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 

I AUGUST Igg3 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. 
--

b The core argument in opposition to licensure by credentials is that it fails to 

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 

{ TABLE 1

/, ‘1THE 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 Delegatespassesa 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 dentist’s 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 ADA’s 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 ADA’s


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 innercity 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 Medicine’s 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 President’s 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 still impose various requirements on 

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 dentist’s 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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FULLY DO NOT EXERCISE K 

7 EXERCISE AUTHORllY 1S HAVE NO 

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Sculax krm?lGmchmiAswddxl ml OtRad!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. 

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 1980’s. 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

‘I’he 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 board’s


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 dentist’s 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 board’s 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-bycase review of a candidate’s qualifications and rely upon a standardized examination to 

help them assess a candidate’s 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 examination’s limitations as a


competency assessment tool, it affords some basis for determining a dentist’s 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 year 25I“t is 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 ADA’s 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 1980’s 

(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 Amen”can 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 ASTDD’S 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


!SI’ATE DENTAL BOARD AUTHORITIESANDPRACI’K33IN GRANTING 

LICENSUREBYCREDENTIALS TOOUT@F-STATECANDIDA= 1987AND1993

BOARD ~ AUTHORITY TO GRANT LICENSURE 

BY CREDENTIALS 

BOARD EXERCISES* ITS

AUTHORITY 

BOARD BOARD 

AUTl+ORITY AUTHORITY 

EXTENDS TO LIMITEDTO


CANDIDATES CANDIDATES


FROMALL FROM STATES


STATES WITHSIMILAR


PRACTICES


STATE 1987 1993 1987 1993


AL


AK x


Az


AR x


CA


co


CT x


DE


DC x x


FL


GA


HI


ID


IL x


IN x x


IA x x


Ks x x


KY x


IA x


ME x x


BOARD HAS 

~ 

BOARDHASNOT AUTHORITY 

EXERCISED ITS TO GRANT 

AUTHORITY LICENSURE 

BY 

CREDENTIALS 

1987 1993 1987 1993 

x x 

x 

x x 

x 

x x 

x x 

x 

x x 

x x 

x x 

x x 

x x 

x 

x 

x 

A-1

~ATE DENTALBOARDAUTHOIUTIESANDPRACIKESINGRANTING 

IKENSUREBYCREDENTIALS ~ OUT~F~ATE Cu4NDB3AT’Ek 1987AND1993

BOARD ~ AUTHORITY TO GRANT LICENSURE 

BY CREDENTIALS 

BOARD EXERCISES” ITS

AUTHORITY 

BOARD BOARD 

AUTHORITY AUTHORITY 

EXTENDS TO LIMITEDTO 

CANDIDATES CANDIDATES 

FROMALL FROMSTATES 

STATES WITHSIMILAR 

PRACTICES


STATE 1987 1993 1987 1993


MD x x


MA x x


MI x x


MN x x


MS


MO x x


MT


NE x x


Nv


NH x x


NJ x


NM


NY x x


NC


ND x


OH x


OK x x


OR


PA x x


RI x


Sc


SD x


TN x


BOARD HAS 

~ 

BOARDHASNOT AUTHORITY 

EXERCISED ITS TO GRANT 

AUTHORITY LICENSURE 

BY 

CREDENTIALS 

1987 1993 1 1987 ! 1993


, x x


x x


x x


x


x x


X1X


x


I xl


x x


x


I


x x


x


x


A-2

....

