Current issues and areas for improvement in the Korean Dental Hygienist National Licensing Examination: an expert Delphi survey among dental hygienists

PURPOSE

This study aimed to investigate current issues and areas for improvement in the Korean Dental Hygienist National Licensing Examination (KDHNLE) through an expert Delphi survey.

METHODS

A Delphi survey was conducted from May through August 2016 in Korea. This Delphi survey included 20 persons representing the field of dental hygiene (7 groups from various dental hygiene-related organizations). The Delphi survey was administered through e-mail as 3 rounds of questionnaire surveys regarding the issues facing the KDHNLE and potential solutions to those challenges. The primary Delphi survey was an open questionnaire. In each round, subjects' responses were categorized according to the detailed themes of their responses. The minimum value of the content validity ratio of the survey results was determined by the number of panels participating in the Delphi survey.

RESULTS

Issues facing the KDHNLE were identified from the results of the Delphi survey. The following 4 items had an average importance score of 4.0 or higher and were considered as important by over 85% of the panels: the failure of the practical test to reflect actual clinical settings, the focus of the practical test on dental scaling, the gap between the items evaluated on the national examination and actual practical work, and insufficiency in strengthening the expertise of licensed dental hygienists. The following items were suggested for improvement: more rigorous rater training, adjustment of the difficulty of the licensing examination, the introduction of a specialized dental hygienist system, and more rigorous refresher training for licensed dental hygienists.

CONCLUSION

Based on the above results, the KDHNLE should be improved according to the core competencies of dental hygienists, including on-site clinical practice experience.

Establishment of a dental license regulation authority is required in Korea: results of the Delphi technique

PURPOSE

In addition to dental education, a system for the evaluation and management of dental licensing and certification is required to meet the growing societal demand for more competent dentists. In this study, the Delphi technique was used to gather opinions from a variety of professionals on the problems of and remedies for the dental license management system in Korea.

METHODS

Delphi surveys were conducted from April 2016 to October 2016 in South Korea. A variety of dental professionals were included and categorized into 3 groups according to their expertise as follows: the basic dentistry group, the clinical dentistry group, and the policy group. The Delphi technique was conducted in 3 rounds of e-mail surveys, each with different questions that probed with increasing depth on the dental license management system. In each successive round, the responses were categorized, scored on a Likert scale, and statistically analyzed.

RESULTS

After categorizing the results of the first survey and ranking the results of the second survey using the Delphi technique, regulation by a licensing authority was found to be the most critical issue. This was followed by the license renewal system, continuing education, a tiered licensure system, improvement of foreign license approval, and utilization of retirees, in decreasing order of importance. The third Delphi survey showed a similar ranking, with regulation by a licensing authority being the major concern. Opinions regarding the dental license management system were provided as open-ended responses. The responses of the 3 groups showed statistically significant differences in the scores for the issue of regulation by a licensing authority. After re-grouping into the dentistry group and the policy group, the issue received a significantly higher score in the dentistry group.

CONCLUSION

The quality of dental treatment should be managed to protect patients and dental professionals. For this purpose, the establishment of an independent license regulation authority along with legislative changes is required.

Non-Patient-Based Clinical Licensure Examination for Dentistry in Minnesota: Significance of Decision and Description of Process

In recent years in the United States, there has been heightened interest in offering clinical licensure examination (CLE) alternatives to the live patient-based method in dentistry. Fueled by ethical concerns of faculty members at the University of Minnesota School of Dentistry, the state of Minnesota's Board of Dentistry approved a motion in 2009 to provide two CLE options to the school's future predoctoral graduates: a patient-based one, administered by the Central Regional Dental Testing Service, and a non-patient-based one administered by the National Dental Examining Board of Canada (NDEB). The validity of the NDEB written exam and objective structured clinical exam (OSCE) has been verified in a multi-year study. Via five-option, one-best-answer, multiple-choice questions in the written exam and extended match questions with up to 15 answer options in the station-based OSCE, competent candidates are distinguished from those who are incompetent in their didactic knowledge and clinical critical thinking and judgment across all dental disciplines. The action had the additional effects of furthering participation of Minnesota Board of Dentistry members in the University of Minnesota School of Dentistry's competency-based curriculum, of involving the school's faculty in NDEB item development workshops, and, beginning in 2018, of no longer permitting the patient-based CLE option on site. The aim of this article is to describe how this change came about and its effects.

