental  Directors  (ASTDD). 
c-1  AMERICAN  ASSOCIATION  OF DENTAL  EXAMINERS 
Chicago  Ave., Suite 644, Chicago, IL 60611  (312)  440-7464 
May  13,  1993 
Mr.  Bryan  B.  Mitchell

B.  Wayne J. h  Principal  Deputy  Inspector  General

2928HmniiIm~  Off  ice  of  Inspector  General

sjouxc~,  IA  51104 
Department  of Health & Human  Services

(712) 2ss-7607 
Washington,  DC 20201

Dear Mr. Mitchell: 
Dr. Jd  F. GJuvcr 
w-w 
Thank you for giving the American  Association  of

Rmo. NvS9509 
Dental  Examiners  an opportunity  to comment  on the

(702)S2S-2417 
draft report  The Licensure  of Out-Of-State

FIRsTwm+mmmr  Dentists.

DrI.i liKiBmald
 am
The report concludes  that Our inquiry  has not

3oEaaaktlsuca 
provided  a basis  for supporting  or opposing

New Yak  NYloo22 
(~12)7554125  licensure  by credentials.  It has, however,

identified  two closely related  issues that are of

SECOND vm3-mEsmNr  considerable  significance  to dentists  and the

general  public.  These are:

c 
Dr. Km  C-ICY 
440 BrtYdsL 
	 the minimal degree to which  States 
cohdliLMs  39429 
(@Ii7)3&1761  currently  assess the continued 
competency  of practicing  dentists,  and 
lnmDvmwsmmw 
t&H.a nyR
DoIwuI   the questionable  performance  of many 
State dental boards  in carrying  out

2860 PiakunKAvc=Ic 
LhlhuhM.N55811  their enforcement  and discipline

(218)7224823 
responsibilities .

Pm  HmlKmrr 
MMmnATE 
As regards the questionable  performance  of manY 
l)r. wT.  RwiI  State dental boards  it 1S  clear  that  the lack of 
475 Mallard AvaxIc  sufficient  funding  is the principle  reason  for 
32701 
Abmul?  s@ga.  FL  enforcement  difficulties. 
(407)831-1747 
FxEamvEDIREcNx
 In addition  the  report  states  If State 
governments  and dental organizations,  such as the 
MLMdty Nder  American  Association  of Dental  Examiners,  the 
2111LChiCJAgV0CaUIC 
American  Dental Association,  the American 
Association  of Dental Schools, and the Association 
ChiagO%, ?il% 
(312)440-7464  of State and Territorial  Dental  Directors,  focus 
constructively  on these  issues,  support  for 
licensure  by credentials  could broaden 
considerably .  This is likely to follow closely

Kth 
Dr. Kuhka  on the heels of continuing  competency  programs.

u  E Mifflia StruI 
Suiac
204 
~  WI53703  The AADE agrees  that continued  competency  should 
(60s)2xw45KJ  be addressed.  AADE established  a Continuing 
Competency  Committee  in 1992,  the  goal  of  which  is  to develop  criteria and mechanisms  for states to

use  in  assessing  the  continued  coxnpetency  of  their 
licensed  dentists.  The AADE  is currently  seeking 
support  for the Committees  activities  from the 
Bureau of Health Professions  of the Department  of 
Health and Human Services,  the American  Dental 
Association,  the Academy of General Dentistry,  and 
the American Association  of Dental Schools. 
The AADE would  like to officially  request  that, if 
possible,  any information  obtained during  the 
Office of Inspector Generals  study on the subject 
of continued  competency  be shared with the AADE 
Continuing  Competency  Committee.  Also, the AADE 
Continuing  Competency  Committee  would  appreciate 
any  information  that  the  IGs  office  has  with 
respect  to  other  health  organizations  activities 
in ~he area of continued  competency. 
Sincerely,

Molly Nadler

Executive  Director

cc	 :  Members,  AADE Executive  Council 
Members,  AADE Continuing  Competency  Committee  . 
Mr.  Mitchell 
May  2a,  1993 
Page  2 
view  that  licensure  by  credential  states  do  not  include  any 
of  the  retirement  areas  in  the  sunbelt  region. 
Continued  Com~etencv 
v

We  agree  with  your  assessment  that  it  is  important,  for  State

governments  and  dental  organizations,  such  as  the  American

Dental  *_s_gciation,,  the  American  Association  of  Dental

Scho.ols  and  o~,:to  focus  constrictively  on  the  issue  of

continued  competencyof  @racticing  dentists.  At  present,  the

American  Association  of  Dental  Examiners  has  an  ongoing  task

force  to  study  this  issue,  with  participation  by  the  American

Dental,  Association,  the  American  Association  of  Dental

Schools  and  :ther  dental  organizations.

We  note  on  this  issue  that  you  may  wish  to  mention  in  the

report  the  importance  of  continuing  education  as  one

mechanism  to  address  clinical  competency.  We  believe

continuing  education  is  a  very  important  aspect  of  this

issue.  The  American  Dental  Association,  through  exlSt~n9

policy,  urges  states  to  develop  mechanisms  to  foster

continuing  education.  In  fact,  to  date  29  states  plus  the

District  of  Columbia  believe  it  is  sufficiently  important

that  they  have  made  continuing  education  mandatory.  There  is

a  growing  trend  i.n  states  to  adopt  mandatory  continuing

education  legislation.

American  Dental  Association  Activities

Your  report  quite  accurately  states  the  American  Dental

Associations  position  on  licensure  by  credentials.  we

support  licensure  by  credentials.  However,  we  also  firmly

support  the  notion  that  this  is  an  issue  to  be  addressed  on  a

state  by  state  basis.  Professional  licensure  has  been  a

traditional  area  of  state  regulation,  and  we  Support  the

rights  of  the  states  to  make  their  own  decisions  in  this

area.

The Association  believes  that it has contributed  proactivelY

to state acceptance  of licensure  by credentials  through  its

many activities  in support  of credentialing.  These  include

most  significantly  a national  conference  on  licensure  hosted

by  the  ADA  in  July  1992.  This  conference,  which  was  attended

by  representatives  of  the  educational  community,  state  regu

latory  agencies,  and  other  interested  groups  and  individuals~

provided  a  forum  for  the  communities  of  interest  to  discuss

progress  toward  appropriate  opportunities  for  licensure  by

credentials.  The  conference  included  presentations  and

workshops  that  provided  the  participants  with  a  forum  in
 Mr~  Mitchell 
May 28,  1993 
Page 3  ~ 
which  to  develop  their  own  strategies  for  irnplementati.on  of 
licensure  by  credentials  in  their  states.  The  conference 
also  sparked  a  momentum  for  several  new  and  important 
resolutions  that  were  adopted  by  the  ADA~S  House  of  Delegates 
in  October  1992.  These  resolutions  provided  direction  on 
specialty  licensure  by  credentials;  supported  ADA  efforts  to 
encourage  state  regulatory  agencies  to  accept  a  common  core 
of  requirements  and  guidelines  for  clinical  examinations;  and 
directed  the  appropriate  agencies  of  the  ADA to  urge  all 
dental  licensing  jurisdictions  to  utilize  the  ADA  guidelines 
for  licensure  by  credentials.  In  short,  ADAs  policy  on 
licensure  by  credentials  is  not  simply  a  statement  of 
position.  It  is  a  core  policy  that  is  actively   supported 
by  the  Association. 
Conclusion 
In  conclusion,  new  data  for  the  first  five  months  of  1993 
supports  the  overall  trend  noted  i.n  your  report:  more  and 
more  states  ~  adopting  licensure  by  credentials  legislation 
and  regulations.  While  the  trend  may  not  be  as  rapid  as 
credentialing  proponents  would  like,  change  is  coming  in  a 
well-reasoned  manner. 
The  American  Dental  Association  supports  licensure  by  Cre
right
dentials  but  just  as  firmly  supports  the  of  states  to 
make  their  own  determination  about  whether  more  licensing 
laws and regulations  should permit  credentialing.  At the

same time, we have taken a number of active  steps, partic

ularly  in the past two years,  to assist  states  in moving

toward  licensing  by credentials,  and will continue  our

efforts  in this regard.

Thank you again for the opportunity  to comment  on  your 
excellent  report. 
Sincerely, 
f&ljlj~DD~ 
- .  . . 
 
Executive  Director 
JSZ/MKL  l)vo  Peachtree  Street

Sixth  ??bor

Atlanta,  GA 30303

PRESIDE\T 
Phone:  (404) 657-2575

Ii ]osePh Alderman.  DDS,  MPH

Office  of Dental  Heaith
 F~:  (404) 257-6631

878  Peachtree  St., NE R-215

June  7, 1993

Atlanta  GA 30309

Phone  404/894.6684

Fax: 404/894-7799

PRESIDENT-ELECT

Bryan B. Mitchell

Richard  j. Hastreiter,  DDS,  MPH

Minnesota Dept.  of Heaith
 Principal  Dep~  Inspector  Geneml

717 Delaware SL, SE

Office  of Inspector  Genend

Minneapolis.  ,MN 55440

Phone  612/ 623-5441
 Washington,  D.C.  21201

FaJC 612.623.5043

\TCE-PRESIDE!ST

Dear Mr.  MitchelZ:

Mark  D. Siegai.  DDS,  MPH

Division  of Dentai  Health

246 N. High  Street
 Zhank you for  the opportunity  to nspond  to the Office of Inspector 
P.O.  Box  118

Columbus,  Ohio  43266.0188
 Genend  drq/1  report,  The  Licensum  of  Out~f-State  Dentists.   l%e 
Phone  614466-4i80

Association  of State and Territoti  Dental Directots  (ASZDD) is an ~~e 
Fax: 614/644.9650

of  the  Association  of  State  and  TehoM  HeaUh  Officials  (ASZEIO). 
SECRETARY.TRE.4SURER

.M. Dean  Perkins,  DDS
 Membership  is composed  of the Chief Den@  Officer  of the Depa~eti  of 
Bureau  of Dentai  Health
 HeaUh,  or  equivalent  public  health  of  tie  states,  tenitones,  or 
agency 
P.0.  Box 570

Jefferson  Ciw,  Missouri  65101
 possessions  of  the  United  States.  ASTDD  considers  pollcies  or 
Phcme  314/751.6247

recommendahons of private  orpublic  agencies pe~ning  to omi and dental 
Fax  3i.$/i51-6010

PASTPRESIDENT  health,  and  adopts  policies  for  gutice  of  its  membem.  17zis mponse 
Robert  Isman,  DDS,  MPH
 represents  my opinion  and  expenence as AS~D  president  and diplomate 
Dentai  Heaith  Section
 of  dental  public  health,  one  of  the  Dental  Association 
eaght  American 
CA Dept.  ot Heaith  Serwicea

P.O.  Box 942732
 dental  speciahies.  Ilis  nport  is  not  necessmiiy  the  officihl  potion  of 
Sacramento,  C.+ 94234.7320

ASTDD,  but the Erecutive  Committee  of ASll)D  has ~viewed  the mpoti. 
Phone  916,324.2230