~ATE DENTALBOARDAUTHORITIESANDPRACIXESINGRANTING 

LICENSUREBYCREDENTIALTOOUT~F-SI’ATECANDIDA~: 1987AND1993 

BOARD ~ AUTHORITY TO GRANT LICENSURE 

I 

I 

STATE 

m


UT


VT


VA


WA


w


WI


WY


TOTALS


BY CREDENTIALS 

BOARD EXERCISES* ITS

AUTHORITY 

BOARD BOARD 

AUTHORITY AUTHORITY 

EXTENDS TO LIMITEDTO

BOARDHASNOT 

EXERCISEDITS 

AUTHORITY 

CANDIDATES CANDIDATES 

FROMALL FROMSTATES 

STATES WITHSIMIL/iR

I PFLKTICES 

1987 1993 1987 1993 1987 1993 

x 

x 

lx 

x 

x 

BOARD HAS 

~ 

AUTHORITY 

TO GRANT 

LICENSURE 

BY 

CREDENTIALS 

1987 I 1993 

lx 

x I 

x I 

X1X 1 

x I +--

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 

REQUIREMENT 

Active practice within former State immediately 

preceding application 

Board in former State must attest that the 

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 

Affidavits or letters from practicing dentists 

regarding moral character 

Good moral character 

Physician’s statement of physical and mental 

health 

Intends to establish mactice 

NUMBER OF 

STATES 

REOUIRING 

24 

20 

14 

8 

6 

3 

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 

B. Wayne J. h 

2928HmniiIm~ 

sjouxc~, IA 51104 

(712) 2ss-7607 

Dr. Jd F. GJuvcr 

w-w 

Rmo. NvS9509 

(’702)S2S-2417 

FIRsTwm+mmmr 

Dr. Iiliiml
 KBadam

3oEaaaktlsuca 

New Yak NYloo22 

(~12)7554125 

SECOND vm3-mEsmNr 

Dr. Km c C-ICY 

440 BrtYdsL 

cohdliLMs 39429 

(@Ii)73&1761 

lnmDvmwsmmw 

t&. Hany
RDoIwuI

2860 PiakunKAvc=Ic 

Lhlhuh. MN55811 

(218)7224823 

MMmnATE Pm HmlKmrr 

l)r. wT. RwiI 

475 Mallard AvaxIc 

Abmul? s@ga. FL 32701 

(407)831-1747 

FxEamvEDIREcNx


MLMdty Nder 

2111LChiCJg0 AVCaUIC 

ChiagO,%?il% 

(312)440-7464 

Dr. Kuhka Kth’ 

u E Mifflia StruI 

Suiac204 

~ WI53703 

(60s)2xw45KJ 

Mr. Bryan B. Mitchell


Principal Deputy Inspector General


Off ice of Inspector General


Department of Health & Human Services


Washington, DC 20201


Dear Mr. Mitchell: 

Thank you for giving the American Association of


Dental Examiners an opportunity to comment on the


draft report “The Licensure of Out-Of-State


Dentists”.


The report concludes that “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 .“


As regards the “questionable performance of manY 

State dental boards” it 1S clear that the lack of 

sufficient funding is the principle reason for 

enforcement difficulties. 

In addition the report states “If 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 .“ This is likely to follow closely


on the heels of continuing competency programs.


The AADE agrees that continued competency should 

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 Committee’s 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 General’s 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 IG’s 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 competency”of @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


Association’s 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, ADA’s 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 

supports the overall trend noted i.n your report: 

more states ~ adopting licensure by credentials 

of 1993 

more and 

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 Credentials but just as firmly supports the rightof 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&’’lj’lj~DD~ . � . . Executive Director 

