Commission on Licensure 1975 annual report T his 1975 annual report o f the C om m ission on Licensure is being published in t h e j o u r n a l to afford the entire mem bership an opportunity to review what th e C om m ission is submitting to the 1975 H ouse o f D elegates. An annual report does not represent A ssociation policy. Policy is made by H o u se action. T he 1975 H o u se o f D elegates will take action on the resolu tions presented by the C om m ission. A D A members who have an interest in licensure should study the report and let their delegates know their reac tions to the approach being taken by the C om m ission.
Meetings: The Commission held its organizational meeting on Jan 30-31 and a second meeting on April 7-8, 1975, in the Headquarters Building. Arrangements are being sought for a third meeting in 1975 to enable the Commission to address problems of licensure more promptly. The Commission was pleased to have consultants representing dental students, dental auxiliaries, and the public participate in its deliberations. Lawrence A. Palmersheim, a stu dent enrolled at Loyola University School of Dentistry, was selected by the American Student Dental Asso ciation to serve as its representative; Kathleen Mast, a dental hygienist from Michigan, by the American Dental Hygienists’ Association; and Robert A. Sutter, a businessman from Chicago, by Kiwanis Interna tional, as a public representative. Background: The Commission on Licensure was created by action of the 1974 House of Delegates (Trans 1974:669) to study all aspects of li censure with a view to developing Association policy for consideration by the House of Delegates or guide lines which might be useful to state boards of dentistry in discharging their public responsibility. The Commis sion recognizes that it has no author ity to legislate guidelines it develops or Association policy it may help develop. However, with the system
of state licensure under increasing attack in recent years, it seems rea sonable for the Association, if it is to continue to support the state sys tem, if the profession is to continue to govern itself, to have a study com mission concentrate on licensure with a view to improving the system as opposed to having the system die because of its real and presumed flaws. Referred Resolutions: The 1974 House of Delegates referred three resolutions (Trans 1974:675, 676) to the Commission for study and report to the 1975 House. R e s o l v e d , that the Am erican D ental A s s o
ciation strongly encourage state boards o f dentistry to develop a creditable system of reciprocity in this country flexible enough to permit qualified dentists the freedom of interstate movement while retaining only those controls necessary to fulfill the re spective board’s public responsibility. (Subm itted by the K en tucky D ental A ss o ciation). R e s o lv e d , that the Board o f G overnors
o f the D ental Society o f the State o f N e w Y o r k petition the Am erican D ental A s s o ciation to endorse reciprocity betw een all states without additional examination o f practicing licensed dentists with suitable safeguards set by individual state boards in order to ensure protection o f the pub lic. R e s o lv e d , that the Am erican D ental A s s o
ciation take those measures within its com petence to further and abet reciprocal
dental licensure agreements betw een all states, so that licensed dentists can obtain licensure without further examination, with suitable safeguards set by the individ ual state boards in order to protect the public. (Submitted by the N inth D istrict D ental S ociety o f the Dental S ociety o f the State o f N ew Y ork)
The language of the three resolutions differs, but none of the three conflicts with current Association policy on reciprocity (Trans 1973:718). T h e A m erican D ental A ssociation favors reciprocal agreem ents for licensed den tists w ho meet specific professional cri teria which have been established by in dividual state boards o f dentistry to en sure the protection o f the public.
In the Commission’s view, one resol ution to reinforce current Associa tion policy on the matter would suf fice. Therefore, it is recommended that the first resolution appended to this report be substituted for and adopted in lieu of the three referred resolutions. Clarification of Association Policy on Licensure: In approaching its as
signment to study all matters related to licensure, the Commission identi fied a need for the Association to reach agreement on what controls are necessary to fulfill public responsi bility. The following statement was developed for that purpose. This is viewed by the Commission as a pre liminary document. It is recommend JADA, Vol. 91, Septem ber 1975 ■ 567
ed that the statement on controls, including the suggested guidelines, be adopted as interim Association pol icy. A resolution to that effect is ap pended to this report. After input from the 1975 House of Delegates, the Commission plans to distribute the statement to each state board of dentistry, state dental association, dental school, recognized specialty board, the American Association of Dental Examiners, American Asso ciation of Dental Schools, American Student Dental Association, and American Dental Hygienists’ Asso ciation. Each will be requested to con sider the statement and either endorse it or submit suggested changes. Based on this broad input, the Commission expects to submit a modified com prehensive statement on licensure to the 1975 House of Delegates. STATEMENT ON CONTROLS NECESSARY TO FULFILL PUBLIC RESPONSIBILITY Reciprocity: Literally, the term reciprocity means mutual exchange. In licensure, however, the term rec iprocity has been used to mean any provision for granting a state license on the basis of credentials, rather than on the basis of again demonstrating competence through examination. In 1971 and again in 1973, the Amer ican Dental Association adopted res olutions supporting the concept of a licensed dentist being able to obtain a license in another state without ex amination if his credentials are satis factory. The 1971 resolution urged the American Association of Dental Ex aminers to develop model provisions that could be used by individual states to license a dentist, already licensed in another jurisdiction, without exam ination or without complete examina tion if his credentials meet or exceed specified standards (Trans 1971:531). The AADE developed and in 1973 adopted model provisions which have been used as guidelines by 19 states in instituting licensure by “ criteria ap proval,” the AADE designation for licensure without examination or without complete examination. The reciprocity resolution adopt ed by the American Dental Associa tion in 1973 favors reciprocal agree 568 ■ JADA, Vol. 91, Septem ber 1975
ments between states for licensed dentists who meet specific profes sional criteria established by the in dividual states for the protection of the public (Trans 1973:718). The 1974 Special Committee of the Associa tion to Study Dental Licensing Pro cedures recommended that high pri ority be placed on defining “ specific professional criteria” for the guidance of states developing provisions for issuing licenses on the basis of cre dentials (Trans 1974:152). Definition of Terms: A difficulty encountered in studying licensure re lates to the words or expressions that are used. As indicated, the term rec iprocity has been used to mean any provision for granting a state license on the basis of credentials, rather than on the basis of again demonstrating competence through examination. Licensure by credentials, licensure by criteria approval, licensure by en dorsement, and licensure on the basis of meeting specific professional cri teria have all been used interchange ably. There are shades of difference in the meaning of these terms. His torically, the AADE objected to the word “ endorsement” because it was equated to a blanket endorsement of any dental license ever issued with out reference to the record of the in dividual. The AADE coined the ex pression “ criteria approval” to avoid the connotation of blanket endorse ment. Then, the ADA introduced “ specific professional criteria” in an attempt to ensure that nothing other than competence to practice dentistry would be used as a basis for issuing licenses. Interests of the AADE and the ADA are not in conflict. “ Criteria approval” means that a state estab lishes certain criteria that must be met. The individual who applies for licensure submits his credentials for approval, not his criteria for approval. If his credentials meet or exceed the criteria which have been established or approved by the state, his creden tials are endorsed and he is issued a license on the basis of his credentials, rather than on the basis of examina tion. In the Commission’s view, “ licen sure on the basis of credentials” is