Fax: 916. 324.7764
 State dental  ptvgmms  should aid in the ticensing  and credenmg 
DIRECTORS  of  dentists.  For  example,  the  State  De&  Director  in the  Rhode  Island 
B,. 
Enrw,sciti.  RDI-L MPH  DeF=~ent  of He~fih ~en,es ~  the ~ai~enon  of the P&ode Island Boani 
MPH 
Eirwr  Green.  DDS, 
lack  Dillenberg.  DDS,  MPH  of  Eraminem  in  Dentistry.  71iis &  ws  for  cootiitiion  of the  two  state 
\, F1,~SLETTFR  EDITOR  entities,  and  increased  public  accountability.  It bnng access  to  care  and 
L ~onan  Davis,  D\{D,  MPH  public  heaith to the foreftvnt  of discussions  that might  be considered  se~
I?cnral  Iicaith  Division 
Bureau  oi Famdv  Hcaith  Services  servingto pnvate pmcticing  dentists  or other  Weciai  interwt  grvups.  iUOst 
Sate  Otfict  i3uiidmg  Board appointments  are made by the Governor fmm  dentists  recommend~  -
:34  i([}nroe  Street 
Mt.ntgt+nicr:,  .+L 5613P  by  state  dental  associations.  However,  state  dental  prvgmms  are  hating-
Phone:  295 Z.+2.5057 
F4x: 2P5,2K-3097  m@or problems.  A December  1992 ASZDD  Survey  indicated:  a.  10 @OYO~ 
states have no state dental pmgmm;  b. 3 (6qo) stutes have dental p~g~$ 
but no director;  c. 32 (64%) states have a fuU tie  director;  and d. 5 (10%) 
states have apart  time director.  All state  must be able 
omJ  hedh  pmgmms 
to  perform  the  core  functions  of  assessment,  development,  and 
poiky 
assumnce.  ASTDD  Letter:  B~an  B. Mitchell:  Page 2 
ASTDD  continues  to be concerned  about  the lack of access  to oml  heahh  serwces, and 
would suppott  methods  to increase  access  to care while ensunng quality  of care. Access  to care 
is a complex  issue.  Makiiistribu~onof dental  heailh  care wonkers is a problem  in many  stiztes 
including  Georgiu.  A public  health  license  by credentials  has helped  bnngpublic  hetdlh dentists 
to  Geo@a.  l%ik  has  helped  in  undememed  areas  and  institutions.  IZe  Gee@  Bod  of 
Dentistry  now requires  dentists  with a public  health license to take the next available  Boani,  and 
this has inhibited  recnulment  of  public  heakh  dentists.  Fortunately  Georgia has started to accept 
the Southern Regional  Boanis  which should help with the decreased  numbem  of licensed dentists 
in our State. 
Specialky Boani  licensure  by cndentials  should  help,  (e.g.  Boani  qualified  or  cetified 
specialists  in good  standing  with their  Specialty  Boanis).  present  method  in many 
However  the 
states of requinng the clinical board and then the Specialty  help recwit  competent 
Boani  does  not 
dentists for the public  sector,  or vatius  specialties.  Speciidty licensure  must not be used to restrict 
competent piimary  care dentists  (i.e. geneml  dentists) fmm  providing  specially  services.  Ailhough 
the  majority  of dentists  and  the  American  Dental  Association  SUppOtt licensurw by cmdentibls 
many of the  decision  makers n both on State Boanis  of Dentistry  and State Dentlzl Associations 
remtunopposed. 
Even though you state  most applicants  pass the examinations  N@age 6), individuals  who 
attempt  the examinatM ns are a select group,  and do not include  many  expenenced dentists  who 
do not want to go through  the truuma of another  Boani. 
Ilere  may  be some  variations  in the  quality  of gmduates,  but in my opinion  a national 
clinical  board  should  be  explored.  If  the  National  Pmctitioner  Data  Bank  does  not  include 
necessary  information  about  disciplined  dentists,  the individual  state  boards  could be contacted 
prior to licensure  by credentials.  l%e example  of  one dental school dean who faled the clinical 
examination  three  times  @age  8) does  not significantly  strengthen  opposition  to  licensurz  by 
credentials.  Seveml  examples  of  the  most  clinically  competent  gmduates  fiuling  the 
examinations  can also  be found. 
A mqior injlux  Rf out-of-state  applicants forthepopuiution  grvwth  states shouki eventually 
be soheti ~  supply  and demand,  not by examinations  restn-ctions. 
If dentistry  is concerned  about quality of dentists,  some periodic  assessment  of competency 
should  be established.  It might  be helpful  to compare  how  the phymctins handle  licensum  by 
credentials  and quahly  of care issues,  especially  in  isohzted prnctices  (e.g.  nmzl).  It is interest?ng 
that  once  licensed,  one  can pmctice  forever.  n Monitoring  ail physlcal and  mental  disabilitie~  
(e.g. impaired  vision)  cannot be expected to be handled by ovenvorked  Eramining  Boards as they  -
are currently  configured.  Licensure  by credentis,  in conjunction  with a n@onal clinical  exam, 
would allow state  boanls  to focus  on more  important  issues like inve~g~ng  compkzints against 
and apprvptiely  discipline  licensees,  or contznuedcredentialing  past  initial  licensure. 
Continuing  education  does not ensure quality  care.  Many pmctitioners  take courses they 
like,  mther  than courses  they need. Assessment  of what a dentist  actually  learned fmm  a course 
(e.g.  knowledge),  does  not necessady  tmnshte  into changes  in pmctice  or attitude.  ASTDD  Letter:  Bryan  B.  Mitchell:  Page 3 
Although the present  growth and acceptance  of regional boanis is to be commended,  a twi 
licensure  by  credentials  could  ensure  quality  of  cam,  and  help  provide  access  to  - in 
undemewed  areas.  Re@onal Boanis  could  begznto form  a  national  clinical  euun  by  u~g 
exiting regional boards.  However,  licensure by cnde&  orfinancing  thrvugh public  orprivate 
insumnce  does  not  guamntee  access  to  onzl  hedh  cam.  other  barnem to  access  include 
economic,  geogmphic  (nmzl,  tmnsients,  migmnts),  cultuml,  and  educational,  as  weg  as 
individuals  who are institutionalized,  homebound,  or have handicapping  conditions. 
I hope this information  is helpful  in your  delibemtions  concerning  licensum  of dentists. 
Xhe licensure  and shoriage  of dental hygienists  is another  issue that  shouhi be addressed. 
ASZDD and ASTHO  are working to establish a National  Oral HeaUh Agendh. ASZDD is an active 
member  of the  Coalition  for  Oml  Health  and strongly  SUppOHSthe  inclusion  of oml  health  in 
heakih care reform.  We believe  that ASZDD  cooperation  and col,lizbomtion  with  fede~  state, 
and local agencies,  the pnvate sectom of dentistry  and dental hyglene, and oml  hedh  advocates 
is the key to ensunng that  eve~one  can enjoy good  oral health  and an enhanced  quality  of we. 
If I or this organization  can be of any futther  assistance,  please  let me know. 
Sincerely, 
E. Joseph  Alderman,  DDS,  MPH 
President,  Association  of State 
& Ternloti  Dental  Directonr 
EJA/ja 
cc:	 ASTDD  Erecutive  Committee 
AS1HO Executive  Director  APPENDIX  D

ENDNOTES 
1.	 American  Dental  Association,  Report  of the Divkion  of Education:  Dental 
Licensure,  April  1992. 
2.	 The  American  Association  of Dental  Schools  (AADS)  has  also addressed  the 
licensure  by credentials  issue.  Of particular  note  is a  10-part  1991 policy 
statement  (presented  in appendix  C of this report).  It calls for AADS  to 
cooperate  in efforts  to develop  uniform  standards  for licensure  and 
credentialing  that  would  permit  freedom  in geographic  mobility  for dentists  and 
dental  hygienists. 
3.	 Charles  R. E. Koch,  cd., H&to~  of Dental  Swgev,  Vol.  1, (Chicago:  The 
National  Art  Publishing  Co.,  1909), p. 691. 
4.	 According  to the  American  Dental  Association,  during  the  years  between  1987 
and  1993, 16 States  authorized  their  dental  boards  to grant  licensure  by 
credentials:  ~  AR,  CT,  GA  IL  KY, ~  NJ, OH, SC,  SD, TX,  Vi  WA 
WI, and  WY.  One  State  board  which  did not  exercise  its authority  in 1987 did 
SOby 1993: ND. 
Three  States,  the  ADA  reports,  moved  in the  opposite  direction  by removing 
the  authority  to grant  licensure  by credentials:  RI, TN,  and  VT.  And  three  of 
the  State  boards  with  newly acquired  authority  have yet  to  exercise  it:  GA  SC, 
and  VA. 
on  balance,  the  number  of State  boards  that  grant  licensure  by credentials 
increased  by eleven  between  1987 and  1993.  See  appendix  A. 
5.	 See  American  Dental  Association,  Report  of the Division  of Education:  Dental 
Licensure,  April  1992, pp.  436-41. 
6.	 Indeed,  in a number  of States  that  do not  grant  licensure  by credentials,  most 
of their  licensees  are  graduates  of out-of-State  dental  schools. 
7.	 An American  Dental  Association  report  describes  the  process  as follows: 
Location  of patients  for examination  in another  state  or distant  city is one  of 
the  most  difficult  parts  of the  examination  process.  The  patients  have  to have 
the  required  oral  problems,  and  they have  to be willing to undergo  a long and 
demanding  series  of procedures.  They  have  to be cooperative,  patient  and 
D-1
 neutral.  They  have  to be  prepared  to receive  treatment  that  may not  be  at an 
acceptable  level.  See American  Dental  Association,  Repoti  of the Division  of 
Education:  Dental  Licensure,  April  1992, p. 429. 
8.	 A recent  article  reporting  significant  variation  within  and  among  state  and 
regional  dental  board  clinical  examinations  seems  to support  the  point,  as the 
authors  suggest,  that  factors  other  than  the  ability  of the  candidates  influence 
exam  outcomes.  See Peter  S. Damiano,  Daniel  Shugars,  and  James  Freed, 
Clinical  Board  Examinations:  Variations  Found  in Pass Rates,  Journal  of the 
American  Dental Association  128 (June  1992): 72. 
9.	 See  Susan  E. Lovelace,  States  Divided, Journal  of the Cahfomia  Dental 
Association  16 (February  2, 1992): 21. 
10.	 The  States  were  California,  Florida,  North  Carolina,  Texas,  and  Washington. 
See American  Dental  Association,  Report  of the  Special  Committee  to Study 
Freedom  of Movement  and  Licensure  Issues, ADA  Annual  Repotts,  1989. 
11.	 Such  doubts  were  expressed  by representatives  of State  dental  boards  that  grant 
licensure  by credentials  as well as those  from  States  that  do not.  In fact,  many 
in the  former  group  of representatives  were  quite  sympathetic  to the  reasons 
advanced  by the  latter  for not  granting  licensure  by credentials. 
12.	 In our  survey  of the  State  dental  boards  we asked  for  information  on the 
number  of licensure  applications  and  the  number  of licenses  granted  in 
calendar  year  1991 or the  fiscal year  ending  in 1992.  The  great  majority  of the 
boards  provided  this information.  However,  few provided  information  in 
response  to our  questions  concerning  whether  or not  those  applying  for a 
license  and  those  receiving  one  held  a dental  license  in another  State. 
Forexample,among thesevenStatesl eadintgh enationinpopulatiognr
 owth

inthe1980so,n lytheNorthCarolinbao ardansweredthesequestionsI.t 

indicated  that  34 percent  of its 144 licensure  applicants  in  1991 already  held  a 
license  in another  State  and  that  17 percent  had  done  so for more  than  5 years. 
Among  the  121 individuals  granted  a dental  license  in  1991, 35 percent  already 
held  a license  in another  State--l6  percent  for more  than  5 years. 
13.	 Here  again,  many  among  the  dental  board  members  we spoke  with who came 
from  States  granting  licensure  by credentials  were  sympathetic  to this point  of 
view. 
14.	 See  Preston  A. Littleton,  Jr.,  Educating  Dentists  for the  Future,  in Human 
Resources for Health:  Defining  the Future,  C. McCollister  Evarts,  Peter  P. 
Bosomworth,  and  Marion  Osterweis,  eds.,  (Washington,  D. C.: Association  of 
Academic  Health  Centers,  1992), p.  142. 
D-2
 15.	 American  Dental  Association,  The1991Survey  of Dental  tiactice:  General 
Charactetitics  of Dentists,  April  1992, p. 2. 
16.  See  Littleton,  p.  142. 
17.	 The  American  Dental  Association,  American  Association  of Dental  Examiners, 
American  Association  of Dental  Schools,  and  other  major  dental  organizations 
provide  support  for this contention.  In making  the  case  for the  funding  of a 
proposal  to develop  interactive  computer-based  patient  simulations,  they point 
out  the  following: 
Dental  practices  generally  are  not  reviewed  by external  organizations, 
nor  are  they  required  to participate  in systematic  quality  assurance 
activities.  Assessments  of provider  competency  are  limited  to a one-time 
state  or regional  examination  prior  to being  granted  a license  to practice 
general  dentistry. 
See  Dental  Interactive  Simulations  Corporation,  Conzputer-llased  Simulations  in 
Dent&try, a grant  application  developed  and  submitted  by the  Dental  Interactive 
Simulations  Corporation,  undated,  p.  14. 
18.	 In recognition  of this situation,  the  W. K  Kellogg  Foundation  in 1982 funded 
Alvin  Morris  and  other  researchers  at the  University  of Pennsylvania  to 
develop  new methods  and  technologies  that  can be  used  by individual  dentists 
and  the  dental  profession  to  assess the  effectiveness  and  efficiency  of the  full 
scope  of dental  practice.  This  ambitious  effort  resulted  in the  development  of 
an assessment  instrument  which  a trained  team  of evaluators  used  to conduct 
l-day  on-site  assessments  of a national  sample  of 300 dentists  who volunteered 
to participate.  The  project  generated  many  articles,  but  to this point  little 
sustained  follow-up.  See Alvin  L. Morris,  J. Marvin  Bentley,  Anthony  A. Vito, 
and  Marguerite  R. Bombs,  Assessment  of Private  Dental  Practice:  Report  of 
Study, Journal  of the American  Dental Association  117 (July  1988):  153-162. 
19.	 American  Dental  Association,  State Dental  Board  Continuing  Education 
Requirements  for Dentists, August  1992. 
20.	 We  sought  data  from  the  regional  testing  agencies  and  from  the  States  that 
conduct  their  own clinical  examinations  to determine  the  proportion  of 
applicants  passing  the  examination--distinguishing  out-of-State  applicants  who 
had  been  practicing  for more  than  five years  from  other  applicants.  However, 
the  data  we obtained  were  extremely  limited  and  insufficient  to offer  any 
generalizations  on the  proportions  passing  the  examinations.  Such  data  could 
add  some  valuable  information  to discussions  of the  pros  and  cons of licensure 
by credentials. 
21.	 American  Dental  Association,  State Dental  Board Continuing  Education 
Requirements  for Dentists, August  1992. 
D-3
 Depafiment  of  Health  and Human  Sewices 
OFFICE  OF 
INSPECTOR  GENERAL 
THE  LICENSURE  OF  OUT-OF-STATE 
DENTISTS 
AUGUST  Igg3 
____ ._  OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General  (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department  of Health and Human Services (HHS) 
programs as well as the health and welfare of beneficiaries seined by those programs.  This 
statutory mission is earned  out through a nationwide network of audits, investigations, and 
inspections conducted by three OIG operating components:  the Office of Audit Semkes,  the 
Office of Investigations, and the Office of Evaluation and Inspections.  The OIG also informs 
the Secretary of HHS of program and management problems and recommends courses to 
correct them. 
OFFICE OF AUDIT  SERVICES 
The OIGS Office of Audit Semites (OAS) provides all auditing services for HHS, either by 
conducting audits with its own audit resources or by overseeing audit work done by others. 
Audits examine the performance of HHS programs and/or its grantees and contractors in 
carrying out their respective responsibilities and are intended to provide independent 
assessments of HHS programs and operations in order to reduce waste, abuse, and 
mismanagement and to promote economy and efficiency throughout  the Department. 
OFFICE OF INVESTIGATIONS 
The OIGS Offke  of Investigations (01) conducts criminal, civil, and administrative 
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of 
unjust enrichment  by providers.  The investigative efforts of 01 lead to criminal convictions, 
administrative sanctions, or civil money penalties.  The 01 also oversees State Medicaid fraud 
control units which investigate and prosecute fraud and patient  abuse in the Medicaid program. 
OFFICE OF EVALUATION  AND  INSPECTIONS 
The OIGS Office of Evaluation and Inspections (OEI) conducts short-term management and 
program evaluations (called inspections) that focus on issues of concern to the Department, 
the Congress, and the public.  The findings and recommendations contained in these inspection 
reports generate  rapid, accurate, and up-to-date  information on the efficiency, vulnerability, 
and effectiveness of departmental  programs. 
This report was prepared  under the direction of Mark R. Yessian, Ph.D., Regional Inspector 
General, and Martha B. Kvaal, Deputy Regional Inspector General, Boston Region, Office of 
Evaluation and Inspections.  Participating in this project were the following people: 
Boston  Headquarters 
Barry McCoy, Lead Analyst  Alan S. Levine 
Ted Wall, Program Analyst 
For additional copies of this repo~  please contact the Boston regional office  at 617/565-1050.  Department  of  Health  and Human  Setices 
OFFICE  OF 
INSPECTOR  GENEML 
THE  LICENSURE  OF  OUT-OF-STATE 
DENTISTS 
AUGUST  Igg3 
I  OEI-01-92-~20  EXECUTIVE  SUMMARY