JSZ/MKL 
PRESIDE\’T 

Ii ]osePh Alderman. DDS, MPH


Office of Dental Heaith


878 Peachtree St., NE R-215


Atlanta GA 30309


Phone 404/894.6684


Fax: 404/894-7799


PRESIDENT-ELECT


Richard j. Hastreiter, DDS, MPH


Minnesota Dept. of Heaith


717 Delaware SL, SE


Minneapolis. ,MN 55440


Phone 612/ 623-5441


FaJC 612.’623.5043


\TCE-PRESIDE!ST


Mark D. Siegai. DDS, MPH


Division of Dentai Health


246 N. High Street


P.O. Box 118


Columbus, Ohio 43266.0188


Phone 614’466-4i80


Fax: 614/644.9650


SECRETARY.TRE.4SURER


.M. Dean Perkins, DDS


Bureau of Dentai Health


P.0. Box 570


Jefferson Ciw, Missouri 65101


Phcme 314/751.6247


Fax 3i.$/i51-6010


PASTPRESIDENT 

Robert Isman, DDS, MPH


Dentai Heaith Section


CA Dept. ot Heaith Serwicea


P.O. Box 942732


Sacramento, C.+ 94234.7320


Phone 916,324.2230


Fax: 916.’ 324.7764


DIRECTORS 

B,. Enrw,sciti. RDI-L MPH 

Eirwr Green. DDS, MPH 

lack Dillenberg. DDS, MPH 

\, F1,~SLETTFR EDITOR 

L ~onan Davis, D\{D, MPH 

I?cnral Iicaith Division 

Bureau oi Famdv Hcaith Services 

Sate Otfict i3uiidmg 

:34 i([}nroe Street 

Mt.ntgt+nicr:, .+L 5613P 

Phone: 295 ‘Z.+2.5057 

F4x: 2P5,’2K-3097 

l)vo Peachtree Street


Sixth ??bor


Atlanta, GA 30303


Phone: (404) 657-2575


F~: (404) 257-6631


June 7, 1993


Bryan B. Mitchell


Principal Dep~ Inspector Geneml


Office of Inspector Genend


Washington, D.C. 21201


Dear Mr. MitchelZ:


Zhank you for the opportunity to nspond to the Office of Inspector 

Genend drq/1 report, The Licensum of Out~f-State Dentists. ” l%e 

Association of State and Territoti Dental Directots (ASZDD) is an ~~e 

of the Association of State and TehoM HeaUh Officials (ASZEIO). 

Membership is composed of the Chief Den@ Officer of the Depa~eti of 

HeaUh, or equivalent public health agency of tie states, teniton”es, or 

possessions of the United States. ASTDD considers pollcies or 

recommendah”ons of private orpublic agencies pe~”ning to omi and dental 

health, and adopts policies for gutice of its membem. 17zis mponse 

represents my opinion and expen”ence as AS~D president and diplomate 

of dental public health, one of the ea”ght American Dental Association 

dental speciahies. Ilis nport is not necessmiiy the officihl potion of 

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

State dental ptvgmms should aid in the ticensing and credenmg 

of dentists. For example, the State De& Director in the Rhode Island 

DeF=~ent of He~fih ~en,es ~ the ~ai~enon of the P&ode Island Boani 

of Eraminem in Dentistry. 71iis & ws for cootiitiion of the two state 

entities, and increased public accountability. It bn”ng access to care and 

public heai’th to the foreftvnt of discussions that might be considered se~­

servi”ngto pn”vate pmcticing dentists or other Weciai interwt grvups. iUOst 

Board appointments are made by the Governor fmm dentists recommend~ -

by state dental associations. However, state dental prvgmms are hatingm@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 omJ hedh pmgmms must be able 

to perform the core functions of assessment, poiky development, and 

assumnce. 
ASTDD Letter: B~an B. Mitchell: Page 2 

ASTDD continues to be concerned about the lack of access to oml heahh serw”ces, and 

would suppott methods to increase access to care while ensun”ng 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 bn”ngpublic 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). However the present method in many 

states of requin”ng the clinical board and then the Specialty Boani does not help recwit competent 

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 

remtu”nopposed. 

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 expen”enced 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 fa”led the clinical 

examination three times @age 8) does not significantly strengthen opposition to licensurz by 

credentials. Seveml examples of the most ‘clinically” competent gmduates fiu”ling the 

examinations can also be found. 

