The Florida Senate
BILL ANALYSIS AND FISCAL IMPACT STATEMENT
(This document is based on the provisions contained in the legislation as of the latest date listed below.)
Prepared By: The Professional Staff of the Committee on Health Policy
BILL: SB 1366
INTRODUCER: Senator Brodeur
SUBJECT: Licensure Examinations for Dental Practitioners
DATE: March 23, 2021 REVISED:
ANALYST STAFF DIRECTOR REFERENCE ACTION
1. Rossitto Van-
Brown HP Favorable
Winkle
2. JU
3. RC
I. Summary:
SB 1366 authorizes the Board of Dentistry (BOD), within the Department of Health (DOH), to
accept passing examination scores for the dental and dental hygiene clinical licensure
examinations developed and administered by the Western Regional Examining Board (WREB)
for licensure as a dentist or dental hygienist as an additional clinical licensure examination. The
bill also:
 Amends legislative intent;
 Requires the BOD to maintain representation on the American Board of Dental Examiners,
Inc.(ADEX) and the WREB’s boards of directors, examination development committees, and
any additional committees the BOD requires to ensure examination standards are maintained;
 Authorizes clinical licensure examinations for dentists and dental hygienists to utilize
mannequins1 during the examinations upon BOD approval; and
 Makes additional conforming changes.
The bill provides an effective date of July 1, 2021.
II. Present Situation:
The Practice of Dentistry
The BOD regulates dental practice in Florida, including dentists, dental hygienists, and dental
assistants under the Dental Practice Act.2 A dentist is licensed to examine, diagnose, treat, and
1
The word “mannequin” is used in ss. 466.006 and 466.007, F.S., but the word “manikin” is used throughout all the materials
researched, including the American Dental Association and the various dental and dental hygiene testing agencies, so they
will be used interchangeably in this analysis.
2 Section 466.004, F.S.
BILL: SB 1366 Page 2
care for conditions within the human oral cavity and its adjacent tissues and structures.3 A dental
hygienist provides education, preventive, and delegated therapeutic dental services.4
Florida currently uses the American Dental Licensing Examination (ADLEX) and the American
Dental Hygiene Licensing Examination (ADHLEX) for its clinical examinations. Both are
produced by the American Board of Dental Examiners, Inc. (ADEX),5 as the legislatively
mandated state clinical licensure examinations for dentists and dental hygienists.6 Both clinical
examinations are administered by two national testing agencies:
 Commission for Dental Competency Assessments (CDCA).
 Council of Interstate Testing Agencies (CITA).
According to the American Dental Association (ADA) and the ADEX, there are currently five
national clinical testing agencies:7,8
 Commission for Dental Competency Assessments (CDCA);
 Council of Interstate Testing Agencies (CITA);
 Central Regional Dental Testing Services, Inc. (CRDTS);
 Southern Regional Testing Agency, Inc. (SRTA); and
 Western Regional Examining Board (WREB).
Only three jurisdictions currently administer their own clinical examinations:
 California;
 Delaware; and
 The U.S. Virgin Islands.9
Dentists
The requirements for dental licensure in Florida are found in s. 466.006, F.S. An applicant must
apply to the DOH to take and pass the following examinations:
 The ADLEX;10 and
 An exam on Florida laws and rules relating to dentistry.
3 Section 466.003(3), F.S.
4 Section 466.003(4) and (5), F.S.
5
The American Board of Dental Examiners, Inc. (ADEX) develops both dental and dental hygiene clinical examinations.
The first ADLEX exam was produced by the ADEX and administered in 2005; and is now simply called the “ADEX Dental
Exam” or the “ADEX Dental Hygiene Exam.” The ADEX does not administer examinations. For clarity purposes, this
analysis will continue to refer to American Dental Licensing Examination as the “ADLEX,” the American Dental Hygiene
Licensing Examination as the “ADHLEX,” and reserve the abbreviation “ADEX” for the American Board of Dental
Examiners, Inc.
6
See ss. 466.006(4)(b) and 466.007(4)(b), F.S.
7
American Dental Association, Licensure Pathways, available at https://www.ada.org/en/education-
careers/licensure/licensure-dental-students/licensure-pathways (last visited Mar. 18, 2021).
8
The American Board of Dental Examiners, Inc., ADEX. What ADEX Does available at https://adexexams.org/about-adex/
(last visited Mar. 19, 2021).
9
American Dental Association, Understanding Licensure, available at
http://www.ada.org/en/~/media/ADA/Education%20and%20Careers/Files/understanding-licensure (last visited Mar. 21,
2021).
10
Section 466.006, F.S.
