Clinical Competence Examination: The Past, Present, and Possible Future of Clinical Board Examinations

The ever-evolving conversation surrounding the requirements for dental hygiene licensure has sparked debate over whether historically accepted prior testing methods are ethical and valid for determining the clinical competence of graduate students versus to alternative methods. The current requirements for obtaining a dental hygiene license, as outlined by the American Dental Hygiene Association (ADHA), are as follows:

  1. Graduation from a dental hygiene program accredited by the Commission on Dental Accreditation (CODA)
  2. Successful completion of the National Board of Dental Hygiene written examination
  3. Successful completion of national or regional clinical board examinations1

Historically, a live patient examination (LPE) has been the chosen measure of clinical competence. In previous years, this modality of testing has come under scrutiny for being ethically inappropriate for determining clinical competence for dental hygiene licensure.

In 2011, the American Dental Education Association (ADEA) issued a policy statement supporting the elimination of the examination of living patients for licensing and suggested that all states should offer other alternatives to determine clinical competence via non-living patient-based methods; despite this policy statement, EPLs are still one of the most widely accepted test formats accepted today.2 Following the COVID-19 pandemic, restrictions have been placed on licensure examination methods to provide alternative assessments that are not based on living patients. This has begged the question of what alternative options are currently available to dental hygiene graduate students, which states across the country accept these options, and why we as a profession should care.

Live Patient Reviews

Beginning in 1929, the Joint Commission on National Dental Examinations (JCNDE) administered the first LPE to establish clinical competence for licensure in dental hygiene.3 This criterion for obtaining a license remained for nearly 100 years in all states except Delaware.4 The desirable aspect of this test format is that it directly assesses a student’s ability to detect and remove calculus in a clinical setting on a living patient.

This style of testing comes with inevitable risks, both physical and ethical, for everyone involved. When compiling the literature, the main concerns with EPLs are that they run counter to the code of ethics that dental hygienists are sworn to uphold. In the ADA’s 64H resolution, it reaffirms its position in favor of the elimination of examinations of living patients. In this white paper, the most common ethical violations of live patient-based examinations are described, such as patient coercion, delay in patient care, lack of continuity of care, etc. The purpose of the document was to provide ways to avoid breaches of the Code of Ethics when examining a living patient.5 The need for such a document, in addition to compiled research that highlights how pervasive the ethical and physical risks associated with EPL are, illustrates that such reviews run counter to what we as a profession , we forbid to be. Industry advancements coupled with a global pandemic that has created the need for new testing methods has prompted the implementation of beta rounds of alternative clinical assessments.

Manikin examinations

The COVID-19 pandemic has made it clear that alternatives to EPLs would be essential for dental hygiene licensing. In 2020, a manikin-based method for determining clinical competence was published. A non-patient-based examination was performed on a Commission on Dental Competency Assessment (CDCA) typodont provided by the American Board of Dental Examiners (ADEX), simulating a live patient. With this method, two hours were allocated for calculus removal in one quadrant and subgingival calculus detection in another, as well as periodontal probing of two randomized teeth. Scoring was based on the student’s ability to detect and remove calculus and accurate measurement of periodontal pockets.

Related Reading:

Full Manikin Certification: Our New (and Improved) Standard

Model Reviews: The Game Changer We’ve Been Waiting For

The obvious benefit to the dummy panel is the removal of ethical scruples from the LPE while maintaining a standardized testing method.6 It is widely accepted that the manikin examination is more standardized than a live patient test. Unlike LPEs, there are no real risks in the mannequin format since it is performed on a typodont rather than a living person. Following the release of this format for clinical guidance, the response from the dental hygiene community has been largely positive, particularly among graduate students and instructors, as evidenced by a commission survey released after the launch of mannequin examination.7 New clinical skill assessment measures are gaining widespread support in the dental hygiene community.


The dummy board has sparked a wave of other alternative testing methods, the future of which will be the Objective Structured Clinical Examination in Dental Hygiene (DHLOSCE), due to launch in 2024. The DHLOSCE, although still in the early stages of development, will be a nationwide clinical exam that will have no variation, creating a standardized measure of clinical competence. Unlike the mannequin board, the DHLOSCE will not take place on a typodont, but will involve x-rays, photographs and/or 3D models for students to demonstrate their knowledge and skills.8. Trained actors will present living patients in case-based sections, but will not have the same level of risk as LPEs as they will not be used for tartar detection and removal.

No exams?

With the 2024 DHLOSCE eliminating not only living patients but also dummy typodonts, the drastic new question is whether clinical board exams are required for dental hygiene licensing. According to the “State Licensing Board Requirements for Entry into the Dental Hygiene Profession, published by Johnson et al., “Most dental hygiene directors believe that it is not testing outside of a CODA-approved program is not necessary for licensing”.4 In the future, would it be out of the question to assume that CODA-accredited dental hygiene programs are sufficient to determine the clinical competence of their students upon graduation? At this time, we still need to understand current testing metrics to defend and advance our authorization requirements.

Who accepts what?

Currently, there are four main regional testing agencies that, in light of the pandemic, have looked to the future and adapted to evolving alternative testing measures: Council of Interstate Testing Agency (CITA), Central Regional Dental Testing Service (CRDTS), Commission on Dental Competency Assessments (CDCA) and Western Regional Examining Board (WREB). Of these agencies, all four offered the mannequin board as an option for testing.

Not all states have accepted these new means of testing. To alleviate the confusion surrounding this, the CDCA and WREB have created an interactive infographic that highlights the states currently accepting the ADEX dummy exam (Figure 1).9

Students should be aware of the current testing methods available to determine and obtain a specific state license. Practicing professionals should be aware of current testing trends by knowing the expected baseline of new hygienists entering the profession. Progress in the profession does not necessarily begin after licensing; it can start earlier. Looking to the future, self-regulation of dental hygiene licensure within CODA-accredited programs may be a possibility, but everyone must agree.

The references

  1. ADHA. Licence. Accessed February 6, 2022.
  2. ADEA. ADEA Policy Statements: Recommendations and Guidelines for Academic Dental Institutions. Accessed February 1, 2022.
  3. ASDA. Use of Human Subjects in Clinical Clearance Reviews. Accessed February 1, 2022.
  4. Johnson K, Gurenlian J, Garland K, Freudenthal J. State licensing board requirements for entry into the dental hygiene profession. Accessed September 30, 2021.
  5. Ethical considerations when using patients in the review process. Accessed September 30, 2021.
  6. CDCA. 202 Information on candidates for the dental hygiene manikin examination. Accessed February 6, 2022.
  7. Walker T. Students and teachers tout the benefits of manikin testing. Accessed February 6, 2022.
  8. JCNDE. Objective Structured Clinical Examination for Dental Hygiene Permit (DHLOSCE). Accessed February 6, 2022,
  9. ADEX Acceptance Maps 2022. Accessed February 6, 2022.

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