PURPOSE 
To describe  and  assess  State  dental  board  policies  for licensing  dentists  already 
licensed  in another  State. 
BACKGROUND 
Dentists  who  have  a license  in one  State  and  wish to  obtain  one  in another  face  two 
different  paths  to licensure.  In one  group  of States,  they  can get  a license  through  a 
process  called  licensure  by credentials.  It allows for the  granting  of a license  on the 
basis  of established  credentials,  with  no further  examination  requirement.  In the  other 
group  of States,  the  out-of-State  dentists  must  pass  a clinical  examination,  regardless 
of their  experience  and  credentials.  The  examination  is the  same  one  given  to those 
seeking  an initial  dental  license.  It involves  the  use  of a live patient  and  calls for the 
applicant  to find  a willing patient  with the  necessary  oral  problems. 
The  chairman  of the  Subcommittee  on Small  Business  Opportunities  and  Energy  of 
the  House  Committee  on Small  Business  asked  the  Office  of Inspector  General  to 
conduct  an inspection.  He  was concerned  that  the  failure  of many  States  to provide 
licensure  by credentials  might  be  detrimental  to consumers  and  might  impede  access 
to dental  services  for those  living in underserved  rural  or inner-city  areas. 
This report  responds  to his request.  It draws  on a survey  of the  dental  boards  for 50 
States  and  the  District  of Columbia  (hereafter  referred  to as a State),  a review  of the 
professional  literature  and  existing  data  on State  licensure  policies,  and  interviews  with 
representatives  of State  dental  boards  and  national  dental  organizations. 
FINDINGS 
Twenty-nine  States  grant  Iicensure  by credential  an  increase  of  11 since  1987. 
The  29 States  are  concentrated  in the  Northeast  and  Midwest. 
 
The  coreargument  in favor  of Iicensure  by credentials  is that  it facilitates 
	
freedom  of movement  by practicing  dentists. 
Twenty-two  States  do not  grant  licensure  by credentials. 
They  are  concentrated  in the  South  and  West  and  include  six of the  seven 
	
States  leading  the  nation  in population  growth  between  1980 and  1990.  The  core  argument  in opposition  to licensure  by credentials  is that  it fails to 
b 
offer  adequate  assurance  of the  competency  of the  out-of-State  dentists  seeking 
licensure. 
The  clinical  examinatiownh ich22Statesr equiroef out-of-stadteen tistsseeking

licensurper ovideas checkonthecontinuecdo mpetencyofpracticidnegn tistsB.u
t

theseStatesd onotapplytherequiremenotr anysimilaars sessmenotf
 competencyto

dentistasl readyp racticiwnigt hint heirb
orders.

tionrequiremencta nimpedeefforttso recruiitn dividudaeln tistwsilling 
The  examina 
tolocate  in underserveadr easwithint heStatesY.etwe foundno da@ norany

tosupporta contentiotnh atithasmuch overalble
 aringon accesstodental 
studi+ 
careintheseareas. 
CONCLUSION 
Since  1987 dentists  have  come  to enjoy  somewhat  greater  freedom  of movement  as 
more  States  have  established  licensure-by-credentials  policies.  Yet,  within  the 
profession,  controversy  over  the  issue remains  and  may even  have  intensified. 
our  inquiry  has not  provided  a basis  for supporting  or opposing  licensure  by 
credentials.  It has,  however,  identified  two closely related  issues  that  are  of 
considerable  significance  to dentists  and  the  general  public.  These  are: 
the  minimal  degree  to which  States  currently  assess  the  continued  competency 
	
of practicing  dentists,  and 
the  questionable  performance  of many  State  dental  boards  in carrying  out  their 
	
enforcement  and  discipline  responsibilities. 
E State  governments  and  dental  organizations,  such as the  American  Association  of 
Dental  Examiners,  the  American  Dental  Association,  the  American  Association  of 
Dental  Schools,  and  the  Association  of State  and  Territorial  Dental  Directors,  focus 
constructively  on these  issues, support  for licensure  by credentials  could  broaden 
considerably.  More  importantly,  the  public  could  receive  increased  protection  for the 
close  to $40 billion  a year  it is spending  on services  provided  by about  145,000 dentists 
across  the  United  States. 
COMMENTS  ON THE  DRAFT  REPORT 
We  received  comments  on the  draft  report  from  the  American  Association  of Dental 
Examiners,  the  American  Dental  Association,  the  American  Association  of Dental 
Schools,  and  The  Association  of State  and  Territorial  Dental  Directors.  In appendix 
C, we present  each  set of comments  in full.  In response  to the  comments,  we have 
made  some  technical  corrections  and  some  updates  in our  data  on States  practices 
concerning  licensure  by credentials. 
ii 
-- TABLE  OF  CONTENTS

PAGE 
=~  s~y 
-mJcrT(IN....  . .. . . . .. . . . . .. . ..  . . . . . . . . . . . . . . . . .. . . . . . . . . ..  I 
mince  . . . . . .. . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..4 
Current  Practices  . . . . . . . . . . 
 
. . . . . . . . . . . . . . . . . . . . . ..O 
. . . . . . ..O  . . . .  4 
.  Rationales  . . . . . . . . . . . . 
. . . . . . . .
. . . . . . . . . . . ..O  . . . . . . . . .OO. . . . . . .  5 
Consequences  . . . . . . . . . . 
 
. . . . . . . .
. . . . . . . . .
. . . . . . . . . . . . . . . . . . . ..O  8
~NcLIJSION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..  II 
~=NTsONTHED~~PORT  . . . . . . . . . . 
. . . . . . .0 . . . . . . . . . . .  12
APPENDI~ 
k	 State  Dental  Board  Authorities  and  Practices  in Granting  Licensure 
by Credentials  to out-of-State  Candidates:  1987 and  1993  . . . . . . . . . . . . . .  A-1 
B:  Credentialing  Requirements  Imposed  by States  that  Grant  Licensureby 
Credentials,  1993  . . . . . . . . . . . . . . . . . . . . . . 
. . . . . . ...  . . . . . . . . . .
. . . .  B-1
C  Detailed  Comments  on the  Draft  Report  . . . . . . . . . . . . 
. . . . . . ...  . . . . . .  c-1
D:--~ndnotes  . . . . . . . . . . 
. . . . . . .. 
. . . . . . ... 
. . . . . . ..  . . . . . . ..  . . . . . . ..  D-I 
  7 
{  1 TABLE 1
~, THE AMERICAN  DENTAL ASSOCIATION AND LICENSURE  BY CREDENTIALS: 
AN HISTORICAL SKETCH 
SIGNIFICANT ACTIONS 
heti~n  Dental-Iation  (ADA)  survey of mem&ship  indicates  that 62 percent  favor licensure 
by credentials. 
ADAHouse  of Delegates  passes a resolution  calling for Stat=  to consider including in their practice 
~cts proviSons  for waiving the written  and clinical Iicensure examination  requirements  for candidates 
who are licensed in another  State. 
4DAHouse  passes a resolution  setting forth guidelines for licensure  by credentials.  The resolution 
lotes  that  the ADA  believes that an evaluation  of a practicing dentists theoretical  knowledge  and 
:linical skill based  upon his performance  record  can provide as much protection  to the public as 
vould an evaluation  based  upon examination. 
4DAsurveyof its membership  show  that 77 percent  favor Iicensure by credentials. 
4DAHouse  adopts  a resolution  calling for ADA  to appoint  a committee  to study the freedom  of 
movement  and Iicensure issues and to report  back to the Housein 1989.  It also calls for ADA  in 
cooperation  with the American  Association  for Dental  Examiners  (HE)  to study (1) the 
comparability  of clinical examinations  in use for dental  licensure  and (2) the feasibility of identifying 
reliable standards  for evaluating  clinical competency. 
The committee  to study freedom  of movement  and Iicensure issues sumeys States with and without 
[icensure  by credential.  Drawing on the committee  re~rt,  the ADA  House  passes resolutions 
extending  the ADAs Iicensure-by-credential  guidelines  for the States, calling for ADA and ME 
to study the development  of mutually  acceptable  continuing  com~tence  criteria,  and urging State 
boards  of dentistry  to grant  mutual  acceptance  to State or regional clinical iicensure examinations 
found  to be comparable. 
ADA/AM3Estudy produces  Guidelines  for Developing  Dental  Limmure  Clinical Examinations.  It 
identifies the minimum  common  core for a clinical Iicensure examination. 
Congressman  Bob Livingston (LA) introduces  in the U.S. Houseof Reprewntatives  H.R.  5444 to

require  State  dental  boards  to grant  licensure  by credentials.  No action  taken on bill.

Congressman  William Jefferson  (LA) introduces  in the U.S. HOUWHR.  2691, a bill to prohibit

discrimination  by the states  on the basis of nonresidency  in the licensing of dental  health  care

professionals.  ADA  House  of Delegates  narrowly votes down a resolution  calling for the ADA  to

actively support  H.R.  269 1.

ADA/&%DE  committee  produces  Guidelines  for Valid and Reliable  Dental  Licensure

Examinations  in order  to further  inform dental  testing agencies concerning  test procedures  that will

comply with professional  testing standards.  The ADA  and AADE  convene  a national  conference  to

address  the document.  Examination  committee  chairs of 20 of the 22 regional and State testing

agencies  make  up the primary audience.

ADA  convenes  a national  conference  on licensure  by credentials.  It draws together  more  than  230

participants  in an effort  to find common  ground.

ADA  House  passes resolutions  on Iicensure by credentials.  Among  them  are ones calling for all

dental jurisdictions  to follow the recommendations  of the Joint  ADA/WE  Guidelines  for Valid

and Refiable  Dental  Licensure  Clinical Examinations,  offering further  elaboration  of ADAs

Guidelines  for Licensure  by Credentials,  and urging State dental  boards  to implement  specialty

licensure  by credentials  and/or  specialty licensure examination  as a top priority.

ADAHouse  of Delegates,  by a considerable  margin, votes dow  a resolution  in support  of H.R.

2691.  H.R.  2691 dies with the close of the  102nd U.S. Congress  in 1992.

1  1993  Congressman  Michael McNuky  (NY)  introduces  H.R.  729, parallel  to H.R.  2691 of 1991. 
2 
  In 1992, Congressman  Ron  Wyden,  Chairman,  Subcommittee  on  Small  Business 
Opportunities  and  Energy,  House  Committee  on Small  Business,  began  his own 
investigation  of the  matter.  He  was concerned  that  the  reluctance  of many  States  to 
grant  licensure  by credentials  might  be  detrimental  to consumers  and  might  be 
countering  efforts  to improve  access  to dental  services  in undersexed  rural  or inner-
city areas.  As a result,  he asked  the  Office  of Inspector  General  to conduct  an 
inspection  on the  nature  and  implications  of State  dental  board  policies  in licensing 
out-of-State  dentists.  This  report  responds  to his request  and  follows  up  on a report 
concerning  State  dental  boards  that  we issued  in 1988 (State  Licensure  and  Discipline 
of Dentists,  OAI-01-88-00580).  It describes  the  current  situation  concerning  the 
licensure  of out-of-State  dentists.  It explains  the  primary  rationales  for and  against 
licensure  by credentials.  And  it identifies  some  key factors  relevant  to an 
understanding  of the  consequences  associated  with the  practice  of granting  licensure 
by credentials. 
METHODOLOGY 
In the  report  we drew  on five major  sources  of information.  Each  is identified  briefly 
below. 
A  of all State  dentalboards.We  conducted  a mail  survey  of all State 
survey 
dental  boards.  We  sought  information  concerning  board  resources  and 
authorities  and  board  actions  involving licensure,  enforcement,  and  discipline. 
The  professional  literature.  We reviewed  articles  identified  through  a search  of 
the  National  Library  of Medicines  on-line  data  base. 
Existing  data  and  materials  available  from  the  ADA  and  the  American 
Association  of Dental  Examiners  (AADE).  We  reviewed  existing  data  on State 
licensure  policies,  reports  on existing policy positions  of the  organizations,  task 
force  reports,  and  other  internal  documents. 
Personal  interviews.  We interviewed  representatives  of national  dental 
organizations,  regional  testing  agencies  and  State  boards,  and  individual 
dentists.  Our  attendance  at  the  August  1992 ADA  conference  on licensure  by 
credentials  offered  a good  opportunity  to conduct  many  such interviews. 
Focus  group  sessions.  During  the  ADA  and  the  AADE  annual  meetings  in 
October  1992, we conducted  locus  group  sessions  addressing  the  rationales  and 
consequences  of licensure-by-credentials  policies.  One  group  was composed  of 
representatives  of States  granting  licensure  by credentials;  the  other  of 
representatives  of States  that  do not. 
We  conducted  our  review  in accordance  with the  Quality  Standards  for  Inspections 
issued  by the  Presidents  Council  on  Integrity  and  Efficiency. 
3
 FINDINGS

CURRENT  PRACTICES 
Twenty-nine  States  grant  licensure  by credentials,  an  increase  of  11 since  1987. 
The  29 States  are  concentrated  in the  Northeast  and  Midwest. 
 