The Buffalo Model: Shifting the Focus of Clinical Licensure Exams in Dentistry to Address Ethical Concerns Regarding Patient Care

Most jurisdictions grant dental licensure to graduating students following successful completion of a clinical exam. Testing agencies, which are independent of dental schools, nevertheless conduct their exams at school facilities. Patient participation in these exams raises ethical concerns regarding such issues as unlicensed providers' performing irreversible procedures with minimal supervision and graduates' limited accessibility to provide follow-up treatment. To address these concerns, a collaborative effort between University at Buffalo School of Dental Medicine faculty and testing agency personnel was launched. The aims of this article are to describe the development and implementation of the resulting Buffalo Model, to highlight ethical advantages in its application, and to identify areas of improvement to be addressed in future iterations. With the Buffalo Model, modifications were made to the traditional exam format in order to integrate the exam into the school curriculum, enabling candidates to take it at various points during their fourth year. In addition, after calibration of school faculty members, 98.5% of cases verified by faculty were accepted by the Commission on Dental Competency Assessments for use in the exam. In two cases, restorative treatment completed during the exam did not meet the school's competency standard. This new approach ameliorates ethical concerns associated with clinical licensure exams because treatment is provided only to patients of record within a sequenced treatment plan and timely and appropriate treatment is provided to all patients. The results of this first year of implementation also suggest that calibrated faculty members will not show bias in the selection of lesions or competency evaluations of candidates.

Attitudes and perceptions of U.S. dental students and faculty regarding dental licensure

The aim of this study was to assess the attitudes and perceptions of U.S. dental students and faculty members about National Board Dental Examination (NBDE) pass/fail reporting, an Integrated NBDE, clinical examinations, licensure process and strategies, and validity of licensure. A survey instrument consisting of ten statements with response options on a five-point Likert scale and a free-text comment section was developed and distributed through SurveyMonkey. A total of 411 students and 186 faculty members from ten U.S. dental schools participated, with an estimated response rate of 17%. Faculty and student responses were compared using the Mann-Whitney U test. These students' and faculty members' attitudes and perceptions were similar. Both groups showed mixed attitudes about NBDE scores as pass/fail, rather than numerical scores. The Integrated NBDE solicited mixed opinions and concerns that it would be complicated and stressful because students would be challenged to memorize information from earlier years. However, a single national clinical examination was highly preferred by both groups, preferably with simulated rather than real patients. Other strategies, such as background checks and continuing education requirements, were supported by both groups. Most of the licensure process strategies and policies were supported by both student and faculty respondents in the dental schools surveyed.

Validity and reliability of portfolio assessment of student competence in two dental school populations: a four-year study

The purpose of this study was to empirically investigate the validity and reliability of portfolio assessment in two U.S. dental schools using a unified framework for validity. In the process of validation, it is not the test that is validated but rather the claims (interpretations and uses) about test scores that are validated. Kane's argument-based validation framework provided the structure for reporting results where validity claims are followed by evidence to support the argument. This multivariate generalizability theory study found that the greatest source of variance was attributable to faculty raters, suggesting that portfolio assessment would benefit from two raters' evaluating each portfolio independently. The results are generally supportive of holistic scoring, but analytical scoring deserves further research. Correlational analyses between student portfolios and traditional measures of student competence and readiness for licensure resulted in significant correlations between portfolios and National Board Dental Examination Part I (r=0.323, p<0.01) and Part II scores (r=0.268, p<0.05) and small and non-significant correlations with grade point average and scores on the Western Regional Examining Board (WREB) exam. It is incumbent upon the users of portfolio assessment to determine if the claims and evidence arguments set forth in this study support the proposed claims for and decisions about portfolio assessment in their respective institutions.