A mqior injlux Rf out-of-state applicants forthepopuiution grvwth states shouki eventually 

be soh’eti ~ 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 phym”ctins 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 physl”cal 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 contz”nuedcredentialing 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 begz”nto form a national clinical euun by u~g 

exiti”ng regional boards. However, licensure by cnde& orfinancing thrvugh public orprivate 

insumnce does not guamntee access to onzl hedh cam. other barn”em 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 pn”vate sectom of dentistry and dental hygl”ene, and oml hedh advocates 

is the key to ensun”ng 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 

AS1’HO 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. 

For example,among thesevenStates leading thenationinpopulation
 growth


inthe1980’s, onlytheNorthCarolina boardansweredthesequestions.
 It 

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 

I AUGUST Igg3 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. 
--

b The core argument in opposition to licensure by credentials is that it fails to 

offer adequate assurance of the competency of the out-of-State dentists seeking 

licensure. 

The clinical examination which22 States require ofout-of-state dentistsseeking


licensure providesa checkon thecontinued competencyofpracticing dentists.
 But


theseStates do notapplytherequirement oranysimilar assessment
ofcompetencyto


dentists already practicing within their
borders.


The examina tionrequirement canimpedeefforts torecruit individual dentistswilling 

tolocate in underserved areaswithin theStates.Yet we foundno da@ norany


studi+ tosupporta contention thatithasmuch overall
 bearingon accesstodental 

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 

{ TABLE 1

~, ‘1THE 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 dentist’s 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 ADA’s 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 ADA’s


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 innercity 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 dentalboards.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 Medicine’s 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 President’s 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 still impose various requirements on 

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 dentist’s 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. 

They areconcentrated intheSouthand West and include
sixoftheseven


States leading thenationinpopulation
 growthbetween1980and 1990.


�	 In 19oftheseStates, thedentalboardhasno authority toprovidelicensure by


credentials; in3 ithastheauthority butdoesnotexerciseh.


The 22 States that do not grant Iicensure by credentials represented the major growth 

areas of the country in the 1980’s. 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: 

� presents minimalriskbecauseofthedisciplinaryction clearinghouses
 runby 

theNational Practitioner Data Bank (NPDB) and AAD~ and


�	 rests on a baseofposhiveexperiences inStates 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 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

‘I’he coreargumentinopposition to liccnsure by credentials is thatitfadstooffer 

adequateassurance ofthecompetencyofout-of-State dentists seekinglicensure.


Supporting
 argumentsarethat:


�	 theNPDB and AADE clearinghouses have limited information and can not 

compensate for the inadequate enforcement efforts of some State dental 

boar(ky and 

� theclinical licensure examination requirement isa vital safety valve, especially


forStates towhichlargenumbersofdentistsseektomove.


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


advocates are seeking is “licensure by convenience,” without regard for a board’s


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 dentist’s 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 board’s 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-bycase review of a candidate’s qualifications and rely upon a standardized examination to 

help them assess a candidate’s 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 ationwhich22 States require ofout-of-State dentistsseeking 

licensure providesa checkon thecontinued
competencyofpracticing dentists. But

these States do notapplytherequirement oranysimilar assessment
 ofcompetencyto 

dentists already practicing within theirborders.


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 examination’s limitations as a


competency assessment tool, it affords some basis for determining a dentist’s 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 which22 States require ofout-of-State dentists seeking licensurecan


impedeefforts torecruit individual dentists willing tolocate inunderserved
 areas 

within theStates.Yet we foundno da@ norany studies, to support a ccmtention that 

ithas much overallbearingon accesstodentalcareintheseareas.


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 year 25I“t is 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 

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 ADA’s 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 1980’s 

(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 

remainsquestionable. 27 lna proposal seeking funding forcomputer-based
 patient


simulations, themajornational dentalorganizations, including
 ADA note:“Itk


widelyagreedthata majorweaknessinmandatorycontinuing education
requirements


k thatfrequently therek little rlationship betweenthecontinuing education
activity


and theprofessional development needsoftheindividual.”%
 The ASTDD, inits 

commentson this report, reinforces this pointby noting:
“Nfany 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 Amen”can 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

ourtext, and didnotaddress theantitrust implications
 -mainlybecausetheywould


call
forjudgmentsby theFederalTradeCommission.