Twenty-two  of them  grant  lkxmsure  by credentials  to applicants  from  all States; 
	
7 do so only for applicants  fkom States  with similar  practices. 
States  that  provide  licensure  by credentials  requirements  on 
	 still  impose  various 
applicants.  Most  common  are  those  calling for  applicants  to be  in active 
practice,  receive  a favorable  report  from  the  dental  board  in their  former  State, 
and  agree  to a personal  interview. 
In 1909, in a book  on the  history  of dental  surgery,  the  author  noted  that  eight  States 
had  a system  for granting  licensure  by credentials  and  that  in time  such  practice  will 
become  general  throughout  the  country.3  Eighty-four  years  later,  the  practice  has 
increased  but  is still far  from  general.  About  half  of the  States  will grant  a dental 
license  on the  basis  of a licensed  dentists  credentials;  about  half will not  (see 
appendix  A). 
Since  our  review  of dental  Iicensure  practices  in  1987, the  number  of States  that 
exercise  licensure-by-credentials  authority  (on either  a complete  or restricted  basis) 
has increased  by one-half.4  The  growth,  however,  has  reinforced  a long-existing 
geographic  concentration  of such States.  They  remain  heavily  concentrated  in the 
middle  and  northeastern  portions  of the  country  (see  figure  1). 
FIGURE 1: STATE DENTAL BOARDS AND 
UCENSURE BY CREDENTIAL  AUGUST 1993 
.. 
tit
 
--
Z? EXERCISE AumOlu&  3 HAVE AUTHOIWW SUT 
FULLY  DO NOT EXERCISE K 
7 EXERCISE AUTHORllY  1S HAVE NO 
ON A UMITED SAW  - AUTHORITY 
Sculax  krm?lGmchmiAswddxl  mlOtRad!nspoduQ,ns@ 
4
 In the  29 States  that  offer  licensure  by credentials,  out-of-State  dentists  seeking  a 
license  do not  automatically  receive  one.  Their  credentials  are  still subject  to review. 
This review  varies  widely among  the  States  in terms  of both  the  type  and  extent  of 
requirements  (see  appendix  B).  One  State  has a particularly  exacting  review  process 
that  calls for applicant  dentists  to submit  a sample  of patient  records  for board  review. 
It reports  denying  licensure  to 5 to  10 percent  of its licensure-by-credentials  applicants. 
Twenty-two  States  do not  grant  licensure  by credentials. 
Theyareconcentrateidn theSouthandWestandincludsei
 xoftheseven

 
Statesl eadingt henationinpopulatiognr
 owthbetween1980and 1990.

In19oftheseStatest,h edentalboardhasno authorittyo providelicensurbey 

	
credentialisn;3 ithastheauthoritbyu tdoesnotexercishe.

The  22 States  that  do not  grant  Iicensure  by credentials  represented  the  major  growth 
areas  of the  country  in the  1980s.  Collectively,  their  population  grew by 19 percent 
from  1980 to  1990 while  that  of the  other  29 States  grew by 5 percent.  Included 
among  the  22 are  6 of the  7 States  with  the  largest  population  increases  during  the 
decade:  California,  Florida,  Georgia,  Arizona,  Virginia,  and  North  Carolina. 
Among  the  States  that  do not  grant  Iicensure  by credentials,  there  are  some  signs of 
change.  Whereas  in 1987 only one  had  the  authority  to engage  in such practice  (see 
appendix  A), by 1993 three  had  such authority.  In others  there  is active  inquiry  into 
the  matter  that  could  well result  in some  liberalizing  changes. 
Yet  in these  22 States,  the  entry-level  clinical  examination  remains  as a major  gateway 
to licensure,  even  for dentists  who have  specialty  practices  and/or  have  many  years  of 
experience.  Eleven  of these  States  devise  and  conduct  their  own examinations;  the 
other  11 typically  rely upon  1 of the  4 regional  dental  testing  services.5 
RATIONALES 
The  coreargumentinfavor  of Iicensure  by credentials  is that  it facilitates  freedom  of 
movement  by practicing  dentists.  Supporting  arguments  are  that  it: 
presentmsi nimalriskbecauseofthedisciplinaacrtyi onc learinghousreusn
 by 
 
theNationalP ractitionDeartaBank (NPDB) andAAD~  and

restso n abaseofposhiveexperienceisn Statesg rantinlgi censurbey 

	
credentials. 
To  practicing  dentists  living in a highly mobile  American  society,  licensure  by 
credentials  makes  good  sense.  It facilitates  their  freedom  of movement  from  one 
State  to another.  Whatever  their  motives  for moving--be  it to live in a better  climate, 
establish  a more  lucrative  practice,  accommodate  a spouse  who has an attractive 
5  employment  opportunity,  accept  a teaching  position  at  a university,  or work  in a clinic

in an underserved  area--the  availability  of licensure  by credentials  makes  it easier  and

more  possible  for them  to move  than  if they  had  to pass  an entry-level  examination  in

general  dentistry.

Dentists  recognize  that  the  examination  requirement  is not  an  impenetrable  barrier  to

licensure  and  that  most  applicants  pass  the  examination.b  Yet  they  raise  concerns

about  it.  Most  prominent  among  them  is the  cost and  inconvenience  associated  with

taking  the  examination  and  finding  patients  who will be  part  of the  examination.

Another  concern  is the  relevance  of the  examination  for experienced  dentists  who  are

specialists  in fields  such  as periodontics  or orthodontics.  Still another  is that  the

examination  requirement  might  have  more  to do with  reducing  competition  to dentists

already  practicing  in highly desirable  States  than  with  assuring  appropriate

qualifications  of out-of-State  dentists!

In response  to those  who  argue  that  licensure-by-credentials  States  will be vulnerable

to bad apples  who  move  from  State  to State,  proponents  point  to the  establishment

and  operation  of the  national  clearinghouses  on disciplinary  actions  run  by NPDB  and

AADE.  Between  them  the  clearinghouses  provide  all State  boards  with  access  to the

names  of dentists  disciplined  by other  State  boards,  professional  associations,  or

hospitals.

For  example,  in a letter  to Congressman  John  I)ingell  (NH), one  dentist  stressed  the

significance  of the  NPDB  and  concluded:  There  is no longer  a need  to restrict  the

movement  of all dental  health  care  professionals  because  this national  clearinghouse

of information  detects  the  few who  try to move  around  for unprofessional  reasons.9

To  further  their  case,  proponents  also point  to the  experiences  of those  States  that

have  granted  licensure  by credentials  for a number  of years.  If the  practice  were

harmful  to the  public,  would  these  States  continue  to practice  it, they  ask.  Before

1987, one  State  did rescind  its licensure-by-credentials  practice,  largely  because  of

concerns  about  a few dentists  who  had  been  licensed  by this route  and  who it later

found  had  been  disciplined  in another  State.  But  it has since  reestablished  the

practice  and  reports  no subsequent  problems.  Similarly,  representatives  from  other

States  that  engage  in the  practice  reported  to us that  they have  had  no bad

experiences  and  expressed  confidence  in their  own credentials  review  process  as a way

of weeding  out  problem  cases.

Two States  we contacted  had  actually  reviewed  the  number  of disciplinary  actions  they

had  taken  against  dentists  to whom  they  had  granted  Iicensure  by credentials.  One

State  found  that  of 59 dentists  issued  a license  in this way since  1974, only  1 was

subsequently  disciplined.  The  other  reported  that  of 171 dentists  licensed  by

credentials  in the  last  10 years,  only  1 had  a complaint  lodged  against  him. This

represented  less than  one-half  of  1 percent  of all complaints  lodged  during  this period.

6
 Ihe coreargumentinopposition  to  liccnsure  by credentials  is thatitfadstooffer 
adequateassurancoef thecompetencyofout-of-Stadteen tistsse ekinglicensure.

Supportinagr
 gumentsarethat:

theNPDB  and  AADE  clearinghouses  have  limited  information  and  can not 
	
compensate  for the  inadequate  enforcement  efforts  of some  State  dental 
boar(ky  and 
thecliniclailc ensureex aminatiorne quiremenits avitasla fetvya lvee,s pecially

 
forStatest owhichlargenumbersofdentistsseektomove.

From  the  opponents  camp  comes  the  message  that  what  licensure-by-credentials

advocates  are  seeking  is licensure  by convenience,  without  regard  for  a boards

obligations  to protect  the  residents  of its State.  In that  context,  they  cite  two

fundamental  bases  for their  contention  that  licensure  by credentials  fails to provide

adequate  protection.

One  is that  some  of the  out-of-State  applicants  may not  be  sufficiently  competent,

This reservation  rests  largely  on perceived  variations  in the  quality  of dental  schools

and  their  graduates.  Indeed,  a committee  formed  by the  ADA  to study  freedom  of

movement  and  licensure  issues  reported  in  1989 that  these  perceived  variations  were  a

primary  reason  why five States  surveyed  opposed  licensure  by credentials.l  The

reservation  about  out-of-State  dentists,  however,  involves  more  than  dental  schools;  it

also extends  to  dental  boards  and  to their  capacity  and  readiness  to identify  and  then

respond  to incompetent  and/or  unprofessional  dentists.  Dental  board  officials we met

with doubted  the  adequacy  of the  enforcement  efforts  of many  State  boards  and  even

the  willingness  of some  boards  to strengthen  these  efforts.ll

The  other  fundamental  basis  offered  for opposing  licensure  by credentials  is that,  in

itself, it is not  a credible  basis  for granting  licensure.  The  argument  is that  the

credentials  available  for review,  the  lack of any disciplinary  action,  the  receipt  of a

supportive  letter  from  a board  or character  witness,  the  conduct  of a personal

interview,  and  the  like simply fail to offer  adequate  assurance  of the  competency  of a

dentist.  A dental  board  owes the  residents  of its State  greater  assurance  than  such

factors  provide.

In this context,  the  fact  that  the  NPDB  and  AADE  clearinghouses  offer  a source  of

information  about  disciplined  dentists  presents  little  assurance.  The  latter,  they  point

out,  does  not  receive  reports  from  a number  of States  and  the  former  does  not  include

any disciplinary  actions  taken  prior  to October  1990.  Even  more  significant,  they  add,

is that  both  of these  clearinghouses  identify  only those  individuals  who  have  had

formal  action  taken  against  them.  That  a dentists  name  does  not  appear  in either

clearinghouse  is no assurance  that  he or she  is competent;  nor  does  it preclude  the

possibility  that  the  dentist  is under  investigation.

7
 Thus,  the  opponents  of licensure  by credentials  hold  to the  argument  that  a clinical 
examination  provides  a minimum  necessary  check  to impose  on any dentist  wishing  to 
practice  in a State.  Many  of them  will grant  that  the  examination  itself  is not  a sure 
measure  of competence  and  that  better  mechanisms  can  probably  be  developed.  Yet, 
even  as it is, they  assert  it provides  better  protection  than  that  offered  through 
Iicensure-by-credentials  reviews.  For  example,  one  dental  board  member  told  of a 
dental  school  dean  who on paper  had  excellent  credentials  and  would  have  easily 
passed  a Iicensure-by-credentials  review,  but  failed  the  boards  clinical  examination 
three  times. 
Further,  representatives  from  States  facing  a major  influx of out-of-State  applicants  for 
licensure  say that  they  have  a particularly  compelling  need  to go beyond  a case-by-
case review  of a candidates  qualifications  and  rely upon  a standardized  examination  to 
help  them  assess  a candidates  capacity  to practice  dentistry.  For  dental  board  officials 
from  California,  which  had  1,294 dental  licensure  applicants  in 1991 or from  Florida, 
which  had  631, the  positive  experiences  of Iowa (70 applicants),  Minnesota  (93),  or 
other  States  which  have  much  smaller  number  of applicants  (and  can  more  readily 
give each  candidate  individual  attention)  seem  of little  relevance.12  It is not,  they 
note,  a matter  of keeping  out  the  competition,  but  giving their  residents  the  assurance 
that  licensed  dentists  are  sufficiently  competent  to practice.13 
CONSEQUENCES 
It is reasonable  to ask what  if any notable  consequences  are  associated  with the 
practice  of granting  licensure  by credentials.  We addressed  that  question  as part  of 
the  rationale  offered  by those  favoring  licensure  by credentials.  They  cite  the  results 
as positive,  with  no particular  dangers  presented  to their  States  residents. 
We gave  more  attention,  however,  to any consequences  associated  with the  practice  of 
not granting  licensure  by credentials--that  is, of requiring  all out-of-State  applicants  to 
take  a clinical  examination.  We  did that  because  the  controversy  concerning  licensure 
by credentials  has  focused  on the  possibly  negative  effects  caused  by the  22 States 
falling in the  latter  category.  Our  inquiry  in this regard  was not  a comprehensive 
assessment  of the  many  possible  consequences.  At a general  level,  however,  it 
surfaced  two central  findings  that  are  pertinent  to further  discussions  of the  pros  and 
cons of licensure  by credentials. 
The  clinical  examin ationwhich22Statesr equiroef out-of-Stadteen tistsseeking 
licensurper ovideas checkon thecontinuecdo
 mpetencyofpracticing  dentists.  But
these Statesd o notapplytherequiremenotr anysimilaars sessmenotf
 competencyto 
dentistasl readyp racticiwnigt hint heirborders.