[Dentists' workforce in Hungary and international migration]

In Hungary, cross-national migration in dental care was performed rather by patients from abroad instead of the domestic dentists' migration for working abroad. Actually, this tacitly realized and so-called dental tourism experienced two basic changes. The National Medical Tourism Ltd. arranged the First Conference for Development of Dental Tourism on 21 April 2011. Hungary's prime minister addressed the meeting and finally signed an agreement with the organizing Ltd. about governmental financial support for development of dental tourism. On the other hand, Germany and Austria deleted all restrictions against the free cross-national workforce migration since 1 May this year. For understanding and prognosis of dentists' future migration, it is inevitable to collect and analyse relevant data of the previous years. This study is presenting data obtained from January 1, 2006 to December 31, 2010. According to the net outcome, the dentists' human resource system was balanced down to the end of 2010. However, this state is unsure even for the near future, thus preventing the deficit of dentists all necessary measures must be taken to keep up the present level of the domestic dentral service.

Board-to-board consistency in initial dental licensure examinations

The consistency between student clinical performance in dental school and performance on initial licensure examinations is known to be weak. A review of the literature failed to identify any reports of the consistency between performance on initial licensure examinations and quality of technical work in practice. This research examines the consistency of performance among candidates who took two initial licensure examinations given by different testing agencies but for the same jurisdiction within a few weeks of each other. Twenty-seven candidates from one dental school took both the California Dental Board examination and the Western Regional Examining Board initial licensure examinations in 2005 and 2006. Their performance on the patient-based amalgam and composite restorations and the root planing tests were compared in these two board settings and with various dental school measures of competence. Consistent with previous findings, school-to-board performance was barely above chance levels. Board-to-board association was also insignificant and accounted for 12 percent of the common variance in the best case. Patient-based initial licensure examinations have yet to demonstrate validity in terms of consistency of performance for candidates from one performance to the next.

The hidden curriculum and my three wishes

Personal ideals often clash with the reward structure of dental education. The hidden curriculum sometimes teaches corner-cutting and worse while publically espousing high standards. Changing the professionals without changing the profession in which they work multiplies frustration and offers little hope of progress. Three wishes for changes to the system are identified: (a) fixed dates for National Board testing, (b) comprehensive admissions standards, and (c) no live-patient, one-shot initial licensure examinations.

Dental education in a flat world: advocating for increased global collaboration and standardization

Globalization is a broad term referring to the increasing connectivity, integration, and interdependence of economies, societies, technologies, cultures, and political and ecological spheres across the world. This position paper was developed by a working group of the 2007 American Dental Education Association (ADEA) Leadership Institute. The authors explore the effect that globalization has had on dentistry and dental education to date and hypothesize what dental education could look like in the years ahead. While the paper is written from a North American perspective, some of the authors bring international expertise and experience to the topic of global dental education in a flat world. Specific issues and barriers addressed in this position paper include variations in accreditation and licensure requirements in dental education throughout the world; the historical development of dental education models (odontology and stomatology) and the need for congruency of these models in the global environment; the competency-based model of education and its relevance to development and implementation of global dental competencies; and the slow adoption of technological advances in dental education for promoting collaborations and encouraging resource sharing among countries. These challenges are discussed as they affect the implementation of a standardized global dental education that can lead to improved access to oral health care services and better oral and overall health for the citizens of the world.

The American Board of Dental Examiners Clinical Dental Licensure Examination: A Strategy for Evidence-Based Testing

The evolution and implementation of a uniform national clinical examination has become a reality under the guidance of the American Board of Dental Examiners (ADEX). The defined purpose of this examination is to provide a defensible construct that assesses the critical clinical competencies of dental and dental hygiene candidates that will differentiate between competent and incompetent entry-level practitioners. The author includes a discussion of validity evidence that will be gathered by ADEX in order to support the decisions and interpretations made concerning competency and the agency's claim for validity. Included is a brief discussion of some controversial opinions regarding general validity concerns involving clinical dental licensure exam constructs. The author intends for this manuscript to provide a better appreciation for the science of psychometrics as it is applied to evidence-based testing for entry-level dental and dental hygiene candidates.