the most descriptive expression for what has been developing in dental licensure. This .can be shortened to “ licensure by credentials” without losing meaning. The Commission considers “ licensure on the basis of credentials” or “ licensure by cre dentials” the preferred expressions. It is recognized that other agencies or individuals may continue to use “ criteria approval,” “ reciprocity,” or “ endorsement,” but the Commis sion plans to use “ licensure on the basis of credentials” or “ licensure by credentials” to differentiate from “ li censure by examination.” Criteria Approval: In attempting to define “ specific professional cri teria’’ to clarify existing ADA policy on licensure, the Commission re viewed the “ criteria approval” pro visions adopted by the AADE in 1973. The Commission commends the AADE for its action in this area. A challenge to develop model en dorsement or “ criteria approval” provisions is much broader than an assignment to define “ specific pro fessional criteria.” Emphasis of the AADE criteria approval provisions appears to be on procedural or me chanical considerations rather than on qualifications for licensure. For example, one criteria approval pro vision of the AADE relates to the applicant for licensure by criteria ap proval being required to fill out an application form. The Commission agrees, but feels that all candidates for licensure should complete a welldesigned application for licensure. This is a procedural matter. Another provision relates to the fee for licen sure by criteria approval being set by the individual state. The Commission agrees, but feels that all candidates for licensure should pay the initial licensure fee set by the state. Simi larly, the provision that credentials be verified would, in the Commis sion’s view, apply equally to candi dates for licensure by examination. The Commission agrees fully that procedural matters are important, but feels that this is an issue separ ate from identifying the credentials that can be used in lieu of retesting candidates for licensure. The Com mission views the identification of
suitable credentials as the major chal lenge for states undertaking licen sure by credentials or by criteria ap proval. In reviewing the AADE criteria approval provisions, the Commission found itself in support of most of those relating to credentials. These have been incorporated into the “ specific professional criteria” section of this statement. The only criteria approval provision of the AADE with which the Commission found difficulty is the one related to providing proof of phys ical condition certified by a medical doctor. The Commission agrees that there might be merit in a physical examination for all candidates, but believes that these concerns should be reflected in procedural require ments and should not be included in professional criteria. Specific Professional Criteria: Li censure is for the protection of the public and for no other purpose. It is not for the protection of the profes sion. It is not to control the supply of dental manpower. Public responsibili ty requires that dental licenses not be issued to the unqualified. Likewise, public responsibility requires that dental licenses be issued to all who are qualified if they seek licensure in the jurisdiction. Public responsibility also requires that increased efforts must be made to identify those who function at a level below today’s standards, and to cause them to upgrade the quality of service provided. Until peer review mechanisms achieve their full poten tial, there seems little likelihood of monitoring qualifications except for those who seek license in a different jurisdiction. The fact that effective monitoring of quality of dental ser vices within states has not been per fected, does not, in the Commission’s view, dictate abandonment of re quirements for issuing new licenses. Requirements for issuing licenses vary somewhat among states. Some have citizenship requirements or age requirements, but all have four re quirements in common: satisfactory education, satisfactory demonstra tion of knowledge through a written examination, satisfactory demon stration of skill through a perform
ance or clinical examination, and sound moral character. These re quirements would seem to dictate the “ specific professional criteria” that should be met before a license is is sued on the basis of credentials, with out examination. Satisfactory Education: The min imum standard of dental education today is graduation from a DDS or DMD education program accredited by the Commission on Accreditation of Dental and Dental Auxiliary Edu cational Programs. Until this year, from 1937 through 1974, the accredit ing agency recognized by the National Commission on Accrediting and US Office of Education was the Council on Dental Education. From 1918 through 1936, the Dental Educational Council of America was the recog nized accrediting agency. The C o m m issio n on L ice n su re re c o m m e n d s th a t g ra d u a tio n fr o m an a c c re d ite d d e n ta l sc h o o l be c o n sid e re d m in i m u m sa tisfa c to r y ed u c a tio n fo r lic e n su re by c red en tia ls.
Satisfactory Written Examination Results: The minimum standard of written licensure examinations today is satisfactory scores on National Board Dental Examinations. National board scores, or results of a state writ ten examination, represent adequate evidence of knowledge at the time taken, but could hardly be equated to evidence of knowledge today. For example, the scores of a dentist who passed the national board examina tions in 1934 would not have the same meaning today as scores of one who passed the examinations 40 years later in 1974. Therefore, the Comis sion feels that national board results or results of a state written examina tion should be accepted as evidence of minimal current knowledge only if taken reasonably recently. Defini tion of “ reasonably recently” could be more than a little arbitrary. No hard data are available to support a 2, 5, 10, 15, or 20 year time-limit on the value of national board results. It is suggested that the Council of Na tional Board of Dental Examiners tabulate information available on cur rent results compared with prior re sults for those who have repeated Part II examinations: Such a tabula
tion might suggest a reasonable shelflife for national board results. In the meantime, the Commission suggests a ten-year limit on recognizing nation al board or state-prepared written examination results as a reflection of minimal current knowledge. Be cause relatively few licensure candi dates have taken state-prepared writ ten examinations in recent years, and because most of these candidates had also taken national board examina tions, it is suggested that national board examinations be used as the minimum standard of knowledge test ing. T h e C o m m issio n on L ic e n su re re c o m m e n d s th a t sa tisfa c to r y p e r fo r m a n c e on N a tio n a l B o a rd D e n ta l E x a m in a tio n s w ithin ten yea rs p rior to a p p lyin g f o r a sta te licen se be c o n sid ere d a d e q u a te kn o w led g e te stin g f o r licen su re b y c red en tia ls.