Dentistry  is often  referred  to as one  of the  last cottage  industries.14  The  relevance 
of this analogy  is indicated  by the  fact  that  69 percent  of dentists  practice  alone  and 
that  89 percent  practice  alone  or with  1 other  dentist.]s  Thus,  dentists  tend  to have 
8
 relatively  little  day-to-day  contact  with  colleagues,  other  health  care  professionals,  or

with hospitals.lb

Dentists  also  tend  to have  little  if any exposure  to quality  assurance  reviews  once  they

receive  their  initial  dental  license.1  Few, for instance,  are  exposed  to  the  kind  of

ongoing  oversight  which  hospitals  and  the  Medicare-funded  Peer  Review

Organizations  conduct  on the  hospital-based  medical  practice  of physicians.18

Among  the  51 States,  30 require  some  continuing  education  courses  as a condition  of

dental  Iicensure,  but  none  calls for any assessment  of what  a dentist  actually  learned

from  a course.lg

Thus,  the  clinical  examination  that  22 States  require  of out-of-State  dentists  seeking

licensure  represents  the  most  significant  quality  assurance  check  that  licensed  dentists

are  likely to face  in their  entire  career.  Whatever  the  examinations  limitations  as a

competency  assessment  tool,  it affords  some  basis for  determining  a dentists  current

clinical  knowledge  and  skill.zo

Notwithstanding  the  quality  assurance  benefits  associated  with the  clinical  examination

requirement,  the  fact  remains  that  the  22 States  imposing  it on licensed  out-of-State

dentists  seeking  licensure  apply  it selectively.  They  require  these  out-of-State

applicants  to take  it regardless  of their  credentials  or the  nature  of their  practice,  but

they  impose  no similar  requirement  on the  much  larger  number  of dentists  already

practicing  in their  own States.  As in all other  States,  licensed  dentists  practicing  in

these  States  are  not  subject  to any ongoing  State-imposed  assessment  of their

competency.  In  11 of the  22 States  that  do not  grant  licensure  by credentials,  dentists

do not  even  have  the  minimal  State-imposed  obligation  of attending  continuing

education  courses.21

Some  representatives  of these  States  defend  this inequity  on the  grounds  that  their

own licensees  have  already  passed  the  clinical  examination  they  require  out-of-State

applicants  to take.  Yet,  when  questioned,  they  acknowledge  that  could  have  been  as

many  as 30 to  40 years  ago and  offers  insufficient  basis  for assuming  current

competency.

Thus,however  much  a clinical  examination  may help  ensure  a certain  minimum  level

of competency,  the  selective  manner  in which  these  States  use  it makes  them

vulnerable  to the  charge  that  it is intended  to reduce  competition  more  than  to protect

patients.  One  educator  who has  studied  this issue described  this  situation  as imposing

a secondary  burden  on out-of-State  competitors  that  does  not  exist for in-State

commercial  interests.  He  adds:

State  licensing  bodies  would  be  hard  pressed  to maintain  that  they  are

ensuring  the  safety  and  health  of in-state  residents  and  not  establishing  a

barrier  to commercial  interests  when  in-state  practitioners  may maintain

Iicensure  for a lifetime  without  some  system  of retesting  and/or

continuing  education.22

9  The  examinatiownh ich22Statesr equiroef out-of-Stadteen tistsse ekingl icensurcean

impedeefforttso recruiitn dividudaeln tists  tolocatei nunderserveadr
 eas 
willing 
withint heStates.Yetwe foundno da@ nor studies,  to support  a ccmtention  that 
any 
ithas much overalblearingonaccesstodentalcareintheseareas.

Another  concern  associated  with  the  clinical  examination  requirement  for out-of-State 
dentists  is that  it might  serve  to hinder  efforts  to improve  access  to dental  services  in 
underserved  areas.  There  are  data  that  lend  some  support  to this concern.  Among 
the  22 States,  16 have  dentist-to-population  ratios  below  the  national  average  of 57.5 
per  100,000 population.  Further,  while  the  22 States  account  for 36 percent  of the 
licensed  dentists  in the  United  States,  they  account  for 54 percent  of the  771 dental 
shortage  areas  and  55 percent  of the  423 shortage  areas  with  20 percent  or more  of 
the  population  below  the  poverty  level.n 
A State  requirement  that  licensed  out-of-State  dentists  take  and  pass  a clinical 
examination  as a condition  of licensure  clearly  does  not  facilitate  the  movement  of 
such dentists  to  shortage  areas  in these  States,  nor  does  it encourage  the  retention  of 
National  Health  Services  Corps  dentists  who work  in undersexed  areas  in these  States 
and  do not  have  a State  license.  Indeed,  we have  been  informed  of individual  cases  of 
these  kinds. 
Yet  we found  no data,  nor  any studies,  to indicate  that  licensure-by-credentials  policies 
have  much  overall  bearing  on the  access  to dental  semices  in underserved  areas.  If 
dentists  enjoyed  complete  freedom  of movement,  it is not  at  all clear  that  many  more 
would  work  in undersexed  areas  than  is now the  case.  Representatives  from  most  of 
the  States  we covered  in our  focus groups--whether  or not  they  grant  Iicensure  by 
credentials--reported  significant  difficulties  in having  dentists  work  in underserved 
areas,  even  in those  underserved  areas  where  they  have  the  opportunity  to make  a 
substantial  income. 
10

  CONCLUSION

Since  1987 dentists  have  come  to enjoy somewhat  easier  freedom  of movement  across 
the  United  States  as more  States  have  established  Iicensure-by-credentials  policies. 
Yet  within  the  profession,  the  controversy  has continued  and  perhaps  even  intensified. 
The  core  of that  controversy  focuses  on the  restrictive  practices  of a few large  sunbelt 
States  and  perhaps  three  to five others  to which significant  numbers  of dentists  might 
wish to move. 
The  ongoing  operation  of the  NPDB  and  AADE  clearinghouses,  the  slow but  clear 
movement  toward  a standardized  clinical  licensure  examination  acceptable  to all 
States,U  and  the  continuing  pressure  exerted  by many  dentists  could  lead  to wider 
adoption  of licensure  by credentials  in the  years  ahead.  Such  direction  would 
obviously  contribute  to the  interstate  mobility  of dentists;  its consequence  for the 
public  at large  is less clear. 
Our  inquiry  has  not  provided  a basis  for supporting  one  side  or the  other  in the 
controversy  concerning  licensure  by credentials.  In examining  the  arguments  for  and 
against  it, however,  we have  identified  two closely related  issues  that  are  of major 
significance  to dentists  and  the  general  public.  These  are: 
the  minimal  degree  to which  States  currently  assess  the  continued  competency 
	
of practicing  dentists,  and 
the  questionable  performance  of many  State  dental  boards  in carrying  out  their 
	
enforcement  and  discipline  responsibilities. 
If State  governments  and  dental  organizations,  such as the  American  Association  of 
Dental  Examiners,  the  American  D>ntal  Association,  the  American  Association  of 
Dental  Schools,  and  The  Association  of State  and  Territorial  Dental  Directors,  focus 
constructively  on these  issues, the  support  for licensure  by credentials  could  broaden 
considerably.  More  importantly,  the  public  could  receive  increased  protection  for the 
close  to $40 billion  a year25Itis spending  on services  provided  by about  145,000 
dentists  across  the  United  States.2G 
11
 COMMENTS  ON  THE  DRAFT  REPORT

We received  comments  on the  draft  report  from  the  American  Association  of Dental 
Examiners  (AADE),  the  American  Dental  Association  (ADA),  the  American 
Association  of Dental  Schools  (AADS),  and  The  Association  of State  and  Territorial 
Dental  Directors  (ASTDD).  In appendix  C, we present  each  set  of comments  in full. 
The  AADE  agreeswith our  concluding  observations  about  the  minimal  attention  given 
continued  competency  and  the  questionable  performance  of boards  in carrying  out 
to 
their  enforcement  responsibilities.  It asked  for  any additional  information  we could 
provide  on continued  competency  facilitate  its own efforts  in that  area.  We  have 
to 
followed  up with AADE  to provide  such information. 
The  ADA  provided  some  updated  information  on licensure  by credentials  policies  of 
the  States  and  indicated  it would  alter  some  of our  observations  on which  States 
engage  in the  practice.  It agreed  with  our  conclusion  about  continued  competency, 
but  suggested  we report  the  importance  of continuing  education  mechanism 
as  a  to 
address  such  competency.  Finally,  it  reviewed  its position  and  actions  concerning 
licensure  by credentials. 
On the  basis  of ADAs  information  and  follow up conversations  with  representatives 
from  Texas  and  Arkansas,  we have  added  them  to the  group  of States  that  is now fully 
exercising  the  authority.  But,  figure  1 indicates,  it remains  that  this group  is 
as 
concentrated  in the  middle  and  northeastern  portions  of the  country  and  still does  not 
include  6 of the  7 States  with the  largest  population  increases  during  the  1980s 
(California,  Florida,  Georgia,  Arizona,  Virginia,  and  North  Carolina). 
In regard  to continuing  education  (CE),  we agree,  as ADA  suggests,  that  mandated 
CE  is important  consider  among  the  array  of approaches  that  are  relevant 
to  to 
continued  competency.  Yet,  we also  point  out  that,  its overall  value  in this regard 
remainsquestionab2l7e .l na proposals eekingf undingf orcomputer-basepda
 tient

simulationtsh,e majornationadle ntalorganizatioinnsc,l udinAgD
A  note:Itk

widelyagreedthata majorweaknessinmandatorycontinuinegd ucatiorne
 quirements

k thatfrequentltyh erek littrleel ationshbiept weenthecontinuinegd ucatioanc
 tivity

andtheprofessiondaelv elopmentn eedsoftheindividual.Th%e
  ASTDD, inits 
commentson thisr eportr,e inforctehsi sp ointbynoting:
 practitioners  take
Nfany 
courses  they  like, rather  than  courses  they need.  Assessment  of what  a dentist  actually 
learned  from  a course  (e.g. knowledge),  does  not  necessarily  translate  into  changes  in 
practice  or attitude. 
The  AADS  offered  some  technical  suggestions,  cited  two recent  articles  in the Journal 
of the Amencan Dental  Association  (JADA)  that  were  relevant  to our  discussion,  and 
urged  that  we more  fully address  antitrust  issues,  We  made  corrections  that  addressed 
their  technical  suggestions,  referenced  one  of the  articles  at an  appropriate  point  in 
12
 ourtexta,n ddidnotaddresst heantitruismtp licatio-nmsa
 inlybecausetheywould

callf
orjudgmentsbytheFederalTradeCommission.

The  ASTDDS president  urged  that  State  public  health  dental  programs  be more 
closely tied  in with  State  licensing  and  credentialing  efforts,  emphasized  its concern 
about  insufficient  access  to oral  health  services,  expressed  its support  for periodic 
assessment  of the  competency  of dentists,  and  suggested  that  it is time  to move  toward 
a national  clinical  licensure  examination  for dentists.  He  did not  call for any changes 
in our  draft  report. 
13
 APPENDIX  A

!SIATDE ENTALBOARDAUTHORITIEAS NDPRACII(3?ISFlGI?ANllNG 
LICENSUREBYCREDEFITIAMTO  OUT@F-STATCEA  NDIDATE!l1987AND1993
BOARD  ~  AUTHORITY  TO GRANT  LICENSURE 
BY CREDENTIALS 
BOARD  HAS 
~ 
BOARD  EXERCISES*  ITS  BOARD  HAS  NOT  AUTHORITY 
AUTHORITY  EXERCISED ITS  TO GRANT 
AUTHORITY 
LICENSURE 
BY 
BOARD  BOARD  CREDENTIALS 
AUTl+ORITY  AUTHORITY 
EXTENDS  TO  LIMITED  TO 
CANDIDATES  CANDIDATES 
FROM  ALL  FROM STATES 
STATES  WITH  SIMILAR 
PRACTICES 
STATE  1987  1993
 1987  1993  1987  1993  1987  1993 
AL
 x x 
AK  x
 x 
Az
 x x 
AR  x
 x 
CA
 x x 
co
 x x 
CT  x
 x 
DE
 x x 
DC
 x x 
FL
 x x 
GA
 x  x 
HI
 x x 
ID
 x x 
IL  x
 x 
IN  x x

IA  x
 x 
Ks  x x

KY
 x  x 
IA  x
 x 
ME  x x

A-1
 ~ATE DENTALBOARDAUTHORITIEASNDPRAmCES IN GRANTING 
LICENSUREB YCREDENTIAL~S  OUT~F~ATE  Cu4NDB3A~  1987AND1993 
BOARD  ~  AUTHORITY  TO  GRANT  LICENSURE 
BY CREDENTIALS 
BOARD  HAS 
~ 
BOARD  EXERCISES  ITS  BOARD  HAS  NOT  AUTHORITY 
AUTHORITY  EXERCISED ITS  TO GRANT 
AUTHORITY 
LICENSURE 
BY 
BOARD  BOARD  CREDENTIALS 
AUTHORITY  AUTHORITY 
EXTENDS  TO  LIMITED  TO 
CANDIDATES  CANDIDATES 
FROM  ALL  FROM  STATES 
STATES  WITH  SIMILAR 
PRACTICES 
STATE  1987  1993  1987  1993  1987  1993  1  1987  !  1993