Continuing dental education requirements for relicensure in the United States

BACKGROUND

Mandatory continuing education (CE) is an almost universal requirement for relicensure of dentists in the United States. In recent years, computer-based methods have become more widely adopted as a vehicle for earning CE credits. To obtain a comprehensive overview of CE requirements in the United States, the authors conducted a survey on how computer-based CE methods are regulated.

METHODS

The authors reviewed the dental statutes of 50 states and the District of Columbia regarding the license renewal period, required number of CE hours, limitations on clinical and nonclinical subjects, on-site versus independent-study courses, and other requirements regarding CE.

RESULTS

The authors found that 45 states and the District of Columbia mandate CE for relicensure at this time. Most dentists were required to complete approximately 20 hours per year. Ten states specified a minimum number of clinical hours, 17 states limited nonclinical hours, and seven states placed constraints on both clinical and nonclinical CE. Sixty-five percent of states limited the number of CE credits that could be accumulated through independent study. Specific requirements for computer-based methods of earning CE credits were absent in general.

CONCLUSIONS

State licensing boards across the United States have implemented comprehensive requirements for CE. Few, if any, provisions addressed computer-based methods of earning CE credits.

PRACTICE IMPLICATIONS

Given the increasing adoption of computer-based methods of earning CE credits, state dental boards and accrediting agencies may want to consider steps to improve the quality of computer-based methods of earning CE credits.

Clinical licensure exams: the unruly gatekeepers

A dental student approaching graduation reflects on concerns over initial licensure examinations. Among the issues that have been recognized but remain unaddressed are ethical treatment of live patients, unfair treatment of candidates, excellent reliability among examiners on any single case but poor consistency across testing, lack of validity, and no evidence of protecting the public. The licensure system would be improved by paying attention to issues of mobility and continued competence.

The relationship between performance in a dental school and performance on a clinical examination for licensure

BACKGROUND

Licensure examinations in dentistry have become an increasing concern, owing to ethical issues in the use of patients, difficulties in seeing relationships between outcomes of licensure examinations and performance in educational programs, and questions on the reliability of "one-shot" clinical examinations. Using data from a nine-year period, the authors compared the results of clinical licensing tests and the academic class ranks of the candidates.

METHODS

The authors studied data for 835 dental school graduates of one school from 1994 through 2002. They compared the dental graduates' results from the North East Regional Board, or NERB, of Dental Examiners examinations with their class ranks. The authors used analysis of variance to analyze the differences among passing, failing and "no data" groups, kappa statistic and logistic regression for variation, and receiver operating characteristic, or ROC, curves for diagnostic utility.

RESULTS

The class rank of graduates who passed and failed NERB's restorative section of the examination did not differ. Differences for other sections of the examination were statistically significant but small. The variation in restorative and manikin exercises over time was highly significant. No consistency existed between these tests, and their ROC curves indicated no utility for diagnosing class rank.

CONCLUSIONS

The authors' analysis of nine years' data called into question the reliability and validity of initial licensure examinations based on certain of the one-time tests used by NERB. Future study should determine if the results generalize to other schools and clinical testing agencies.

PRACTICE IMPLICATIONS

If the results of this study can be generalized to all U.S. licensure examinations, basing licensing decisions on clinical licensure examination alone risks licensure decisions of low validity. Use of patients in examinations of questionable validity may be unethical because they may have been subjected to risk of irreversible damage without contribution to a valid decision-making process by the licensing authority.