Guidelines for Alternate Documen tation of Current Knowledge: For a system of licensure to be effective in ensuring protection of the public with out precluding the competent den tist from moving his practice, pro vision should be made to consider those who do not meet the criterion of having passed national board ex aminations within ten years prior to applying for a new state license. A recommendation that recent satisfac tory national board results be con sidered adequate evidence of current knowledge does not imply that those who do not have recent satisfactory national board results do not have adequate current knowledge. Rather, they should be required to submit alternate documentation of current knowledge for licensure by creden tials. The following guidelines are sug gested for consideration as alternate documentation with the thought that fulfilling any one would be adequate to waive the written examination re quirement. 1. Successful completion of an ac credited graduate or postgraduate dental education program in the last ten years. 2. A total of at least 180 hours of ac ceptable formal scientific continu ing education in the last ten years, with a maximum credit of 60 hours for each two-year period. COMMISSION ON LICENSURE ■ 569
3. Successful completion of a fellow’s or master’s examination of the Academy of General Dentistry (when instituted). 4. Successful completion of a recog nized specialty board examination in the last ten years. 5. Teaching experience of at least one day per week or its equivalent in an accredited dental or dentally related education program for at least six of the last ten years. Satisfactory Clinical Examination Results: The minimum standard of performance on clinical licensure ex aminations today is satisfactory re sults on a state or regional clinical examination. Performance examina tions are not yet as standardized as are the written examinations. How ever, the regional clinical testing agen cies have done much to standardize and improve the reliability of clinical licensure examinations. The progress that has been made in a relatively short period of time is truly impres sive. However, it would seem prudent for state boards of dentistry to acceler ate their efforts to achieve a greater degree of mutual agreement on min imum standards of performance test ing. For example, each state board of dentistry could today, based on the knowledge of its members, list the states or regional agencies conduct ing a clinical examination it considers at least equivalent to its own. It could then accept results of clinical exam inations conducted by those states or regional agencies. This may seem to be an unrealistic idea, but that is the way the accredi tation of dental schools started. It is the basis of regional clinical examina tions. Each state accepting the ac creditation classifications of the Com mission on Accreditation of Dental and Dental Auxiliary Educational Programs is satisfied that the evalua tion of the Commission on Accredi tation is at least equivalent to the evaluation it could conduct. Each state accepting results of a regional clinical testing agency is satisfied that the examination of the testing agency is at least equivalent to the one it con ducts. On the subject of clinical examina tions, the Commission views the ad 570 ■ JADA, Vol. 91, September 1975
vent of regional clinical testing agen cies as the single best factor in dental licensure in recent years. More has been done in terms of setting perform ance standards and criteria for evalu ation under regional agencies than had been accomplished in the whole his tory of state clinical licensure exam inations. For this reason, th e C o m m issio n on L ic e n su re re c o m m e n d s th a t sta te s n o t cu rren tly p a rtic ip a tin g in reg io n a l clin ica l te stin g services p r o c e e d p ro m p tly to p o o l ta le n ts a n d reso u rc e s to d evelo p a n d utilize re g io n a l clinical te stin g a g en cie s.
The foregoing comments reflect what the Commission feels must hap pen in terms of performance testing for licensure. Current and future trends in clinical examinations do not, however, solve the current problem of needing a mechanism for licensure on the basis of credentials. As an in terim measure, the C o m m issio n on L ic en su re re c o m m e n d s th a t s a tis fa c to ry p erfo rm a n c e o n a sta te o r re g io n a l clin ica l ex a m in a tio n w ithin ten y ea rs p rio r to a p p lyin g fo r a s ta te li c e n se be c o n sid e re d a d e q u a te clin ica l te stin g fo r licen su re b y cred en tia ls, p ro v id e d th e c a n d id a te fo r licensure (a) has b een in c o n tin u o u s p ra ctice in th e in terim , (b) is cu rren tly licen sed in a n o th e r ju risd ic tio n , (c) is e n d o rse d by a p e e r review or e q u iv a le n t c o m m itte e a n d the b o a rd o f d e n tistry in th e s ta te o f his cu rren t p ra c tic e , (d) has n o t h a d a s ta te licen se revo ked ; f u r th er, a s ta te m a y refu se licen su re by c re d en tia ls to a ca n d id a te w ho has fa ile d w ithin th e la st th ree y e a rs the c lin ica l e x a m in a tio n o f th e sta te to w hich he is a pplying.
Guidelines for Alternate Documen tation of Current Clinical Skills: For a system of licensure to be effective in ensuring protection of the public with out precluding the competent dentist from moving his practice, provision should be made to consider those who do not meet the criterion of having passed a clinical examination con ducted by a state board or regional clinical testing service within ten years prior to applying for a new state li cense. A recommendation that suc cessful completion of a recent state or regional clinical examination be con sidered adequate evidence of current
clinical skills does not imply that those who have not passed a state or region al clinical examination within the last ten years do not have adequate clin ical skills. Rather, they should be re quired to submit alternate documen tation of current clinical skills for li censure by credentials. The following guidelines are sug gested for consideration as alternate documentation with the thought that any one would be adequate to waive the clinical examination requirement, provided the candidate for licensure (a) has been in practice for a minimum of ten years, (b) is currently licensed in another jurisdiction, (c) is endorsed by a peer review or equivalent com mittee and the board of dentistry in the state of practice, and (d) has not had a state license revoked; further, a state may refuse licensure by creden tials to a candidate who has failed within the last three years the clinical examination of the state to which he is applying. 1. Successful completion of an ac credited general practice residency or dental internship within the last ten years. 2. Successful completion of an ac credited graduate or postgraduate dental education program in a clin ical discipline within the last ten years. (This would also fulfill the written examination requirement.) 3. A total of at least 180 hours of ac ceptable clinically oriented con tinuing education in the last ten years with a maximum credit of 60 hours for each two-year period. (This would also fulfill the written examination requirement.) 4. Hospital appointment at an accred ited teaching hospital with respon sibility for the education program for dental residents for at least six of the last ten years. 5. Clinical teaching of at least one day per week or its equivalent in an ac credited dental education program for at least six of the last ten years. 6. Presenting case histories of pa tients treated by the candidate in the last five years, with pre- and post-operative radiographs and photographs, covering procedures required on the state clinical exam inations, for discussion with the
state board. Sound Moral Character: Licensure provisions for all professions in all states include a requirement of sound moral character. Perhaps because one fears that a traffic ticket or un paid telephone bill will follow a per son to his grave, regardless of the cir cumstances causing the incident, men tion of a character requirement for licensure by credentials raises the hackles on some. It might be noted that a requirement of sound moral character applies equally whether one is licensed by examination or by cre dentials, just as an education require ment applies whether one is licensed by examination or by credentials. The Commission agrees with those who object to licensure applications inquiring into religious preferences, race, fraternal memberships, marital status, or plans for location of prac tice. None of these factors relates to a candidate’s competence to provide dental service. The Commission on
Licensure recommends that each state board o f dentistry review its ap plication for licensure to ensure that data unrelated to competence to pro vide dental service are not required. Demographic data, if needed, can be gathered after licenses are issued. These comments are not meant to imply that an application for licensure should avoid inquiring into those fac tors related to sound moral charac ter. There are character flaws in some individuals that make them unsuitable for licensure in any state. The Com
mission on Licensure recommends that credentials and application data for all candidates for dental licen sure be verified before licenses are issued. Federal Licensure: In 1973, the American Dental Association reaf firmed its long-standing opposition to federal licensure (Trans 1973:721). Despite this opposition and opposi tion of other health associations, there is indication of growing federal con cern in the area of licensure. One of the proposed amendments to the ex tension of the Health Manpower Act considered in 1974 and approved by the US Senate Committee on Labor and Public Welfare included establish
