Bulletin of Dental Education

Dental Hygiene Licensure: Demonstrating Flexibility During a Pandemic

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UNMC Manikin PhotoWhen the COVID-19 pandemic surged to the point of becoming a national emergency in mid-March, the ramifications for dental higher education and the pathway to licensure were unclear.

Yet, three months after students in the University of Nebraska Medical Center College of Dentistry (UNMC COD) Dental Hygiene program graduated, they were finally able to take their licensure exams, thanks to the creative efforts of dental hygiene faculty.

Unable to take the traditional clinical, patient-based licensure exam due to the restrictions of the pandemic, all of the students successfully passed the nation’s first dental hygiene simulated patient examination performed on a manikin.

When the pandemic was upon us and our university closed, we immediately committed to educating our students with the goal of ensuring they would graduate on time. For the remaining five weeks of the semester, lectures continued without interruption on Zoom and other remote platforms. The challenge became our clinical and laboratory educational experiences and assessments, due to the closure of clinics to all but emergency care. Faculty quickly developed objective, structured clinical examinations to evaluate adjunct procedures, such as amalgam marginations and placement of localized chemotherapeutics, among others. Patient education and caries risk assessments were evaluated during senior case presentations via Zoom. Clinical skills assessment was conducted via individual, two-hour Zoom sessions with faculty focusing on instrumentation technique and identifying weaknesses in students’ skills. Faculty and students alike soon came to appreciate alternative methodologies for teaching and evaluating clinical skills. Our virtual graduation occurred on time, on May 7, with all dental hygiene students having met the requirements of the program.

Amidst the joys of several virtual celebrations, stress levels among the graduates continued to rise as most had secured employment but were unable to practice until completing the National Board Dental Hygiene Exam (NBDHE) and a required clinical licensure examination. 

The ability to take the NBDHE was finally resolved, but meant that over the course of three months, our graduates traveled to five different states to sit for the NBDHE. The clinical examination, however, remained in question, due to the numbers of COVID-19 positive individuals in our community and state and the directed health measures in place. It became apparent that the likelihood of a traditional patient-based examination would not be possible in the near future. Meanwhile, important conversations were taking place with the Nebraska Department of Health and Human Services, the Nebraska Board of Dentistry and a regional testing agency concerning the predicament of a patient-based licensing examination and possible alternatives.

Ongoing conversations with Central Regional Dental Testing Service (CRDTS) resulted in their willingness to administer the first simulated patient dental hygiene manikin exam by adapting their dental periodontal manikin examination to accommodate the new graduates. Approval was obtained from the Nebraska Board of Dentistry to allow the 2020 dental hygiene graduates to complete a manikin exam for licensure. 

Simulated patient examinations on manikins were initially created as a remediation and re-licensure resource for state dental boards. The examination components contained in the CRDTS Simulated Patient Manikin Examination are aligned with those in the current patient-based examination construct evaluating the same clinical skillsets, including:

  • Periodontal measurements,
  • Calculus detection,
  • Subgingival and supragingival calculus removal using hand and ultrasonic instrumentation and
  • Tissue and treatment management.

On June 26, 22 UNMC dental hygiene graduates and one outside candidate sat for the adapted simulated patient manikin dental hygiene exam administered by CRDTS. To conduct the examination, infection control protocols were followed according to state and local health directives and included appropriate personal protective equipment and social distancing. All students and examiners were screened prior to entry into the college and temperatures taken. The examination was overseen by a CRDTS clinic floor examiner in the UNMC COD’s dental hygiene clinic on a simulated patient using a manikin typodont provided by CRDTS. An anonymous, calibrated CRDTS examining team conducted three independent assessments. Evaluation criteria were the same as the traditional patient-based examination. Individual results were disclosed to the candidates at the completion of the examination. The CRDTS executive director reported the candidate scores to the UNMC Dental Hygiene Program Chair as well as the Nebraska Board of Dentistry. Post-examination statistical data and analysis will be provided at a later date.

Keys to the success of this alternative approach to a traditional patient-based examination were the support of our institution’s administration, the faculty dedicated to the program, the profession, the students’ success, and ongoing discussions with the state board of dentistry and the testing agency. Without this unified approach, the graduates would likely still not be eligible for licensure.

The person hours devoted to this collaborative effort required us to open our minds, drop historical biases about the clinical evaluation process, and as always, keep the focus on preparing our students for graduation and licensure. We have realized and cannot emphasize enough the important role that the dental hygiene program faculty play in advocating for their students and working with their respective institution, state boards of dentistry and testing agencies to reconsider traditional patient-based examinations. 

A paradigm shift from a patient-based exam to a manikin exam in this pandemic helped address concerns such as stress on the candidates, the lack of patient availability, the safety of the patients and candidates, and associated financial concerns. 

As Commission on Dental Accreditation (CODA) accredited programs, the faculty of a dental hygiene program have the responsibility to determine if students are clinically prepared for today’s dental hygiene practice. Assessments are done continually throughout the dental hygiene program to ensure that the student has the knowledge, skills and values to practice dental hygiene. Third-party testing agencies currently serve as the platform for regulatory clinical evaluation leading to licensure required by individual states.

Strategic changes and updates in examination content and criteria by third-party testing agencies are needed to address the ever-changing dental and dental hygiene professions as are periodic statutory changes for licensure. Examples of such historic paradigm shifts include:

  • Local anesthesia administration,
  • Utilization of ultrasonics,
  • Restorative procedures for expanded function dental hygienists and assistants, and
  • Clinical licensure examination for dental therapists.

We are grateful to have been pioneers for the first simulated patient manikin examination for our dental hygiene graduates in lieu of a patient-based examination. These innovative and strategic changes addressed many safety issues and candidate concerns during this pandemic. Importantly, the opportunity to complete this examination eliminated a potential months-long wait for licensure and our graduates are now fully employed.

As a result, many of the lessons learned would indicate there is a future for the use of simulated patient manikin-based examinations:

  • For safety reasons,
  • To standardize the clinical evaluation process for all candidates,
  • To prevent unexpected financial costs to candidates for patient participation,
  • To eliminate long-standing ethical concerns regarding the use of human subjects as patients, and
  • For licensure portability.

We highly encourage dental hygiene faculty and dental hygiene programs to work with their institutions and their individual state dental boards and testing agencies to consider flexibility in statutory language not just in these pandemic times, but going forward. Manikin-based examinations may be part of this solution.

Courtesy of University of Nebraska Medical Center College of Dentistry Dental Hygiene Department

Published on August 12, 2020

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