The ASTDD’S 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


!SI’ATE DENTALBOARDAUTHORITIES ANDPRACI’I(3?SIFlGI?ANllNG 

LICENSUREBYCREDEFITIAM TOOUT@F-STATE CANDIDATE!l1987AND1993

BOARD ~ AUTHORITY TO GRANT LICENSURE 

BY CREDENTIALS 

BOARD EXERCISES* ITS 

AUTHORITY 

BOARD 

AUTl+ORITY 

EXTENDS TO 

CANDIDATES 

FROM ALL 

STATES 

STATE 1987 1993


AL


AK x


Az


AR x


CA


co


CT x


DE


DC


FL


GA


HI


ID


IL x


IN x x


IA x


Ks x x


KY


IA x


ME x x


BOARD 

AUTHORITY 

LIMITED TO 

CANDIDATES 

FROM STATES 

WITH SIMILAR 

PRACTICES 

1987 1993 

x x 

x 

x 

BOARD HAS NOT 

EXERCISED ITS 

AUTHORITY 

1987 1993 

x 

BOARD HAS 

~ 

AUTHORITY 

TO GRANT 

LICENSURE 

BY 

CREDENTIALS 

1987 1993 

x x 

x 

x x 

x 

x x 

x x 

x 

x x 

x x 

x 

x x 

x x 

x 

x 

x 

A-1

~ATE DENTALBOARDAUTHORITIESANDPRAmCES IN GRANTING 

LICENSURE BYCREDENTIALS ~ 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 DENTALBOARDAUTHOIUTBZj ANDPRA(THCES INGIIANTTNG

LI(3ZNSUREBYCREDENl%UJjTOOUT~F~ATE CANDIDA~: 1987AND1993 

BOARD ~ AUTHORITY TO GRANT LICENSURE 

BY CREDENTIALS 

I 

BOARD EXERCISES* ITS 

AUTHORITY 

I 

BOARD BOARD 

AUTHORITY AUTHORITY 

EXTENDS TO LIMITED TO 

CANDIDATES CANDIDATES 

FROM ALL FROM STATES 

STATES WITH SIMIM.R 

I PFLKTICES 

STATE 1987 1993 1987 1993 

m x 

UT 

VT x 

VA 

WA x 

w 

WI x 

WY x 

TOTALS 11 

........... ....... 

BOARD HAS NOT 

EXERCISED ITS 

AUTHORITY 

1987 1993 

lx 

BOARD HAS 

~ 

AUTHORITY 

TO GRANT 

LICENSURE 

BY 

CREDENTIALS 

1987 I 1993 

lx 

x I 

x I 

X1X 1 

I +--

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 

REQUIREMENT 

Active practice within former State immediately 

preceding application 

Board in former State must attest that the 

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 

Affidavits or letters from practicing dentists 

regarding moral character 

Good moral character 

Physician’s statement of physical and mental 

health 

Intends to establish mactice 

NUMBER OF 

STATES 

REOUIRING 

24 

20 

14 

8 

6 

3 

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 

B. Wayne J. h 

2928HmniiIm~ 

sjouxc~, IA 51104 

(712) 2ss-7607 

Dr. Jd F. GJuvcr 

w-w 

Rmo. NvS9509 

(’702)S2S-2417 

FIRsTwm+mmmr 

Dr.Iiliiml KBadam 

3oEaaaktlsuca 

New Yak NYloo22 

(~12) 7554125 

SECOND vm3-mEsmNr 

Dr. Km c C-ICY 

440 BrtYdsL 

cohdliLMs 39429 

(@ii) 73&1761 

lnmDvmwsmmw 

t&.HanyRDoIwuI 

2860 PiakunKAvc=Ic 

lhlhuh. MN 55811 

(218) 7224823 

MMmnATE Pm mmlumrr 

l)r. wT. RwiI 

475 MaMad AvaxIc 

Ablxul? s@ga. FL 32701 

(407) 831-1747 

FxEamvEDIREcNx 

ML MdtyNder 

2111LChiCJg0AVCaUIC 

ChiagO, %?il% 

(312) 440-7464 

Dr. Kuhka Kth’ 