ment of national standards for licen sure of physicians and dentists. The Association was among those agen cies testifying in opposition to this feature of the bill. Although the sec tion dealing with licensure standards was not approved by the Senate, it seemed clear that the Association’s testimony would have been stronger if Association official policy detailed reasons for opposition rather than merely stating opposition to federal control of dental licensure. For this reason, the Commission developed the following statement and recom mends that it be adopted. An appro priate resolution is appended to this report. POSITION STATEMENT ON FEDERAL INTERVENTION IN LICENSURE The American Dental Association has repeatedly recorded its support for the principle of dental licensure at the individual state level and its oppos ition for placing this important func tion under federal control. The pur pose of this statement is to identify the reasons underlying the Associa tion’s position. A basic premise of the Associa tion’s position is that American den tistry has reached a level of quality and availability not matched else where in the world. The system of state licensure has been an important factor in dentistry’s development. Therefore, the Association would op pose replacement of the state licen sure system. In the opinion of the Association, federal control of dental licensure would not only fail to solve existing problems involving delivery of dental care to the public, but also could be expected to create new prob lems. Maldistribution: One of the most widely recognized and most com plex problems facing dentistry in volves the distribution of dentists throughout the country. Typically, inner city and rural areas have diffi culty attracting dentists. Some pro ponents of abandoning the state licen sure system believe that federal licen sure would help alleviate the distribu tion problem. Presumably, federal licensure would eliminate red tape
for dentists moving from one state to another. Then, underserved areas might be able to attract dentists from other states. Although the Association recog nizes the maldistribution problem, it does not believe federal licensure to be a potential solution. A review of dentist to population ratios by coun ty and state indicates greater variance within states than among states. Cur rently, nothing impedes a dentist li censed in a state from moving to an underserved area in the same state. Since this has not occurred, it is doubt ful that dentists from other states would flock to these underserved areas. Mobility of Dentists: Even though not important as a solution to maldis tribution of dentists, the Association is committed to seeking a mechan ism that would allow competent prac titioners to relocate in a different state with a minimum of inconvenience. This goal is not incompatible with the system of state licensure. Licensing a dentist licensed in another state on the basis of his credentials meeting specific professional criteria is one mechanism currently being vigorous ly pursued. In considering various alternatives, however, the Associa tion has maintained the position that each state should retain sufficient safeguards to ensure that any dentist granted a license in the state is com petent to serve the people of the state. Any lesser condition would fail to provide adequate public protection. Experimentation: The current statebased licensure system is composed of 53 jurisdictions, each attempting to develop the most effective system possible for regulating the practice of dentistry. When new systems or reg ulations are proposed, initial evalua tion must, of necessity, be based upon supposition. Because hard evidence about new proposals is seldom avail able, new proposals usually evoke mixed reactions. Although few new ideas gain majority approval quickly on a national level, many are approved by one or more states. Experience of these states forms a basis for other states to make a higher quality de cision about the proposal within a rel atively short time. In a sense, a few COMMISSION ON LICENSURE ■ 571
states provide a controlled experi ment for the majority. Examples of this process can be found in accept ance of national board scores, devel opment of the concept of licensure by credentials, growth of regional clinical testing services, and assignment of duties to dental auxiliary personnel. In contrast to the state-based licen sure system, a system controlled by the federal government would have only one decision-making unit. Cen tralized decision making is contrary to the best interests of the public. Fur thermore, the possibility of experi mentation with a subset of the entire country would be hampered or elim inated. Influence on the Dental Curriculum: Dental schools have a responsibility to graduate individuals capable of practicing dentistry. Since meeting licensure requirements is a prerequi site to practice, dental schools also prepare students to pass licensure ex aminations. Consequently, the agency that establishes licensure standards can have an influence over dental cur rículums. Under the state licensure system this influence is shared among 53 jurisdictions, and thus moderated. With a single federal agency setting standards, the influence of licensure examinations might become excessive and virtually dictate the content and emphasis for all dental currículums. This centralization would tend to make a static situation which would inhibit evolution and change. Also, the cooperation that has developed among educators, examiners, and the practicing profession at the state level has been effective in dealing with the relationship between licensure re quirements and the dental curriculum. The same degree of cooperation could not be expected at the federal level. Enforcement: Licensure involves more than issuing licenses to candi dates who qualify. Regulatory agen cies also must ensure that licensed dentists maintain competence and practice in accordance with the law. It is in this policing function that fed eral licensure seems most inadequate. To be most effective, regulatory re sponsibility should be placed at the lowest level of government capable of performing the function—in this in 572 ■ JADA, Vol. 91, Septem ber 1975
stance, the state, through its board of dentistry. Summary: For the reasons cited, the American Dental Association strongly opposes federal licensure and federal intervention in the state licens ing system. Evaluation of Need for Repeating a Licensure Survey: The 1973 House of Delegates adopted a resolution direct ing that a survey of attitudes on dental licensing procedures be repeated in three to five years to determine wheth er changes in attitudes about licen sure were occurring (Trans 1973:721). With adoption of this resolution, a licensure survey would be repeated in or before 1978. The Board of Trustees requested that the 1974 Special Com mittee of the Association to Study Dental Licensing Procedures com ment on whether a licensure survey should be repeated prior to 1978. The 1974 Special Committee saw no reason to repeat the survey in the near future, but expressed the view that the agency studying licensing matters after 1974 would be in a better position to recommend timing for re peating a licensure survey. The Commission on Licensure is that agency. At this time, the Com mission sees no useful purpose that would be served by repeating an at titude survey prior to 1978. The pro posal to repeat an attitude survey in three to five years was initiated by the original or 1973 Special Commit tee. Its interest was in studying whether the difference in response patterns for various age groups re flected changing times or a change in vantage point. It was speculated that both might be factors. A student fac ing licensure examinations or a den tist approaching retirement age might be expected to have attitudes differ ent from those of dentists intending to maintain their present practices for another 20 years. The Commission agrees that this might be an interesting study, but feels that there are more productive activities that need to be addressed in the area of licensure. In the Commission’s view, repeating an attitude survey before positive chang es are made and more information on licensure disseminated would pro
duce little additional useful informa tion. Planned Activities: In approaching its assignment to study all aspects of licensure, the Commission found itself in the position of having to narrow its focus for 1975 to the four items covered in this report. A number of other items were identified as need ing study. In addition to obtaining broader input for refining guidelines for issuing state licenses on the basis of credentials, the Commission plans to direct attention to mechanisms for improving liaison among examiners, educators, and the practicing profes sion; possible relations between peer review and licensure; performance standards in licensure examinations and criteria for evaluation; merits or disadvantages of multiple state licens es; and enforcement problems. RESOLUTIONS 1.Resolved, that the American Dental Association, through its constituent and component societies, strongly urge state boards of dentistry, con sonant with their responsibility to the public, to adopt systems of li censure by credentials which will permit licensed dentists the free dom of interstate movement. 2. Resolved, that the Statement on
Controls Necessary to Fulfill Pub lic Responsibility be approved as interim policy of the American Dental Association. 3. Resolved, that the Statement on
Federal Intervention in Licensure be approved. Commission on Licensure: Robert B. Dixon, Texas, 1976, chairman-, C. F. Barrett, Iowa, 1975; Ashur G. Chavoor, District of Columbia, 1976; James E. Connolly, Massachusetts, 1975; John Cook, Washington, 1976; Robert E. Doerr, Michigan, 1975; Lee E. Haines, New Mexico, 1977; Duncan A. King, Kentucky, 1975; Judson Klooster, California, 1977; Richard A. Kozal, Illinois, 1977; Ed mund R. Mihalski, Pennsylvania, 1976; William P. Schlansker, New York, 1975; Robert E. Shellenberger, Indiana, 1977; John A. Stewart, Flor ida, 1975; John M. Coady, staff dir
ector.