Convergence towards higher standards in international dental education

This paper emanates from the findings of "DentEd" and "DentEdEvolves," two sequential European Union-funded Thematic Network Projects on Dental Education. Despite the existence of EU Directives and Guidelines, which were devised to assure comparable and acceptable standards of dental education and competence gained from training programs, there are serious differences among countries. The differences are greater in those countries about to join an expanding EU, where the stomatological approach to education predominates. Both projects had considerable support and advice from the Association from Dental Education in Europe, the American Dental Education Association and the International Federation of Dental Education Associations. An international effort is now proposed to converge towards higher standards in dental education by agreeing to broad principles for the "Profile of an International Dentist" (see www.dented.org/dresden.php3). The UK's General Dental Council recently adopted its profile of a dentist, which is compatible with and related to the EU's Dental Directives and Guidelines (see www.gdc-uk.org/pdfs/first_five_years_2002.pdf). An agreed profile provides a basis on which to structure a pan-European approach and could be more widely adopted. Dental schools throughout the world might be asked to verify those elements with which their graduates actually comply. It is also intended to use the profile as a basis for a modularized approach that would facilitate students studying elements of their course in different universities as part of an EU drive towards convergence in third- level education. It is not intended to promote a single educational approach. Unfortunately, at this stage, it will have little impact on global ill health, mainly associated with poverty and more recently the HIV/AIDS pandemic. The University of Columbia's Earth Centre has made enormous strides in focusing attention on global health and deprivation. Almost one-sixth of the world's population is starving. In sub-Saharan Africa, where poverty is exacting its greatest toll, the HIV/AIDS pandemic is devastating populations, including health care workers. Realistically, our impact as dental educators on global health will be limited. Nevertheless, a better educated and understanding profession is more likely to apply the benefits of knowledge, science and affluence to help those most in need.

Portfolios for determining initial licensure competency

BACKGROUND

Because attempts to improve initial licensure examinations have not been grounded in measurement theory, partial and inadequate remedies have led to a cycle of refutations, defenses and political polarization.

TYPES OF STUDIES REVIEWED

The author reviewed the psychometric literature, focusing on high-stakes professional decisions. Editorials in the dental literature and position papers of involved organizations often use words from this literature without incorporating its fundamental concepts.

RESULTS

The reliability of one-shot initial licensure examinations is estimated to be approximately r = .40, which is a value well under the standard for such tests in other professions. Validity has not been investigated rigorously, but the one-shot format and proposals to remove live patients certainly would reduce validity. The use of portfolios--a small number of evaluations in several realistic task domains--is a viable means of achieving psychometric standards for initial licensure decisions.

CLINICAL IMPLICATIONS

Boards are charged with making valid and reliable licensure decisions, not with conducting examinations. At a minimum, they must define the competencies of beginning practitioners and establish the psychometric criteria for their decisions (neither of which are done currently). Gathering data then can be delegated to whoever is best qualified to meet these standards.

Confirming the validity of Part II of the National Board Dental Examinations: a practice analysis

Successful completion of Part II of the National Board Dental Examinations is a part of the licensure process for dentists. Good testing practice requires that the content of a high stakes examination like Part II be based on a strong relationship between the content and the judgments of practicing dentists on what is important to their practice of dentistry. In an effort to demonstrate this relationship for Part II, the Joint Commission conducted a practice analysis, which involved a two-dimensional model. The sixty-three Competencies of the New Dentist, developed and promulgated by the American Dental Education Association, were used for one dimension, and the current content specifications were used for the other. A survey of 520 practicing dentists was conducted to determine the importance of each of the competencies for patient care. These dentists were recent graduates of accredited programs and passed Part II three to five years prior to the conduct of the practice analysis. The survey directed the respondents to rate the importance of the competencies on a scale from 1 to 5. Of the 520 in the sample, 244 dentists responded. The reliability index was above 0.90. The importance rating for each competency was translated into the associated number of items. The number of items devoted to each competency was allocated to the current content elements that are related to the knowledge and problem-solving skills that support each competency. The findings specified revisions in the relative number of items dedicated to the various elements in the specifications. These findings indicate that the items on the examination under the current distribution adequately reflected practice. In general, there were relatively small changes in the content specifications. The total number of changes in items was forty-eight, which represents changes in slightly less than 10 percent of the overall number of items.