u E Mifflia StruI 

Suiac204 

~ WI 53703 

(60s) 2XW45EJ 

Mr. Bryan B. Mitchell


Principal Deputy Inspector General


Off ice of Inspector General


Department of Health & Human Services


Washington, DC 20201


Dear Mr. Mitchell:


Thank you for giving the American Association of


Dental Examiners an opportunity to comment on the


draft report “The Licensure of Out-Of-State


Dentists”.


The report concludes that “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.“


As regards the “questionable performance of manY 

State dental boards” it 1S clear that the lack of 

sufficient funding is the principle reason for 

enforcement difficulties. 

In addition the report states “If 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 .“ This is likely to follow closely


on the heels of continuing competency programs.


The AADE agrees that continued competency should 

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 Committee’s 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 General’s 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 IG’s 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 

Association’s 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 consideration 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 

report’s 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.ols”and o~,~to focus constrictively on the issue of


continued competency”of @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


Association’s 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 regulatory 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, ADA’s 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


supports the overall trend noted in your report:


more states ~ adopting licensure by credentials


of 1993 

more and 

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 credentials 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, particularly 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&’’lj’lj~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 

Principal ~puty Inspector
 General


202.6679433 Office oftheInspector
 Genexal


Department ofHealth
andHuman


Services


Washington,
 D.C.20201


Dear Mr. Mitchell: 

on behalf oftheAmerican
Association of Dental SChOOls(AADS), we appreciate the 

Opportunityto review the ~ ~pector Gene@’s Repo~ ‘“me Lice= of Out-of-Stilte 

Dentists.” 

FirsL we compliment you, Dr. Ma.ricyessi~ M~a Kv@, ~d other ~ fim the Boston 

R@OIl~ office on the development of this K!po~ ~dq the Association WN pleased 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,line 4 ofthefirst full
paragmpkThishe sho~dbeedi~ toreadasfollows:
 ,,


,... taking theexaminati on andfinding patien~ who will bepart
oftheexaminatiOrL”


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 p~ents for the examinatiorl. 

3.	 Page 2,Table1,Significant Actions: we su~est M tie ~on u&em by the AADS 

House of Delegates in 1991 to update @ ~is~ the Association’s policy on dental 

licensure be cited in this Table. A COpyof the MS policy s~tement is enclosed. 

The inchsion of the AADS policy will give -r Unde-ng ~d jusl.ifi~rion to the 

report’s Iwcmlmendation found in the wnc~usion (page 11) ~ e~ewhere th~ W fOrthe 

American Association of Dental Schoois, ~ong other org~z~om, to WOk for the aui.nued 

improvement in the dental licenswe process. 

4.	 FuU)J Ct)gni=t oftherepofi’s h~vy emp~is on i~es of ~~ss, we suggest m the 

report’s dkcussiontheissue ofqualityandtheprotection of the public could be 

strengthened. Inpticular, there aretworecent articles, notcitedintherepmtwhich


suggest thathecunentsystem haslitie
 rel~on10~suring ~~ty (i.e., board pilssing 

!“dRs~ ftirly axbitrary and everyone eventu~y p~s=). me ~cles are “Clinical 

BoardExaminations: Vatiation Found 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 a significant vaxiation in paSSrates within and among state and 

regional dental boiud clinical exsms during 19’79-8& This suggests factors other than 

the abilities of candidates influence exam outwm~. %= inconsistencies should W 

ofconsiderable mncem tothepublic andtheprof~sion we astheyundermine the


perceivedffectiveness oftheboards toprotect thepublic.”
 Thesecond axticle is in

b Iv@ 1993 JADA by the Same SUthOrS, “Asmsing Q~ty in Dentistry: Dental€

Boards, Peer Review Vary on Disciplinary Actions.” “’1’’his
 study raises questions 

about theabfity ofthepeerreview system and ~ s- d~ bards to function asa

consistent naional system ofquality
 assurance.”