Meetings: The Commission held its organizational meeting on Jan 30-31 and a second meeting on April 7-8, 1975, in the Headquarters Building. Arrangements are being sought for a third meeting in 1975 to enable the Commission to address problems of licensure more promptly. The Commission was pleased to have consultants representing dental students, dental auxiliaries, and the public participate in its deliberations. Lawrence A. Palmersheim, a stu dent enrolled at Loyola University School of Dentistry, was selected by the American Student Dental Asso ciation to serve as its representative; Kathleen Mast, a dental hygienist from Michigan, by the American Dental Hygienists’ Association; and Robert A. Sutter, a businessman from Chicago, by Kiwanis Interna tional, as a public representative. Background: The Commission on Licensure was created by action of the 1974 House of Delegates (Trans 1974:669) to study all aspects of li censure with a view to developing Association policy for consideration by the House of Delegates or guide lines which might be useful to state boards of dentistry in discharging their public responsibility. The Commis sion recognizes that it has no author ity to legislate guidelines it develops or Association policy it may help develop. However, with the system
of state licensure under increasing attack in recent years, it seems rea sonable for the Association, if it is to continue to support the state sys tem, if the profession is to continue to govern itself, to have a study com mission concentrate on licensure with a view to improving the system as opposed to having the system die because of its real and presumed flaws. Referred Resolutions: The 1974 House of Delegates referred three resolutions (Trans 1974:675, 676) to the Commission for study and report to the 1975 House. R e s o l v e d , that the Am erican D ental A s s o
ciation strongly encourage state boards o f dentistry to develop a creditable system of reciprocity in this country flexible enough to permit qualified dentists the freedom of interstate movement while retaining only those controls necessary to fulfill the re spective board’s public responsibility. (Subm itted by the K en tucky D ental A ss o ciation). R e s o lv e d , that the Board o f G overnors
o f the D ental Society o f the State o f N e w Y o r k petition the Am erican D ental A s s o ciation to endorse reciprocity betw een all states without additional examination o f practicing licensed dentists with suitable safeguards set by individual state boards in order to ensure protection o f the pub lic. R e s o lv e d , that the Am erican D ental A s s o
ciation take those measures within its com petence to further and abet reciprocal
dental licensure agreements betw een all states, so that licensed dentists can obtain licensure without further examination, with suitable safeguards set by the individ ual state boards in order to protect the public. (Submitted by the N inth D istrict D ental S ociety o f the Dental S ociety o f the State o f N ew Y ork)
The language of the three resolutions differs, but none of the three conflicts with current Association policy on reciprocity (Trans 1973:718). T h e A m erican D ental A ssociation favors reciprocal agreem ents for licensed den tists w ho meet specific professional cri teria which have been established by in dividual state boards o f dentistry to en sure the protection o f the public.
In the Commission’s view, one resol ution to reinforce current Associa tion policy on the matter would suf fice. Therefore, it is recommended that the first resolution appended to this report be substituted for and adopted in lieu of the three referred resolutions. Clarification of Association Policy on Licensure: In approaching its as
signment to study all matters related to licensure, the Commission identi fied a need for the Association to reach agreement on what controls are necessary to fulfill public responsi bility. The following statement was developed for that purpose. This is viewed by the Commission as a pre liminary document. It is recommend JADA, Vol. 91, Septem ber 1975 ■ 567
ed that the statement on controls, including the suggested guidelines, be adopted as interim Association pol icy. A resolution to that effect is ap pended to this report. After input from the 1975 House of Delegates, the Commission plans to distribute the statement to each state board of dentistry, state dental association, dental school, recognized specialty board, the American Association of Dental Examiners, American Asso ciation of Dental Schools, American Student Dental Association, and American Dental Hygienists’ Asso ciation. Each will be requested to con sider the statement and either endorse it or submit suggested changes. Based on this broad input, the Commission expects to submit a modified com prehensive statement on licensure to the 1975 House of Delegates. STATEMENT ON CONTROLS NECESSARY TO FULFILL PUBLIC RESPONSIBILITY Reciprocity: Literally, the term reciprocity means mutual exchange. In licensure, however, the term rec iprocity has been used to mean any provision for granting a state license on the basis of credentials, rather than on the basis of again demonstrating competence through examination. In 1971 and again in 1973, the Amer ican Dental Association adopted res olutions supporting the concept of a licensed dentist being able to obtain a license in another state without ex amination if his credentials are satis factory. The 1971 resolution urged the American Association of Dental Ex aminers to develop model provisions that could be used by individual states to license a dentist, already licensed in another jurisdiction, without exam ination or without complete examina tion if his credentials meet or exceed specified standards (Trans 1971:531). The AADE developed and in 1973 adopted model provisions which have been used as guidelines by 19 states in instituting licensure by “ criteria ap proval,” the AADE designation for licensure without examination or without complete examination. The reciprocity resolution adopt ed by the American Dental Associa tion in 1973 favors reciprocal agree 568 ■ JADA, Vol. 91, Septem ber 1975
ments between states for licensed dentists who meet specific profes sional criteria established by the in dividual states for the protection of the public (Trans 1973:718). The 1974 Special Committee of the Associa tion to Study Dental Licensing Pro cedures recommended that high pri ority be placed on defining “ specific professional criteria” for the guidance of states developing provisions for issuing licenses on the basis of cre dentials (Trans 1974:152). Definition of Terms: A difficulty encountered in studying licensure re lates to the words or expressions that are used. As indicated, the term rec iprocity has been used to mean any provision for granting a state license on the basis of credentials, rather than on the basis of again demonstrating competence through examination. Licensure by credentials, licensure by criteria approval, licensure by en dorsement, and licensure on the basis of meeting specific professional cri teria have all been used interchange ably. There are shades of difference in the meaning of these terms. His torically, the AADE objected to the word “ endorsement” because it was equated to a blanket endorsement of any dental license ever issued with out reference to the record of the in dividual. The AADE coined the ex pression “ criteria approval” to avoid the connotation of blanket endorse ment. Then, the ADA introduced “ specific professional criteria” in an attempt to ensure that nothing other than competence to practice dentistry would be used as a basis for issuing licenses. Interests of the AADE and the ADA are not in conflict. “ Criteria approval” means that a state estab lishes certain criteria that must be met. The individual who applies for licensure submits his credentials for approval, not his criteria for approval. If his credentials meet or exceed the criteria which have been established or approved by the state, his creden tials are endorsed and he is issued a license on the basis of his credentials, rather than on the basis of examina tion. In the Commission’s view, “ licen sure on the basis of credentials” is
the most descriptive expression for what has been developing in dental licensure. This .can be shortened to “ licensure by credentials” without losing meaning. The Commission considers “ licensure on the basis of credentials” or “ licensure by cre dentials” the preferred expressions. It is recognized that other agencies or individuals may continue to use “ criteria approval,” “ reciprocity,” or “ endorsement,” but the Commis sion plans to use “ licensure on the basis of credentials” or “ licensure by credentials” to differentiate from “ li censure by examination.” Criteria Approval: In attempting to define “ specific professional cri teria’’ to clarify existing ADA policy on licensure, the Commission re viewed the “ criteria approval” pro visions adopted by the AADE in 1973. The Commission commends the AADE for its action in this area. A challenge to develop model en dorsement or “ criteria approval” provisions is much broader than an assignment to define “ specific pro fessional criteria.” Emphasis of the AADE criteria approval provisions appears to be on procedural or me chanical considerations rather than on qualifications for licensure. For example, one criteria approval pro vision of the AADE relates to the applicant for licensure by criteria ap proval being required to fill out an application form. The Commission agrees, but feels that all candidates for licensure should complete a welldesigned application for licensure. This is a procedural matter. Another provision relates to the fee for licen sure by criteria approval being set by the individual state. The Commission agrees, but feels that all candidates for licensure should pay the initial licensure fee set by the state. Simi larly, the provision that credentials be verified would, in the Commis sion’s view, apply equally to candi dates for licensure by examination. The Commission agrees fully that procedural matters are important, but feels that this is an issue separ ate from identifying the credentials that can be used in lieu of retesting candidates for licensure. The Com mission views the identification of
