Full manikin licensure: Our new (and improved) normal

As an experienced Southern Regional Testing Agency (SRTA) dental hygiene examiner who’s been in the dental industry for more than 30 years, I’ve seen hundreds of students proudly move forward in their careers upon passing their clinical exams.

This year, I’ve had the pleasure of helping to develop and administer one of the first manikin-based exams to address the unique challenges presented by the coronavirus pandemic. My most recent exam took me to Chattanooga State Community College where I witnessed future dental hygienists testing their clinical skills on a manikin typodont rather than a selected patient. It went well.

• Traditionally, every dental hygiene student must complete the following requirements for licensure:
• Accredited dental hygiene education
• Successful completion of written National Board Dental Hygiene Examination (NBDHE)
• Successful completion of clinical skills examination

Dental and dental hygiene licensing can be obtained through five licensing agencies, and it’s up to each state which agencies to accept. SRTA, one of the five licensing agencies, has been making significant strides at modernizing the dental and dental hygiene licensing process—always with the safety of the students, patients, and schools as its top priority. Around for 45 years and accepted across 70% of the United States, SRTA was one of the first agencies to develop and administer a complete manikin-based dental hygiene licensing exam.

Before the pandemic

Before this year, SRTA’s dental hygiene clinical licensing exam consisted of:

• Presenting radiographs that are of diagnostic quality
• Detecting all types of dental calculus and recognizing when a surface is free of calculus
• Completing a partial oral prophylaxis while preserving the integrity of the surrounding tissue
• Completing a partial periodontal assessment by recording periodontal pocket depths
• Presenting an eligible patient and a case selection that meets all required criteria

Historically, both dental and dental hygiene students were required to perform these clinical exams on live patients. The use of live patients has been a topic of debate for a number of years, and many in the dental industry hope to transition to a complete manikin-based licensing exam.

Taking into account the prevailing perspective, SRTA began developing fully manikin-based dental and dental hygiene exams more than two years ago with a focus on the best real-world simulation. I believe that evaluating students’ hands-on clinical skills is crucial to arriving at an honest, thorough assessment, but I do not believe that this necessitates live patients.

While SRTA was on its way to offering complete manikin-based exams for dental and dental hygiene well before 2020, COVID-19 brought a sense of urgency to the process. Schools and dental practices were closing; the whole dental and dental education industry was halted. Because of health and safety guidelines, using live patients to obtain licensure was no longer an option. The unforeseen circumstances brought on by the pandemic proved that the current curriculum could not continue without schools and state boards needed to adapt to complete manikin-based examinations, at least for a limited time.

Hands-on clinical skills

While SRTA will continue to offer both live and manikin-based testing, challenges with using live patients in testing have always been prevalent. Patients must be identified for the exam, they must be present on exam day, and then there’s always the possibility that issues will arise that cause the patient to fall short of testing requirements on exam day.

There are some in the industry who feel that a clinical licensing examination is not needed. Some conclude that dental hygiene students go through enough clinical practice in their schooling that the requirement of a hands-on clinical exam is redundant. Up until recently, hygiene candidates were required to find and test on live patients, which even before the pandemic had its own safety and ethical concerns. Back in 2018, the American Dental Hygienists’ Association House of Delegates announced its support of eliminating the use of live patients for clinical exams.

It has been said that the licensing exam is a one-time snapshot of a candidate’s work, but it can also be argued that a candidate should, by that point, possess the skills and knowledge to successfully detect the presence or absence of calculus, correctly take periodontal measurements, remove calculus, etc. The clinical exam is not a barrier to preventing these candidates from becoming practicing dental hygienists; it is an overview of what they have learned and what is expected of them to safely and adequately practice in the industry. It bestows validity and legitimizes the candidate’s skill set.

Candidates taking the SRTA exam are scored using a triple-blind scoring system by three examiners calibrated at every exam. A testing agency takes away any form of bias by asserting anonymity into evaluation and assessment. The manikin-based exam also levels the playing field by presenting a manikin that is standardized from candidate to candidate, unlike traditional live-patient exams.

The SRTA examination was developed to provide reliable clinical assessments for state boards to make valid licensing decisions. It has been developed, administered, and reviewed in accordance with guidelines from the American Dental Association (ADA), the American Association of Dental Boards (AADB), the American Psychological Association (APA), the American Educational Research Association (AERA), and the National Council on Measurement in Education (NCME).

We know there is a critical need to independently assess the hands-on skills of our students, and no written or online test can make that determination. New technology has helped, as we can now assess candidates on high-tech simulators that mirror the real world, and we can do that so confidently that it is suitable even for testing situations.

A justifiable alternative

With SRTA’s complete manikin-based exam, students are released from the burden of finding their own patients to test their clinical skills, but they are still able to efficiently perform on typodonts that simulate real-tooth anatomy and accurate occlusion.

This modernized exam follows the same criteria and process as the patient-based exam. It remains a thorough assessment that includes proper tissue management, detecting various types of dental calculus, and completing a partial oral prophylaxis and partial periodontal pocket depth assessment. These manikin-testing modules give measurable probing depths, a realistic sense of pressure, and a lifelike feel when removing calculus. Candidates may use power scalers as well as hand scalers with instruments of their choosing.

The typodont offers a more reasonable and reliable testing environment for students because they no longer run the risk of finding live patients who are deemed unacceptable by examiners the day of the test. The absence of a live patient also extinguishes the risk of disease transmission. Manikins have the added benefit of leveling the playing field, as every student’s exam is exactly the same—something impossible with live patients.

Moving forward

Please keep in mind that the acceptance of manikin-based exams remains at the discretion of state regulatory boards. I encourage everyone to advocate for SRTA and its complete manikin-based exams. We meet criteria that state boards require, whether a traditional exam or a manikin-based exam is needed. While SRTA will continue to offer live-patient exams, we recognized the safety risks and began the transition to a complete manikin-based exam well before the severity of COVID-19 was widely understood, making us a pioneer in this consistent, risk-free, hands-on method of clinical testing.

I’m incredibly proud of the adaptability of the dental industry, especially of those actively advocating for our dental and dental hygiene students. Supporting a quality manikin-based licensing exam that properly assesses the knowledge and hand-skills of future dental professionals will only add credibility to our industry and attract the best and brightest prospective students.