5.	 We mmnmend that the qort *W mo~ fUUy the po~tial anti-trust implications 

fora XIXJUk!m~t that selves torestri~ thecom~titio~ butd~ l,ide m ensure
the

quality ofpractitioners who w eventually licensed ortheir continued
 compe­


(pages
9-10).


The Association appreciates this OppOrCU@ to provide these ~mments. please call me or 

Mr. ScotI Litch, AADS Legislative Counsel, should you have any questions. 

/ 

Proton A. 1411eton,Jr., D.D.S., Ph.D. 

Executive Director 

Enclosure 

cc: AADS Executive Committee 
.


American hSOCidiOIi of Dental Schools 

Policy Statement on Licensureand Certification 

1.	 The American Association of Dental Schools should cooperate with the ~erican Dental 

Associatio~ the American Dental Hygienists’ Association 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 orgardzstions and agencies, should exphn’e 

the development of alternative testing meth~ and SUppOrtthe development of appropriate 

demonstration projects andpilotprograms.


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

clinical licensum examinations fordentists anddental hygienists who 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. 
PRESIDE\’T 

E Joseph Alderman. DDS, MPH


Office of Dental Heaich


878 Peachtree St., NE R-215


Atlanta GA 30309


Phone 404/894.6684


Fax: 404/894-7799


PRESIDENT-ELECT 

Richard j. Hastreiter, DDS, MPH 

Minnesota Dept. of Heaith


717 Delaware SL, SE


Minneapolis. ,MN 55440


Phone 612/ 623-5441


Fax 612.’623.5043


\7CE-PRESIDE!ST 

Mark D. Siegai. DDS, MPH


Division of Dentai Health


246 N. High Street


P.O. Box 118


Columbus, Ohio 43266.0188


Phone 614’466-4i80


Fax: 614/644.9650


SECRHARY.TRE.4SURER


.M. Dean Perkins, DDS


Bureau of Dentai Health


P.(J Box 570


Jefferson Ciw, Missouri 65101


Phcme 314/751.6247


Fax 3i.$/i51-6010	

PAST PRESIDENT


Robert Isman, DDS, MPH


Dentai Heaith Section


CA Dept. ot Heaith Serwicea


P.O. Box 942732


Sacramento, C.+ 94234.7320


Phone 916,324.2230


Fax: 916.’ 324.7764


DIRECTORS


f3ev Enrw,sciti. RDI-L MPH


Eirwr Green. DDS, MPH


lack Dillenberg. DDS, MPH


\,FT,~SLETTFR EDITOR


L Lonan Davis, D\{D, MPH


I?cnd Iicaith Division


Bureau oi Famdv Hcdth Services


Sate Otfict i3uiidmg


:34 i([}nroe Street


Mt.ntgi+nicr:, .+L 5613P 

Phone: 205 ‘Z.+2.5057 

F4x: 2P5,’2K-3097 

l)vo Peachtree Street	

Sixth ??bor	

Atlanta, GA 30303	

Phone: (404) 657-2575	

F~: (404) 257-6631	

June 7, 1993	

Bryan B. Mitchell	

Principal Dep~ Inspector Geneml	

Office of Inspector Genend	

Washington, D.C. 21201	

Dear Mr. MitchelZ:	

Zhank you for the opportunity to nspond to the Office of Inspector 

Genend drq/1 report, The Licensum of Out~f-State Dentists. * l%e 

Association of State and Territoti Dental Directots (ASZDD) is an ~~e 

of the Association of State and TehoM HeaUh Officials (ASIZIO). 