suitable credentials as the major chal lenge for states undertaking licen sure by credentials or by criteria ap proval. In reviewing the AADE criteria approval provisions, the Commission found itself in support of most of those relating to credentials. These have been incorporated into the “ specific professional criteria” section of this statement. The only criteria approval provision of the AADE with which the Commission found difficulty is the one related to providing proof of phys ical condition certified by a medical doctor. The Commission agrees that there might be merit in a physical examination for all candidates, but believes that these concerns should be reflected in procedural require ments and should not be included in professional criteria. Specific Professional Criteria: Li censure is for the protection of the public and for no other purpose. It is not for the protection of the profes sion. It is not to control the supply of dental manpower. Public responsibili ty requires that dental licenses not be issued to the unqualified. Likewise, public responsibility requires that dental licenses be issued to all who are qualified if they seek licensure in the jurisdiction. Public responsibility also requires that increased efforts must be made to identify those who function at a level below today’s standards, and to cause them to upgrade the quality of service provided. Until peer review mechanisms achieve their full poten tial, there seems little likelihood of monitoring qualifications except for those who seek license in a different jurisdiction. The fact that effective monitoring of quality of dental ser vices within states has not been per fected, does not, in the Commission’s view, dictate abandonment of re quirements for issuing new licenses. Requirements for issuing licenses vary somewhat among states. Some have citizenship requirements or age requirements, but all have four re quirements in common: satisfactory education, satisfactory demonstra tion of knowledge through a written examination, satisfactory demon stration of skill through a perform
ance or clinical examination, and sound moral character. These re quirements would seem to dictate the “ specific professional criteria” that should be met before a license is is sued on the basis of credentials, with out examination. Satisfactory Education: The min imum standard of dental education today is graduation from a DDS or DMD education program accredited by the Commission on Accreditation of Dental and Dental Auxiliary Edu cational Programs. Until this year, from 1937 through 1974, the accredit ing agency recognized by the National Commission on Accrediting and US Office of Education was the Council on Dental Education. From 1918 through 1936, the Dental Educational Council of America was the recog nized accrediting agency. The C o m m issio n on L ice n su re re c o m m e n d s th a t g ra d u a tio n fr o m an a c c re d ite d d e n ta l sc h o o l be c o n sid e re d m in i m u m sa tisfa c to r y ed u c a tio n fo r lic e n su re by c red en tia ls.
Satisfactory Written Examination Results: The minimum standard of written licensure examinations today is satisfactory scores on National Board Dental Examinations. National board scores, or results of a state writ ten examination, represent adequate evidence of knowledge at the time taken, but could hardly be equated to evidence of knowledge today. For example, the scores of a dentist who passed the national board examina tions in 1934 would not have the same meaning today as scores of one who passed the examinations 40 years later in 1974. Therefore, the Comis sion feels that national board results or results of a state written examina tion should be accepted as evidence of minimal current knowledge only if taken reasonably recently. Defini tion of “ reasonably recently” could be more than a little arbitrary. No hard data are available to support a 2, 5, 10, 15, or 20 year time-limit on the value of national board results. It is suggested that the Council of Na tional Board of Dental Examiners tabulate information available on cur rent results compared with prior re sults for those who have repeated Part II examinations: Such a tabula
tion might suggest a reasonable shelflife for national board results. In the meantime, the Commission suggests a ten-year limit on recognizing nation al board or state-prepared written examination results as a reflection of minimal current knowledge. Be cause relatively few licensure candi dates have taken state-prepared writ ten examinations in recent years, and because most of these candidates had also taken national board examina tions, it is suggested that national board examinations be used as the minimum standard of knowledge test ing. T h e C o m m issio n on L ic e n su re re c o m m e n d s th a t sa tisfa c to r y p e r fo r m a n c e on N a tio n a l B o a rd D e n ta l E x a m in a tio n s w ithin ten yea rs p rior to a p p lyin g f o r a sta te licen se be c o n sid ere d a d e q u a te kn o w led g e te stin g f o r licen su re b y c red en tia ls.
Guidelines for Alternate Documen tation of Current Knowledge: For a system of licensure to be effective in ensuring protection of the public with out precluding the competent den tist from moving his practice, pro vision should be made to consider those who do not meet the criterion of having passed national board ex aminations within ten years prior to applying for a new state license. A recommendation that recent satisfac tory national board results be con sidered adequate evidence of current knowledge does not imply that those who do not have recent satisfactory national board results do not have adequate current knowledge. Rather, they should be required to submit alternate documentation of current knowledge for licensure by creden tials. The following guidelines are sug gested for consideration as alternate documentation with the thought that fulfilling any one would be adequate to waive the written examination re quirement. 1. Successful completion of an ac credited graduate or postgraduate dental education program in the last ten years. 2. A total of at least 180 hours of ac ceptable formal scientific continu ing education in the last ten years, with a maximum credit of 60 hours for each two-year period. COMMISSION ON LICENSURE ■ 569
3. Successful completion of a fellow’s or master’s examination of the Academy of General Dentistry (when instituted). 4. Successful completion of a recog nized specialty board examination in the last ten years. 5. Teaching experience of at least one day per week or its equivalent in an accredited dental or dentally related education program for at least six of the last ten years. Satisfactory Clinical Examination Results: The minimum standard of performance on clinical licensure ex aminations today is satisfactory re sults on a state or regional clinical examination. Performance examina tions are not yet as standardized as are the written examinations. How ever, the regional clinical testing agen cies have done much to standardize and improve the reliability of clinical licensure examinations. The progress that has been made in a relatively short period of time is truly impres sive. However, it would seem prudent for state boards of dentistry to acceler ate their efforts to achieve a greater degree of mutual agreement on min imum standards of performance test ing. For example, each state board of dentistry could today, based on the knowledge of its members, list the states or regional agencies conduct ing a clinical examination it considers at least equivalent to its own. It could then accept results of clinical exam inations conducted by those states or regional agencies. This may seem to be an unrealistic idea, but that is the way the accredi tation of dental schools started. It is the basis of regional clinical examina tions. Each state accepting the ac creditation classifications of the Com mission on Accreditation of Dental and Dental Auxiliary Educational Programs is satisfied that the evalua tion of the Commission on Accredi tation is at least equivalent to the evaluation it could conduct. Each state accepting results of a regional clinical testing agency is satisfied that the examination of the testing agency is at least equivalent to the one it con ducts. On the subject of clinical examina tions, the Commission views the ad 570 ■ JADA, Vol. 91, September 1975
vent of regional clinical testing agen cies as the single best factor in dental licensure in recent years. More has been done in terms of setting perform ance standards and criteria for evalu ation under regional agencies than had been accomplished in the whole his tory of state clinical licensure exam inations. For this reason, th e C o m m issio n on L ic e n su re re c o m m e n d s th a t sta te s n o t cu rren tly p a rtic ip a tin g in reg io n a l clin ica l te stin g services p r o c e e d p ro m p tly to p o o l ta le n ts a n d reso u rc e s to d evelo p a n d utilize re g io n a l clinical te stin g a g en cie s.