MD  x x

MA  x x

MI  x x

MN  x x

, 
MS  x x

MO  x x

MT  x x

NE  x x

Nv  x x

NH  x x

NJ  x x

NM  x x

NY  x x

NC  X1X 
ND x  x

OH  x  I  xl 
OK  x x

OR  x x

PA  x x

RI  x x

I

Sc  x x

SD  x x

TN x  x

A-2
 ~ATE DENTALBOARDAUTHOIUTBZAjN  DPRA(THCEISN GIIANTTNG
LI(3ZNSURBEYCREDENl%UJTjOOUT~F~ATE  CANDIDA~:  1987AND1993 
BOARD  ~  AUTHORITY  TO  GRANT  LICENSURE 
BY CREDENTIALS 
I  BOARD  HAS 
~ 
BOARD  EXERCISES*  ITS  BOARD  HAS  NOT  AUTHORITY 
AUTHORITY  EXERCISED  ITS  TO  GRANT 
I  AUTHORITY  LICENSURE 
BY 
BOARD  BOARD  CREDENTIALS 
AUTHORITY  AUTHORITY 
EXTENDS  TO  LIMITED  TO 
CANDIDATES  CANDIDATES 
FROM  ALL  FROM  STATES 
STATES  WITH  SIMIM.R 
I  PFLKTICES 
STATE  1987  1993  1987  1993  1987  1993  1987  I  1993 
m  x 
UT 
VT  x  lx 
VA  lx  x  I 
WA  x  x  I 
w  X1X 
1 
WI  x 
WY  x  I  +--
TOTALS  11 
........... ........... 
Sourctx  American  Dental  Association  ADA  News, Juiy 8, 1987 and  October  5, 1992  Updated  throu& 
August  1993  by Ofice  of Inspector  General  telephone  contacts  with ADA  and Stare boards. 
  We sou@  dam porn  the individual  Stoles  on how ojkn  they acmal(y  ererctied  their licensure-Qy-credemials 
atuhor@  in Fiscal  Year 1991.  However,  most  of the States were unable  to provide  us with the akta. 
A-3
 APPENDIX  B

CREDENTIAUNG  REQUREMHWS  IMPOSED  BY STATES  THAT  GRANT 
LICENSURE  BY CRED ENTIALs,  1993 
NUMBER  OF 
REQUIREMENT  STATES 
REOUIRING 
Active practice within former  State immediately  24 
preceding  application 
Board  in former  State must attest  that the  20 
subject  was in legal and reputable  practice  (no 
unresolved  complaint,  review procedure,  or 
disciplinary proceeding,  and license has not 
been  revoked) 
Must  be personally interviewed  14 
Affidavits or letters  from practicing dentists  8 
regarding  moral character 
Good  moral character  6 
Physicians statement  of physical and mental  3 
health 
Intends  to establish  mactice  2 
Source:  American  Dental  Association, Repro  of the Division  of Education: 
Dental Licensure, April 1992. 
B-1
 APPENDIX  C

DETAILED  COMMENTS  ON THE DRAFT  REPORT

In this appendix,  we present  the  complete  comments  on the  draft  report  received  from 
the  American  Association  of Dental  Examiners  (AADE),  the  American  Dental 
Association  (ADA),  the  American  Association  of Dental  Schools  (AADS),  and  The 
Association  of State  and  Territorial  Dental  Directors  (ASTDD). 
c-1  AMERICAN  ASSOCIATION  OF DENTAL  EXAMINERS 
Chicago  Ave., Suite 644, Chicago, IL 60611  (312)  440-7464 
May  13,  1993 
Mr. Bryan B. Mitchell

B.  Wayne J. h  Principal  Deputy  Inspector General

2928HmniiIm~  Office of Inspector General

sjouxc~,  IA  51104  Department  of Health  & Human Services

(712) 2ss-7607 
Washington,  DC 20201

Dear Mr. Mitchell:

Dr. Jd  F. GJuvcr 
w-w  Thank you for giving the American  Association of

Rmo. NvS9509 
Dental Examiners an opportunity to comment on the

(702)S2S-2417 
draft report The Licensure of Out-Of-State

FIRsTwm+mmmr  Dentists.

Dr.IiliKiBmaldam 
The report concludes that Our inquiry has not

3oEaaaktlsuca  provided a basis for supporting or opposing

New Yak  NYloo22 
licensure by credentials.  It has, however,

(~12) 7554125 
identified two closely related issues that are of

SECOND vm3-mEsmNr  considerable significance to dentists and the

general public.  These are:

c 
Dr. Km  C-ICY 
440 BrtYdsL 
	 the minimal degree to which States 
cohdliLMs  39429 
currently assess the continued 
(@ii) 73&1761 
competency of  practicing  dentists,  and 
lnmDvmwsmmw 
t&.HanyRDoIwuI    the questionable performance of many 
State  dental  boards in carrying out 
2860PiakunKAvc=Ic 
lhlhuh. MN 55811  their enforcement and discipline

(218) 7224823  responsibilities.

Pm  mmlumrr 
MMmnATE  As regards the questionable performance of manY 
l)r. wT.  RwiI  State dental boards it 1S  clear  that  the lack of 
475  MaMad  AvaxIc  sufficient  funding  is the principle  reason  for 
Ablxul?  s@ga.  FL 32701  enforcement  difficulties. 
(407) 831-1747 
FxEamvEDIREcNx  In addition  the report states  If State

governments  and dental organizations,  such as the

ML MdtyNder  American  Association of Dental Examiners, the

2111LChiCJg0AVCaUIC  American Dental Association, the American

Association of Dental Schools, and the Association

ChiagO, %?il% 
of State and Territorial Dental Directors, focus

(312) 440-7464 
constructively  on these issues, support  for

licensure  by credentials  could broaden

considerably .  This is likely to follow closely

Dr. Kuhka  Kth  on the heels of continuing  competency  programs.

u  E Mifflia StruI 
Suiac204 
The AADE agrees that continued competency should 
~  WI 53703 
(60s) 2XW45EJ  be addressed.  AADE established a Continuing 
Competency  Committee  in 1992,  the goal of which  is  to develop criteria and mechanisms for states to 
use  in assessing  the  continued  competency  of their 
licensed dentists.  The AADE  is currently  seeking 
support  for the Committees  activities  from the 
Bureau of Health Professions  of the Department  of 
Health and Human Services,  the American  Dental 
Association,  the Academy of General Dentistry,  and 
the American Association  of Dental Schools. 
The AADE would  like to officially  request  that, if

possible,  any information  obtained during  the

Office of Inspector Generals  study on the subject

of continued  competency  be shared with the AADE

Continuing  Competency  Committee.  Also, the AADE

Continuing  Competency  Committee  would appreciate

any information  that the IGs office has with

respect to other health organizations  activities

in ~he area of continued competency.

Sincerely,

Molly Nadler

Executive  Director

cc:  Members, AADE Executive Council 
Members, AADE Continuing  Competency  Committee  American 
Denta( 
Association 
211 East  Chicago  Avenue 
Chicago,  IllInoIs  60611-2678 
!312)  440-2500 
May 28,  1993 
Mr.  Bryan  B.  Mitchell 
Principal  Deputy  .Inspector  General 
U.S.  Department  of  Health  & Human  Services 
Office  of  Inspector  General 
Washington,  D.C.  20201 
RE :	 Draft  Inspection  Report, 
The  Licensure  of  Out-of-State  Dentists 
Dear  Mr.  Mitchell: 
Thank  you  for  your  recent  letter  inviting  the  American  Dental 
Associations  comments  on  your  draft  inspection  report,  The 
Licensure  of  Out-of-State  Dentists.  We greatly  appreciate 
this opportunity  to provide  comments  and your offer to

include them  in your final report.  We would  like  to  begin  by 
stating  quite  simply  that  the  report.  is  excellent.  We  also 
commend  the  thoroughness  of  the  report,  as  well  as  the 
accuracy  of.the  data  on  the  licensing  requirements  of  each 
state,  which  we  are  pleased  is  based  on  reports  from  the 
American  Dental  Association:  The  remainder  of  this  letter 
will  provide  our  specific  comments. 
Uudate on Data

This year, the State of Arkansas enacted legislation in

support of licensure by credentials.  It is our understanding

that the legislation will now go to the state dental board

for implementation.  As of this date you may wish to report

that implementation is pending with the  state  board. 
Licensure  by  credentials  also  is  currently  under  consider
ation  in  the State of Texas.  A bill is progressing  through 
the Texas legislature that, if adopted, will require the

de~tal boa- to  implement  llcensure  by  credentials.  This 
- bill is supported by the Texas Dental Association.  Licensure

by credentials also is beingconsidered  at the present time

at the regulatory level by the dental board in Texas.

The addition of two sunbelt states this year  would alter your 
reports analysis that the states with licensure by cre

dentials:  (1) are concentrated heavily in the middle and

northeastern portions of the country, and (2) do not rePre

sent the fastest growing states in the country.  MOreOVer, 
the addition  of  Texas  runs  counter  to  the  sometimes  cited  . 
Mr. Mitchell 
May 2a,  1993 
Page 2 
view that licensure by credential states do not include any

of the retirement areas in the sunbelt region.

Continued  Com~etencv 
v

We agree  with your  assessment  that  it  is  important,for state 
governments and dental organizations, such as the American 
Dental *_s_~ciation,,the American  Association  of Dental

Scho.olsand o~,~to  focus constrictively  on the issue of

continued  competencyof  @racticing  dentists.  At present,  the

American  Association  of Dental  Examiners  has an ongoing task

force to study this issue, with participation  by the American

Dental,Association,  the American  Association  of Dental

Schools and ~ther dental  organizations.

We note  on  this  issue  that  you  may  wish  to  mention  in  the

report  the  importance  of  continuing  education  as  one

mechanism  to  address  clinical  competency.  We  believe

continuing  education  is  a  very  important  aspect  of  this

issue.  The  American  Dental  Association,  through  exlSt~n9

policy,  urges  states  to  develop  mechanisms  to  foster

continuing  education.  In  fact,  to  date  29  states  plus  the

District  of  Columbia  believe  it  is  sufficiently  important

that  they  have  made  continuing  education  mandatory.  There  is

a  growing  trend  i.n  states  to  adopt  mandatory  continuing

education  legislation.

American Dental Association Activities

Your report quite accurately states the American Dental

Associations position on licensure by credentials.  we

support licensure by credentials.  However, we also firmly

support the notion that this is an issue to be addressed on a

state by state basis.  Professional licensure has been a

traditional area of state regulation, and we support the

rights of the states to make their own decisions in this

area.

The Association believes that it has contributed proactivelY

to state acceptance of licensure by credentials through its

many activities in support of credentialing.  These include 
most significantly a  national  conference  on  licensure  hosted 
by  the  ADA  in  July  1992.  This  conference,  which  was  attended 
by  representatives  of  the  educational  community,  state  regu
latory  agencies,  and  other  interested  groups  and  individuals~ 
provided  a  forum  for  the  communities  of  interest  to  discuss 
progress  toward  appropriate  opportunities  for  licensure  by 
credentials.  The  conference  included  presentations  and 
workshops  that  provided  the  participants  with  a  forum  in  Mr~  Mitchell 
May 28, 1993

Page 3  ~

which to develop their own strategies for implementation of

licensure by credentials in their states.  The conference

also sparked a momentum for several new and important

resolutions that were adopted by  the  ADA~S  House  of  Delegates 
in  October  1992.  These  resolutions  provided  direction  on 
specialty  licensure  by  credentials;  Supported  ADA efforts  to 
encourage  state  regulatory  agencies  to  accept  a  common  core 
of  requirements  and  guidelines  for  clinical  examinations;  and 
directed  the  appropriate  agencies  of  the  ADA to  urge  all 
dental  licensing  jurisdictions  to  utilize  the  ADA guidelines 
for  licensure  by  credentials.  In  short,  ADAs  policy  on 
licensure  by  credentials  is  not  simply  a  statement  of 
position.  It  is  a  core  policy  that  is  actively   supported 
by the  Association. 
Conclusion

In conclusion,  new data for the first five months
 of  1993 
supports  the overall trend noted  in your report:
 more and 
more states ~  adopting licensure by credentials
 legislation 
and regulations.  While the trend may not be as rapid as

credentialing proponents would like, change is coming in a

well-reasoned manner.

The American Dental Association  supports  licensure  by cre
dentials  but just as firmly supports  the right of  states  to 
make their  own determination  about whether  more  licensing 
laws and regulations  should permit  credentialing.  At the 
same time, we have taken a number of active  steps, partic
ularly  in the past two years,  to assist  states  in moving 
toward  licensing  by credentials,  and will continue  our 
efforts  in this regard. 
Thank you again for the opportunity  to comment  on your

excellent  report.

Sincerely,

f&ljlj~DD~ 
- .  . . 
 