Membership is composed of the Chief Den@ Officer of the Depa~eti of 

HeaUh, or equivalent public health agency of tie states, teniton”es, or 

possessions of the United States. ASTDD considers pollcies or 

recommend~”ons of private orpublic agencies pe~”ning to omi and dental 

health, and adopts policies for gutice of its membem. 17zis mponse 

represents my opinion and expen”ence as AS~D president and diplomate 

of dental public health, one of the ea”ghtAmerican Dental Association 

dental speciahies. Ilis nport is not necessmiiy the officihl potion of 

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

State dental ptvgmms should aid in the ticensing and credenmg 

of dentists. For example, the State De& Director in the Rhode Island 

DeF=~ent of He~fih ~en,es ~ the ~ai~enon of the P&ode Island Boani 

of Eraminem in Dentistry. TM/s& ws for cootiitiion of the two state 

entities, and increased public accountability. It bn”ng access to care and 

public heai’th to the foreftvnt of discussions that might be considered se~­

servi”ngto pn”vate pmcticing dentists or other Weciai interwt grvups. Most 

Board appointments are made by the Governor fmm dentists recommend~ -

by state dental associations. However, state dental prvgmms are hatingmjor problems. A December 1992 ASZDD Survey indicated: a. 10 (20qo) 

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 serw”ces, and 

would suppott methods to increase access to care while ensun”ng 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 bn”ngpublic 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 requin”ng the clinical board and then the Specialty Boani does not help recmit competent 

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 

remtu”nopposed. 

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 expen”enced 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 fa”led the clinical 

examination three times @age 8) does not significantly strengthen opposition to licensurz by 

credentials. Seveml examples of the most ‘clinically” competent gmduates fiu”ling the 

examinations can also be found. 

A mqior injlux Rf out-of-state applicants forthepopuiution grvwth states shouki eventually 

be soh’eti ~ 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 phym”ctins 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 physl”cal 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 contz”nuedcredentialing 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 begz”nto form a national clinical euun by u~g 

exiti”ng regional boards. However, licensure by cnde& orfinancing thrvugh public orprivate 

insumnce does not guamntee access to onzl hedh cam. other barn”em 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 pn”vate sectom of dentistry and dental hygl”ene, and oml hedh advocates 

is the key to ensun”ng 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 

AS1’HO 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 bycredentials isue. Of particular noteisa 10-part
 1991policy

statement (presented inappendix C ofthis report). Itcalls
 forAADS to


cooperate inefforts“to develop uniform standards forlicensure
 and


credentialing that wouldpermit freedomingeographic mobility fordentists
 and


dental
hygienists.”


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

neutral. Theyhavetobe prepared toreceive treatment
 thatmay notbe atan


acceptablevel.” SeeAmericanDental 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 (June1992):72.


9. See SusanE.Lovelace, “States Divided,” Journal of the Cahfomia Dental 

Association 16 (February 2, 1992): 21. 

10.	 The States wereCalifornia, Florida, NorthCarolina, Texas, andWashington.


SeeAmericanDentalAssociation, “Report oftheSpecialCommitteetoStudy


FreedomofMovementandLicensure 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. 

For example,among thesevenStates leading thenationinpopulation growth

inthe1980’s, onlytheNorthCarolina boardansweredthesequestions.It 

indicated that34 percent ofits144licensure applicants in1991alreadyhelda 

licenseinanotherStateand that17percenthad done soformore than5 years. 

Among the121individuals granteda dentallicensein1991,35 percentalready 

helda license inanotherState--l6percentformore 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. 

D-3

22.	 H. Barry Waldman, “Reciprocity: Why Doesn’t 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.	 Particularly notable inthis regard isthepublication bytheAmericanDental

Association andtheAmericanAssociation ofDentalExaminers inMay 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 President’s Column: The Neglected American Epidemic,” The 

Nation’s 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. 

D-4