The foregoing comments reflect what the Commission feels must hap pen in terms of performance testing for licensure. Current and future trends in clinical examinations do not, however, solve the current problem of needing a mechanism for licensure on the basis of credentials. As an in terim measure, the C o m m issio n on L ic en su re re c o m m e n d s th a t s a tis fa c to ry p erfo rm a n c e o n a sta te o r re g io n a l clin ica l ex a m in a tio n w ithin ten y ea rs p rio r to a p p lyin g fo r a s ta te li c e n se be c o n sid e re d a d e q u a te clin ica l te stin g fo r licen su re b y cred en tia ls, p ro v id e d th e c a n d id a te fo r licensure (a) has b een in c o n tin u o u s p ra ctice in th e in terim , (b) is cu rren tly licen sed in a n o th e r ju risd ic tio n , (c) is e n d o rse d by a p e e r review or e q u iv a le n t c o m m itte e a n d the b o a rd o f d e n tistry in th e s ta te o f his cu rren t p ra c tic e , (d) has n o t h a d a s ta te licen se revo ked ; f u r th er, a s ta te m a y refu se licen su re by c re d en tia ls to a ca n d id a te w ho has fa ile d w ithin th e la st th ree y e a rs the c lin ica l e x a m in a tio n o f th e sta te to w hich he is a pplying.
Guidelines for Alternate Documen tation of Current Clinical Skills: For a system of licensure to be effective in ensuring protection of the public with out precluding the competent dentist from moving his practice, provision should be made to consider those who do not meet the criterion of having passed a clinical examination con ducted by a state board or regional clinical testing service within ten years prior to applying for a new state li cense. A recommendation that suc cessful completion of a recent state or regional clinical examination be con sidered adequate evidence of current
clinical skills does not imply that those who have not passed a state or region al clinical examination within the last ten years do not have adequate clin ical skills. Rather, they should be re quired to submit alternate documen tation of current clinical skills for li censure by credentials. The following guidelines are sug gested for consideration as alternate documentation with the thought that any one would be adequate to waive the clinical examination requirement, provided the candidate for licensure (a) has been in practice for a minimum of ten years, (b) is currently licensed in another jurisdiction, (c) is endorsed by a peer review or equivalent com mittee and the board of dentistry in the state of practice, and (d) has not had a state license revoked; further, a state may refuse licensure by creden tials to a candidate who has failed within the last three years the clinical examination of the state to which he is applying. 1. Successful completion of an ac credited general practice residency or dental internship within the last ten years. 2. Successful completion of an ac credited graduate or postgraduate dental education program in a clin ical discipline within the last ten years. (This would also fulfill the written examination requirement.) 3. A total of at least 180 hours of ac ceptable clinically oriented con tinuing education in the last ten years with a maximum credit of 60 hours for each two-year period. (This would also fulfill the written examination requirement.) 4. Hospital appointment at an accred ited teaching hospital with respon sibility for the education program for dental residents for at least six of the last ten years. 5. Clinical teaching of at least one day per week or its equivalent in an ac credited dental education program for at least six of the last ten years. 6. Presenting case histories of pa tients treated by the candidate in the last five years, with pre- and post-operative radiographs and photographs, covering procedures required on the state clinical exam inations, for discussion with the
state board. Sound Moral Character: Licensure provisions for all professions in all states include a requirement of sound moral character. Perhaps because one fears that a traffic ticket or un paid telephone bill will follow a per son to his grave, regardless of the cir cumstances causing the incident, men tion of a character requirement for licensure by credentials raises the hackles on some. It might be noted that a requirement of sound moral character applies equally whether one is licensed by examination or by cre dentials, just as an education require ment applies whether one is licensed by examination or by credentials. The Commission agrees with those who object to licensure applications inquiring into religious preferences, race, fraternal memberships, marital status, or plans for location of prac tice. None of these factors relates to a candidate’s competence to provide dental service. The Commission on
Licensure recommends that each state board o f dentistry review its ap plication for licensure to ensure that data unrelated to competence to pro vide dental service are not required. Demographic data, if needed, can be gathered after licenses are issued. These comments are not meant to imply that an application for licensure should avoid inquiring into those fac tors related to sound moral charac ter. There are character flaws in some individuals that make them unsuitable for licensure in any state. The Com
mission on Licensure recommends that credentials and application data for all candidates for dental licen sure be verified before licenses are issued. Federal Licensure: In 1973, the American Dental Association reaf firmed its long-standing opposition to federal licensure (Trans 1973:721). Despite this opposition and opposi tion of other health associations, there is indication of growing federal con cern in the area of licensure. One of the proposed amendments to the ex tension of the Health Manpower Act considered in 1974 and approved by the US Senate Committee on Labor and Public Welfare included establish
ment of national standards for licen sure of physicians and dentists. The Association was among those agen cies testifying in opposition to this feature of the bill. Although the sec tion dealing with licensure standards was not approved by the Senate, it seemed clear that the Association’s testimony would have been stronger if Association official policy detailed reasons for opposition rather than merely stating opposition to federal control of dental licensure. For this reason, the Commission developed the following statement and recom mends that it be adopted. An appro priate resolution is appended to this report. POSITION STATEMENT ON FEDERAL INTERVENTION IN LICENSURE The American Dental Association has repeatedly recorded its support for the principle of dental licensure at the individual state level and its oppos ition for placing this important func tion under federal control. The pur pose of this statement is to identify the reasons underlying the Associa tion’s position. A basic premise of the Associa tion’s position is that American den tistry has reached a level of quality and availability not matched else where in the world. The system of state licensure has been an important factor in dentistry’s development. Therefore, the Association would op pose replacement of the state licen sure system. In the opinion of the Association, federal control of dental licensure would not only fail to solve existing problems involving delivery of dental care to the public, but also could be expected to create new prob lems. Maldistribution: One of the most widely recognized and most com plex problems facing dentistry in volves the distribution of dentists throughout the country. Typically, inner city and rural areas have diffi culty attracting dentists. Some pro ponents of abandoning the state licen sure system believe that federal licen sure would help alleviate the distribu tion problem. Presumably, federal licensure would eliminate red tape