Executive Director 
JSZ/MKL
 American  .koclation 
ot Dental  Schools  June 17, 1993 
16Z5 
,Massachuser[s 
Avenue,  NW 
Washington  DC  Mr.BxyanB.Mitchell
20036  -22[2 
Princip~aplu tyInspectGoern
 eral

202.6679433  Officoef theInspectGoern
 exal

Departmenotf Healtahn
 dHuman

Services

WashingtoDn.,C
 .20201

Dear Mr. Mitchell: 
on behaloff theAmericaAn
ssociation of Dental SChOOls(AADS), we appreciate the 
Opportunityto review the ~  ~pector  Gene@s Repo~  meLice=  of Out-of-Stilte 
Dentists. 
FirsL we compliment you, Dr. Ma.ricyessi~  M~a  Kv@,  ~d  other ~  fim  the Boston 
development  of this K!po~  ~dq  the Association  WN pleased 
R@OIl~  office  on  the  to  have 
been contacted by these individuals during the muse  of the study. 
We offer the following comments and suggestions: 
1.  Page 1, first paragraph of the i%cic~munclstio~  tie  7:  We suggest this line be 
edited as follows  .....  responsibility of fiding  cooperative patie~- with the necessary 
oral problems. 
2.  page6,lin4e ofthefirsftu lpla
 ragmpkThishe sho~dbeedi~ toreadasfollows:

,,

,..t.a kintgh eexaminaotnia ndfindinpga tienw~h owillb eparto
ftheexaminatiOrL

The  rationale for nxomrnendatio~  num~m  1 ~d  2 ~  &  found in the Appendix  C 
endnotes,  number  6 (page c-1)  which  s~tes  the n- to fid  for the examinatiorl. 
p~ents 
3.	 Page 2,Table1,Significant  Actions:  we  su~est  M  tie  ~on  u&em by the AADS 
House of Delegates in 1991 to  on dental 
update  @  ~is~  the  Associations  policy 
licensure be cited in this Table.  A COpyof the MS  policy s~tement  is enclosed. 
The inchsion  of the AADS policy will give -r  to the 
Unde-ng  ~d  jusl.ifi~rion 
reports Iwcmlmendation  found  in the wnc~usion  (page  11) ~  e~ewhere  th~  W  fOrthe 
American Association  of Dental  Schoois,  ~ong  other org~z~om,  to  for the aui.nued 
WOk 
improvement  in the dental  licenswe  process. 
4.	 FuU)CJt )gni=otf therepofis  emp~is  on i~es  of ~~ss,  we suggest m  the 
h~vy
reports dkcussioonn theissuoef qualiatnydtheprotection of the public could be 
strengthenIendp.t iculart,h eraer etworecenatr ticlneost,c iteidntherepmtwhich

suggestth att hecunentsystemh aslitiree
 l~on10 pilssing 
~suring  ~~ty  (i.e.,  board 
!dRs~  ftirly  axbitrary and everyone eventu~y  p~s=).  me  ~cles  are Clinical 
BoardExaminationVsa:t iatiFoonu nd in Pass Ram  by Damiano, Shugars~,d  FXWXL
 Mr. Bryan B. Mitchell

June 17, 1993

Page 2

in the June1992 issue of the Journai of the Arnetic~  Dental Association (JADA). 
The finding was asignificvaaxniattion in paSSrates within and among state and 
regional dental boiud clinical exsms during 1979-8& This suggests factors other than 
the abilities of candidates influence exam outwm~.  %=  inconsistencies should W 
ofconsiderambnlcee m tothepubliacn dtheprof~siowne   astheyunderminteh e

perceiveefdf ectivenoefstsh eboardtso protectth epublic.Th
esecond axticle is in
b  Iv@  1993 JADA by the Same SUthOrS,  Asmsing  Q~ty  in Dentistry: Dental
Boards, Peer Review Vary on Disciplinary Actions.  1his
 raisesquestions 
study 
aboutt heabfitoyf thepeerreview  functioansa 
system  and  ~  s- d~  bards  to 
consistennatt ionsayls temo fqualitays
surance.
5.	 We mmnmend  that the qort  *W  mo~  implications 
fUUy  the  po~tial  anti-trust 
foraXIXJUk!m~tth ats elvetso restrtih~e com~titiob~u td~  l,idme  ensurteh
 e
qualitoyf practitiownheorsw  eventuallliyc enseodrt heicro ntinuecdo
mpe

(page9s-
 10).

The Association  appreciates this  provide  these  ~mments.  please  call me or 
OppOrCU@  to 
Mr. ScotI Litch, AADS Legislative Counsel, should you have any questions. 
/ 
Proton  A. 1411eton,Jr., D.D.S., Ph.D. 
Executive Director 
Enclosure 
AADS Executive Committee 
cc:  American  hSOCidiOIi  of Dental  Schools 
Policy  Statement  on Licensuraend  Certification 
1.	 The American Association  of Dental Schools should cooperate with the ~erican  Dental 
Associatitoh~eA mericaDne ntaHly gienisAtsssociation  and the American  Association  of 
Dental Bxaminers to develop uniform standmds for Iicensure and credent.kdingthat would 
permit freedom in geographic mobility  for dendsts  and dental  hygienists. 
2.	 The Association  should  explore the medical-legal  and infection-control  liabilities  and the 
ethical  issues  associated  with the delivery  of care in clinical  entry-levei  board  examinations. 
3.	 The Association,  in cooperation  with  appropriate  organizations  and agencies,  should  ident@ 
the minimum  competencies  needed  by dental personnel to participate effectively in the delivery 
of health care. 
4.	 The Association,  both through  coopemtive  venturss  and on its own initiatives, should support 
the development  of valid and reliable  methods  that can be used nationally  to measure 
minimum competencies of dental personnel. 
5.	 The tksociati~  in cooperation  with  appropriate  agencies,  should exphne 
orgardzstions  and 
the development  of alternative  testing  meth~  and SUppOrtthe development  of appropriate 
demonstratpiroonj ecatnsd piloptrograms.

6.	 As a long-term  goal, the Association  recommends  eii~tion  of state  md 
regional  entry-level 
.

clinical licensuemx aminatiofnosrd entisatnsd dentahly gieniswthso are graduates of 
programs accredited by the Commimion on Dentai Accreditation,  and have succ.eddly 
completed  the National  Board Dental  Examinations  or the Natio~  Board  Dental Hygiene 
Examinations. 
7.	 The Association  supports the continual evaluation of tie  ~m~tenci=  of dentists and dental 
hygienists throughout their professional lifetimes. 
8.	 The !ADS  supports  the appointment  of qualified  dental hygienists  to all state  boards of 
dentistry  to participate  in the examina tion  of candidates  for dental  hygiene  licensure  and to 
serve  as full voting  and policy-making  members  in all matters  relating  to dental  hygiene. 
9.	 Successful  completion of a program approved by the Commissim  on Den~  Accreditation or 
the Canadian Dental Association  through its Councii on Educati~  should be a prerequkitc 
for eligibility  for the text.ifkation  exarnina tion of the Dental  Assisting  National  Board. 
10.  Dental laboratory technicians should be eligible for certification immediately following 
successfid completion of a program approved by the Cornmission on Dental Accreditation and 
the passing of the National Board of Certification Examination.  l)vo  Peachtree  Street	
Sixth  ??bor	
Atlanta,  GA 30303	
PRESIDE\T 
Phone:  (404) 657-2575	
E Joseph  Alderman.  DDS,  MPH

Office of Dental Heaich
 F~:  (404) 257-6631	
878 Peachtree St., NE R-215

June  7, 1993	
Atlanta  GA 30309

Phone  404/894.6684

Fax: 404/894-7799

PRESIDENT-ELECT 
Bryan B. Mitchell	
Richard  j. Hastreiter,  DDS,  MPH 
Minnesota Dept.  of Heaith
 Principal  Dep~  Inspector  Geneml	
717 Delaware SL, SE

Office  of Inspector  Genend	
Minneapolis.  ,MN 55440

Phone  612/ 623-5441
 Washington,  D.C.  21201	
Fax  612.623.5043

\7CE-PRESIDE!ST 
Dear Mr.  MitchelZ:	
Mark  D. Siegai.  DDS,  MPH

Division  of Dentai  Health

246 N. High  Street
 Zhank you for  the opportunity  to nspond  to the Office of Inspector 
P.O.  Box  118

Columbus,  Ohio  43266.0188
 Genend  drq/1  report,  The  Licensum  of  Out~f-State  Dentists. *  l%e 
Phone  614466-4i80

Association  of State and Territoti  Dental Directots  (ASZDD) is an ~~e 
Fax: 614/644.9650

of  the  Association  of  State  and  TehoM  HeaUh  Officials  (ASIZIO). 
SECRHARY.TRE.4SURER

.M. Dean  Perkins,  DDS
 Membership  is composed  of the Chief Den@  Officer  of the Depa~eti  of 
Bureau  of Dentai  Health
 HeaUh,  or  equivalent  public  health  agency  of  tie  states,  tenitones,  or 
P.(J  Box 570

Jefferson  Ciw,  Missouri  65101
 possessions  of  the  United  States.  ASTDD  considers  pollcies  or 
Phcme  314/751.6247

recommend~ons  of private  orpublic  agencies pe~ning  to omi and dental 
Fax  3i.$/i51-6010	
health,  and  adopts  policies  for  gutice  of  its  membem.  17zis mponse 
PAST  PRESIDENT

Robert  Isman,  DDS,  MPH
 represents  my opinion  and  expenence as AS~D  president  and diplomate 
Dentai  Heaith  Section
 of  dental  public  health,  one  of  the  eaghtAmerican  Dental  Association 
CA Dept.  ot Heaith  Serwicea

P.O.  Box 942732
 dental  speciahies.  Ilis  nport  is  not  necessmiiy  the  officihl  potion  of 
Sacramento,  C.+ 94234.7320

ASTDD,  but the I%recutive Committee  of ASlllD  has ~viewed  the mpoti. 
Phone  916,324.2230

Fax: 916. 324.7764
 State dental  ptvgmms  should aid in the ticensing  and credenmg 
DIRECTORS
 of  dentists.  For  example,  the  State  De&  Director  in the  Rhode  Island 
f3ev Enrw,sciti.  RDI-L MPH
 DeF=~ent  of He~fih ~en,es ~  the ~ai~enon  of the P&ode Island Boani 
Eirwr  Green.  DDS,  MPH

lack  Dillenberg.  DDS,  MPH
 of  Eraminem  in  Dentistry.  TM/s&  ws for  cootiitiion  of the  two  state 
\,FT,~SLETTFR  EDITOR
 entities,  and  increased  public  accountability.  It bnng access  to  care  and 
L Lonan  Davis,  D\{D,  MPH
 public  heaith to the foreftvnt  of discussions  that might  be considered  se~
I?cnd  Iicaith  Division

Bureau  oi Famdv  Hcdth  Services
 servingto pnvate pmcticing  dentists  or other  Weciai  interwt  grvups.  Most 
Sate  Otfict  i3uiidmg
 Board appointments  are made by the Governor fmm  dentists  recommend~  -
:34  i([}nroe  Street

Mt.ntgi+nicr:,  .+L 5613P  by  state  dental  associations.  However,  state  dental  prvgmms  are  hating
Phone:  205  Z.+2.5057 
mjor  problems.  A December  1992 ASZDD  Survey  indicated:  a.  10 (20qo) 
F4x: 2P5,2K-3097 
states have no state dental pmgmm;  b. 3 (6qo) stutes have dental p~g~$ 
but no director;  c. 32 (64%) states have a fuU tie  director;  and d. 5 (10%) 
states have apart  time director.  All state oti  hedh  pmgmms  must be able 
to  perform  the  core  functions  of  assessment,  poiicy  development,  and 
assumnce.  ASTDD  Letter:  B~an  B. Mitchell:  Page 2 
ASTDD  continues  to be concerned  about  the lack of access  to oml  heahh  serwces, and 
would suppott  methods  to increase  access  to care while ensunng quality  of care. Access  to care 
is a complex  issue.  Makiiistribu~onof dental  heailh  care wonkers is a problem  in many  stiztes 
including  Georgiu.  A public  health  license  by credentials  has helped  bnngpublic  hetdlh dentists 
to  Geo@a.  l%ik  has  helped  in  undememed  areas  and  institutions.  IZe  Gee@  Bo&  of 
Dentistry  now requires  dentists  with a public  health license to take the next available  Boani,  and 
this has inhibited  recnulment  of  public  heakh  dentists.  Fortunately  Georgia has started to accept 
the Southern Regional  Boanis  which should help with the decreased  numbem  of licensed dentists 
in our State. 
Specialky Boani  licensure  by cndentials  should  help,  (e.g.  Boani  qualified  or  cetified 
specialists  in good  standing  with their  Specialty  Boanis).  However  the present  method  in many 
states of requinng the clinical board and then the Specialty  help recmit  competent 
Boani  does  not 
dentists for the public  sector,  or vatius  specialties.  Speciidty licensure  must not be used to restrict 
competent piimary  care dentists  (i.e. geneml  dentists) fmm  providing  specially  services.  Ailhough 
the  majority  of dentists  and  the  American  Dental  Association  SUppOtt licensum  by cmdentibls 
many of the  decision  makers n both on State Boanis  of Dentistry  and State Dentlzl Associations 
remtunopposed. 
Even though you state  most applicants  pass the examinations  N@age 6), individuals  who 
attempt  the examinatM ns are a select group,  and do not include  many  expenenced dentists  who 
do not want to go through  the truuma of another  Boani. 
Ilere  may  be some  variations  in the  quality  of gmduates,  but in my opinion  a national 
clinical  board  should  be  explored.  If  the  National  Pmctitioner  Data  Bank  does  not  include 
necessary  information  about  disciplined  dentists,  the individual  state  boards  could be contacted 
prior to licensure  by credentials.  l%e example  of  one dental school dean who faled the clinical 
examination  three  times  @age  8) does  not significantly  strengthen  opposition  to  licensurz  by 
credentials.  Seveml  examples  of  the  most  clinically  competent  gmduates  fiuling  the 
examinations  can also  be found. 
A mqior injlux  Rf out-of-state  applicants forthepopuiution  grvwth  states shouki eventually 
be soheti ~  supply  and demand,  not by examinations  restn-ctions. 
If dentistry  is concerned  about quality of dentists,  some periodic  assessment  of competency 
should  be established.  It might  be helpful  to compare  how  the phymctins handle  licensum  by 
credentials  and quahly  of care issues,  especially  in  isohzted prnctices  (e.g.  nmzl).  It is interest?ng 
that  once  licensed,  one  can pmctice  forever.  n Monitoring  ail physlcal and  mental  disabilitie~  
(e.g. impaired  vision)  cannot be expected to be handled by ovenvorked  Eramining  Boards as they  -
are currently  configured.  Licensure  by credentis,  in conjunction  with a n@onal clinical  exam, 
would allow state  boanls  to focus  on more  important  issues like inve~g~ng  compkzints against 
and apprvptiely  discipline  licensees,  or contznuedcredentialing  past  initial  licensure. 
Continuing  education  does not ensure quality  care.  Many pmctitioners  take courses they 
like,  mther  than courses  they need. Assessment  of what a dentist  actu~ly  learned fmm  a course 
(e.g.  knowledge),  does  not necessady  tmnshte  into changes  in pmctice  or attitude.  ASTDD  Letter:  Bryan  B.  Mitchell:  Page 3 
Although the present  growth and acceptance  of regional boanis is to be commended,  a twi 
licensure  by  credentials  could  ensure  quality  of  cam,  and  help  provide  access  to  - in 
undemewed  areas.  Re@onal Boanis  could  begznto form  a  national  clinical  euun  by  u~g 
exiting regional boards.  However,  licensure by cnde&  orfinancing  thrvugh public  orprivate 
insumnce  does  not  guamntee  access  to  onzl  hedh  cam.  other  barnem to  access  include 
economic,  geogmphic  (nmzl,  tmnsients,  migmnts),  cultuml,  and  educational,  as  weg  as 
individuals  who are institutionalized,  homebound,  or have handicapping  conditions. 
I hope this information  is helpful  in your  delibemtions  concerning  licensum  of dentists. 
Xhe licensure  and shoriage  of dental hygienists  is another  issue that  shouhi be addressed. 
ASZDD and ASTHO  are working to establish a National  Oral HeaUh Agendh. ASZDD is an active 
member  of the  Coalition  for  Oml  Health  and strongly  SUppOtiSthe  inclusion  of oml  health  in 
heakih care reform.  We believe  that ASZDD  cooperation  and collizbomtion  with  fede~  state, 
and local agencies,  the pnvate sectom of dentistry  and dental hyglene, and oml  hedh  advocates 
is the key to ensunng that  eve~one  can enjoy good  oral health  and an enhanced  quality  of we. 
If I or this organization  can be of any futther  assistance,  please  let me know. 
Sincerely, 
E. Joseph  Alderman,  DDS,  MPH 
President,  Association  of State 
& Ternloti  Dental  Directonr 
EJA/ja 
cc:	 ASTDD  Erecutive  Committee 
AS1HO Executive  Director  APPENDIX  D	
ENDNOTES 
1.	 American  Dental  Association,  Report  of the Divkion  of Education:  Dental 
Licensure,  April  1992. 
2.	 The  American  Association  of Dental  Schools  (AADS)  has  also addressed  the 
licensubryec redentiiaslssu eO.f  particulnaort eisa 10-par1t9
 91policy
statemen(tp resenteidna ppendiCx  ofthirse port)I.t callfso
 rAADS to

cooperatien effortstod evelopu niforms tandardfso rlicensuarned
 

credentialtihnagtw ouldpermitf reedomingeographimco bilitfyo rdentisatnsd
 

dentahly
 gienists.

3.	 Charles  R. E. Koch,  cd., H&to~  of Dental  Su~e~,  Vol.  1, (Chicago:  The 
National  Art  Publishing  Co.,  1909), p. 691. 
4.	 According  to the  American  Dental  Association,  during  the  years  between  1987 
and  1993, 16 States  authorized  their  dental  boards  to grant  licensure  by 
credentials:  ~  AR,  CT,  GA  IL  KY, ~  NJ, OH, SC,  SD, TX,  Vi  WA 
WI, and  WY.  One  State  board  which  did not  exercise  its authority  in 1987 did 
SOby 1993: ND. 
Three  States,  the  ADA  reports,  moved  in the  opposite  direction  by removing 
the  authority  to grant  licensure  by credentials:  RI, TN,  and  VT.  And  three  of 
the  State  boards  with  newly acquired  authority  have yet  to  exercise  it:  GA  SC, 
and  VA. 
on  balance,  the  number  of State  boards  that  grant  licensure  by credentials 
increased  by eleven  between  1987 and  1993.  See  appendix  A. 
5.	 See  American  Dental  Association,  Report  of the Division  of Education:  Dental 
Licensure,  April  1992, pp.  436-41. 
6.	 Indeed,  in a number  of States  that  do not  grant  licensure  by credentials,  most 
of their  licensees  are  graduates  of out-of-State  dental  schools. 
7.	 An American  Dental  Association  report  describes  the  process  as follows: 
Location  of patients  for examination  in another  state  or distant  city is one  of 
the  most  difficult  parts  of the  examination  process.  The  patients  have  to have 
the  required  oral  problems,  and  they have  to be willing to undergo  a long and 
demanding  series  of procedures.  They  have  to be cooperative,  patient  and 
D-1
 neutralT.h eyhavetobepreparetdo receivter eatmentth
atmaynotbeatan

acceptablleev el.Se eAmericanDentalA ssociatiRoenp,o
ti  of the Division  of 
Education:  Dental  Licensure,  April  1992, p. 429. 
8.	 A  recent  article  reporting  significant  variation  within  and  among  state  and 
regional  dental  board  clinical  examinations  seems  to support  the  point,  as the 
authors  suggest,  that  factors  other  than  the  ability  of the  candidates  influence 
exam  outcomes.  See Peter  S. Damiano,  Daniel  Shugars,  and  James  Freed, 
Clinical  Board  Examinations:  Variations  Found  in Pass Rates,  Journal  of the 
American  Dental Association  128 (June1992)7:2.

9.  See  SusanE.Lovelace,S tateDsi videdJ,ournal  of the Cahfomia  Dental 
Association  16 (February  2, 1992): 21. 
10.	 The Statewse reCalifornFilao,r idNao,r thCarolinTae,x as,a ndWashington.

SeeAmericanDentalAssociatioRne,p orto ftheSpeciaClommitteetoStudy

FreedomofMovementandLicensurIes suesA,DA
  Annual  Repotts,  1989. 
11.	 Such  doubts  were  expressed  by representatives  of State  dental  boards  that  grant 
licensure  by credentials  as well as those  from  States  that  do not.  In fact,  many 
in the  former  group  of representatives  were  quite  sympathetic  to the  reasons 
advanced  by the  latter  for not  granting  licensure  by credentials. 
12.	 In our  survey  of the  State  dental  boards  we asked  for  information  on the 
number  of licensure  applications  and  the  number  of licenses  granted  in 
calendar  year  1991 or the  fiscal year  ending  in 1992.  The  great  majority  of the 
boards  provided  this information.  However,  few provided  information  in 
response  to our  questions  concerning  whether  or not  those  applying  for a 
license  and  those  receiving  one  held  a dental  license  in another  State. 
For example,among thesevenStatesl eadintgh enationinpopulatiognr owth
inthe1980so,n lytheNorthCarolinbao ardansweredthesequestionsI.t 
indicatetdh at34 percento fits144licensuraep plicantisn 1991alreadhyelda 
licensienanotherStateandthat17percenthaddonesoformore than5years. 
Among the121individuaglrsa nteda dentallicensien1991,35percentalready 
helda licensien anotherState--lp6ercentformore than5 years. 
13.	 Here  again,  many  among  the  dental  board  members  we spoke  with who came 
from  States  granting  licensure  by credentials  were  sympathetic  to this point  of 
view. 
14.	 See  Preston  A. Littleton,  Jr.,  Educating  Dentists  for the  Future,  in Human 
Resources for Health:  Defining  the Future,  C. McCollister  Evarts,  Peter  P. 
Bosomworth,  and  Marion  Osterweis,  eds.,  (Washington,  D. C.: Association  of 
Academic  Health  Centers,  1992), p.  142. 
D-2
 15.	 American  Dental  Association,  The1991Survey  of Dental  tiactice:  General 
Charactetitics  of Dentists,  April  1992, p. 2. 
16.  See  Littleton,  p.  142. 
17.	 The  American  Dental  Association,  American  Association  of Dental  Examiners, 
American  Association  of Dental  Schools,  and  other  major  dental  organizations 
provide  support  for this contention.  In making  the  case  for the  funding  of a 
proposal  to develop  interactive  computer-based  patient  simulations,  they point 
out  the  following: 
Dental  practices  generally  are  not  reviewed  by external  organizations, 
nor  are  they  required  to participate  in systematic  quality  assurance 
activities.  Assessments  of provider  competency  are  limited  to a one-time 
state  or regional  examination  prior  to being  granted  a license  to practice 
general  dentistry. 
See  Dental  Interactive  Simulations  Corporation,  Conzputer-llased  Simulations  in 
Dent&try, a grant  application  developed  and  submitted  by the  Dental  Interactive 
Simulations  Corporation,  undated,  p.  14. 
18.	 In recognition  of this situation,  the  W. K  Kellogg  Foundation  in 1982 funded 
Alvin  Morris  and  other  researchers  at the  University  of Pennsylvania  to 
develop  new methods  and  technologies  that  can be  used  by individual  dentists 
and  the  dental  profession  to  assess the  effectiveness  and  efficiency  of the  full 
scope  of dental  practice.  This  ambitious  effort  resulted  in the  development  of 
an assessment  instrument  which  a trained  team  of evaluators  used  to conduct 
l-day  on-site  assessments  of a national  sample  of 300 dentists  who volunteered 
to participate.  The  project  generated  many  articles,  but  to this point  little 
sustained  follow-up.  See Alvin  L. Morris,  J. Marvin  Bentley,  Anthony  A. Vito, 
and  Marguerite  R. Bombs,  Assessment  of Private  Dental  Practice:  Report  of 
Study, Journal  of the American  Dental Association  117 (July  1988):  153-162. 
19.	 American  Dental  Association,  State Dental  Board  Continuing  Education 
Requirements  for Dentists, August  1992. 
20.	 We  sought  data  from  the  regional  testing  agencies  and  from  the  States  that 
conduct  their  own clinical  examinations  to determine  the  proportion  of 
applicants  passing  the  examination--distinguishing  out-of-State  applicants  who 
had  been  practicing  for more  than  five years  from  other  applicants.  However, 
the  data  we obtained  were  extremely  limited  and  insufficient  to offer  any 
generalizations  on the  proportions  passing  the  examinations.  Such  data  could 
add  some  valuable  information  to discussions  of the  pros  and  cons of licensure 
by credentials. 
21.	 American  Dental  Association,  State Dental  Board Continuing  Education 
Requirements  for Dentists, August  1992. 
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 22.	 H. Barry  Waldman,  Reciprocity:  Why Doesnt  Someone  Try this  Idea, 
Compendium  of Continuing  Education  in Dent&try XII  (November  1991): 86. 
23.	 See  U.S.Department  of Health  and  Human  Services,  Public  Health  Service, 
Sixth Repoti  to the ??esident and  Congress on the Status  of Health  Personnel  in 
the  United States,  March  1988;  U.S. Department  of Health  and  Human 
Setices,  Public  Health  Service, Health  1+-ofessionalShortage Areas,  July 7, 1992; 
and  American  Association  of Dental  Examiners,  Composite,  1991 edition. 
24.	 Particulanroltya blien thirse gardi sthepublicatiboynt heAmericanDental
Associatiaonnd theAmericanAssociatioofnD entalExaminerisn May 1992of
theGutielines  for  Valid and Reliable  Dental  Licensure  Clinical  Examination.r. 
25.	 Sally T. Sonnefeld,  Daniel  R. Waldo,  Jeffrey  A. Lemieux,  and  Daniel  R. 
McKusik,  Projections  of National  Health  Expenditures  Through  the  Year 
2000, Health  Care Financing  Review  13 (Fall  1991): 22. 
26.	 U.S. Department  of Commerce,  Bureau  of the  Census,  Statistical  Abstract  of the 
United States,  1992, Table  160, p.  109.  Based  on data  supplied  by American 
Dental  Association,  Bureau  of Economic  and  Behavioral  Research.  Further,  it 
is relevant  to note  that  many  who are  in need  of dental  care  are  not  receiving 
it, with the  result  that  neglected  oral  diseases  are  widespread.  See  Myron 
Allukian,  The  Presidents  Column:  The  Neglected  American  Epidemic,  The 
Nations  Health,  (May-June  1990). 
27.	 In a recent  article  addressing  quality  assurance  in dentistry,  Damiano  et al. 
note,  The  effectiveness  of continuing  education  as it currently  exists has  never 
been  adequately  demonstrated.  See  Peter  C. Damiano,DanielA.  Shugars, 
and  James  R. Freed,  Assessing Quality  in Dentistry:  Dental  Boards,  Peer 
Review  Vary  on Disciplinary  Actions, Journal of the American  Dental 
Association  124 (May  1993):  130. 
28.	 Dental  Interactive  Simulations  Corporation,  Computer-Based  Patient 
Simulations  in Dentist)y,  a grant  application  submitted  by the  Dental 
Interactive  Simulations  Corporation,  undated,  p.  10. 
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