for dentists moving from one state to another. Then, underserved areas might be able to attract dentists from other states. Although the Association recog nizes the maldistribution problem, it does not believe federal licensure to be a potential solution. A review of dentist to population ratios by coun ty and state indicates greater variance within states than among states. Cur rently, nothing impedes a dentist li censed in a state from moving to an underserved area in the same state. Since this has not occurred, it is doubt ful that dentists from other states would flock to these underserved areas. Mobility of Dentists: Even though not important as a solution to maldis tribution of dentists, the Association is committed to seeking a mechan ism that would allow competent prac titioners to relocate in a different state with a minimum of inconvenience. This goal is not incompatible with the system of state licensure. Licensing a dentist licensed in another state on the basis of his credentials meeting specific professional criteria is one mechanism currently being vigorous ly pursued. In considering various alternatives, however, the Associa tion has maintained the position that each state should retain sufficient safeguards to ensure that any dentist granted a license in the state is com petent to serve the people of the state. Any lesser condition would fail to provide adequate public protection. Experimentation: The current statebased licensure system is composed of 53 jurisdictions, each attempting to develop the most effective system possible for regulating the practice of dentistry. When new systems or reg ulations are proposed, initial evalua tion must, of necessity, be based upon supposition. Because hard evidence about new proposals is seldom avail able, new proposals usually evoke mixed reactions. Although few new ideas gain majority approval quickly on a national level, many are approved by one or more states. Experience of these states forms a basis for other states to make a higher quality de cision about the proposal within a rel atively short time. In a sense, a few COMMISSION ON LICENSURE ■ 571
states provide a controlled experi ment for the majority. Examples of this process can be found in accept ance of national board scores, devel opment of the concept of licensure by credentials, growth of regional clinical testing services, and assignment of duties to dental auxiliary personnel. In contrast to the state-based licen sure system, a system controlled by the federal government would have only one decision-making unit. Cen tralized decision making is contrary to the best interests of the public. Fur thermore, the possibility of experi mentation with a subset of the entire country would be hampered or elim inated. Influence on the Dental Curriculum: Dental schools have a responsibility to graduate individuals capable of practicing dentistry. Since meeting licensure requirements is a prerequi site to practice, dental schools also prepare students to pass licensure ex aminations. Consequently, the agency that establishes licensure standards can have an influence over dental cur rículums. Under the state licensure system this influence is shared among 53 jurisdictions, and thus moderated. With a single federal agency setting standards, the influence of licensure examinations might become excessive and virtually dictate the content and emphasis for all dental currículums. This centralization would tend to make a static situation which would inhibit evolution and change. Also, the cooperation that has developed among educators, examiners, and the practicing profession at the state level has been effective in dealing with the relationship between licensure re quirements and the dental curriculum. The same degree of cooperation could not be expected at the federal level. Enforcement: Licensure involves more than issuing licenses to candi dates who qualify. Regulatory agen cies also must ensure that licensed dentists maintain competence and practice in accordance with the law. It is in this policing function that fed eral licensure seems most inadequate. To be most effective, regulatory re sponsibility should be placed at the lowest level of government capable of performing the function—in this in 572 ■ JADA, Vol. 91, Septem ber 1975
stance, the state, through its board of dentistry. Summary: For the reasons cited, the American Dental Association strongly opposes federal licensure and federal intervention in the state licens ing system. Evaluation of Need for Repeating a Licensure Survey: The 1973 House of Delegates adopted a resolution direct ing that a survey of attitudes on dental licensing procedures be repeated in three to five years to determine wheth er changes in attitudes about licen sure were occurring (Trans 1973:721). With adoption of this resolution, a licensure survey would be repeated in or before 1978. The Board of Trustees requested that the 1974 Special Com mittee of the Association to Study Dental Licensing Procedures com ment on whether a licensure survey should be repeated prior to 1978. The 1974 Special Committee saw no reason to repeat the survey in the near future, but expressed the view that the agency studying licensing matters after 1974 would be in a better position to recommend timing for re peating a licensure survey. The Commission on Licensure is that agency. At this time, the Com mission sees no useful purpose that would be served by repeating an at titude survey prior to 1978. The pro posal to repeat an attitude survey in three to five years was initiated by the original or 1973 Special Commit tee. Its interest was in studying whether the difference in response patterns for various age groups re flected changing times or a change in vantage point. It was speculated that both might be factors. A student fac ing licensure examinations or a den tist approaching retirement age might be expected to have attitudes differ ent from those of dentists intending to maintain their present practices for another 20 years. The Commission agrees that this might be an interesting study, but feels that there are more productive activities that need to be addressed in the area of licensure. In the Commission’s view, repeating an attitude survey before positive chang es are made and more information on licensure disseminated would pro
duce little additional useful informa tion. Planned Activities: In approaching its assignment to study all aspects of licensure, the Commission found itself in the position of having to narrow its focus for 1975 to the four items covered in this report. A number of other items were identified as need ing study. In addition to obtaining broader input for refining guidelines for issuing state licenses on the basis of credentials, the Commission plans to direct attention to mechanisms for improving liaison among examiners, educators, and the practicing profes sion; possible relations between peer review and licensure; performance standards in licensure examinations and criteria for evaluation; merits or disadvantages of multiple state licens es; and enforcement problems. RESOLUTIONS 1.Resolved, that the American Dental Association, through its constituent and component societies, strongly urge state boards of dentistry, con sonant with their responsibility to the public, to adopt systems of li censure by credentials which will permit licensed dentists the free dom of interstate movement. 2. Resolved, that the Statement on
Controls Necessary to Fulfill Pub lic Responsibility be approved as interim policy of the American Dental Association. 3. Resolved, that the Statement on
Federal Intervention in Licensure be approved. Commission on Licensure: Robert B. Dixon, Texas, 1976, chairman-, C. F. Barrett, Iowa, 1975; Ashur G. Chavoor, District of Columbia, 1976; James E. Connolly, Massachusetts, 1975; John Cook, Washington, 1976; Robert E. Doerr, Michigan, 1975; Lee E. Haines, New Mexico, 1977; Duncan A. King, Kentucky, 1975; Judson Klooster, California, 1977; Richard A. Kozal, Illinois, 1977; Ed mund R. Mihalski, Pennsylvania, 1976; William P. Schlansker, New York, 1975; Robert E. Shellenberger, Indiana, 1977; John A. Stewart, Flor ida, 1975; John M. Coady, staff dir
ector.