BILL: SB 1366 Page 3
To take the ADLEX clinical examination, a dental applicant must be at least 18 years of age and
must be:
 A graduate from a dental school accredited by the ADA Commission on Dental
Accreditation (CODA) or any other dental accrediting entity recognized by the U.S.
Department of Education (DOE); or
 A dental student in the final year of a program at an ADA-CODA-accredited dental school
who has completed all the coursework necessary to prepare the student to perform the
clinical and diagnostic procedures required to pass the examinations. A passing score on the
examination is valid for 365 days; and
 Have passed Parts I and II of the National Board Dental Examination (NBDE), administered
by the Joint Commission on National Dental Examinations (JCNDE).11
Current law requires the ADLEX clinical dental examination to include the following:
 Comprehensive diagnostic skills examination including an examination, clinical diagnosis
and treatment planning;
 Two restorations on a live patient or patients;12
 Demonstration of periodontal skills on a live patient;
 Demonstration of prosthetics and restorative skills in complete and partial dentures and
crowns and bridges and the utilization of practical methods of evaluation;
 Demonstration of restorative skills on a manikin including procedures performed in
preparation for a cast restoration;
 Demonstration of endodontic skills; and
 Diagnostic skills examination demonstrating ability to diagnose conditions within the human
oral cavity and its adjacent tissues and structures from photographs, slides, radiographs, or
models.13
A dental school graduate from a school not accredited by the ADA CODA, a United States
DOE-recognized dental accrediting entity, or approved by the BOD, and desiring to take the
ADLEX, is not entitled to do so unless the applicant:
 Demonstrates completion of a program defined by BOD rule at an accredited American
dental school and receives either a D.D.S. or D.M.D. from the school; or
 Submits proof of successful completion of at least two consecutive years at a full-time
supplemental general dentistry program accredited by the ADA CODA.
11
American Dental Association, Joint Commission on National Dental Examinations, About the JCNDE, available at
https://www.ada.org/en/jcnde/about-us (last visited Mar. 19, 2021) The Joint Commission on National Dental Examinations
(JCNDE) is the agency responsible for the development and administration of the National Board Dental Examinations
(NBDE). This 16-member Commission includes representatives from dental schools, dental practice, state dental examining
boards, dental hygiene, dental students, and the public.
12
See Fla. Admin. Code R. 64B5-2.013 (2021), which specified the class of restorations required for the clinical examination.
It was repealed by the BOD in May 2012, after the clinical examination was transitioned to the ADLEX, because the ADEX
had specified the class of restorations required to be performed in the ADLEX.
13
Section 466.006(5)(a), F.S.
BILL: SB 1366 Page 4
Dental Hygienists
The requirements for licensure as a dental hygienist are found in s. 466.007, F.S. An applicant
must apply to the DOH to take the ADHLEX and is entitled to licensure if he or she is 18 years
of age or older and has:14
 Graduated from a dental hygiene college or school that is:
o Board approved;
o Accredited by the ADA CODA;
o Accredited by any other dental accrediting entity recognized by the United Stated DOE;
 Passed the Florida Laws and Rules examination; and
 Passed the ADHLEX examination.
A dentist who is a graduate of an accredited dental college or school or a graduate of an
unaccredited dental college or school, may also take the ADHLEX and obtain licensure as a
dental hygienist if he or she meets certain additional criteria.15
Dental and Dental Hygiene Examinations
The Legislature has authorized the BOD to use the ADLEX and the ADHLEX developed by
ADEX in lieu of an independent state-developed practical or clinical examination for both
dentists and dental hygienists.16 Dental licensure is a process every dentist must go through, and,
in the United States, licensure requirements vary from state to state. State legislatures and dental
boards establish the licensure requirements, including which licensure examinations its
prospective licensees must take and pass as evidence of clinical competence for a dental license.
The American Dental Licensing Examination (ADLEX)
The ADLEX clinical examination administered by CDCA and the CITA is accepted in 48 states
plus Puerto Rico, Jamaica, and the United States Virgin Islands.17 The ADLEX clinical
examination is given in two formats:
 The traditional format;18,19 and
 The Patient-Centered Curriculum Integrated Format (PC CIF).20,21
14
Section 466.007, F.S.
15
See s. 466.007 (2)(b)1. and (3), F.S.
16
See ss. 466.006(4)(b) and 466.007(4)(b), F.S.
17
The Commission on Dental Competency Assessments, 2021 ADEX Acceptance Maps, Dental, available at
https://www.cdcaexams.org/ADEX-acceptance-map/ (last visited Mar. 18, 2021).Only New York and Delaware do not
accept the ADEX dental examination.
18
The Commission on Dental Competency Assessments, Dental (ADEX), available at https://www.cdcaexams.org/dental-
exams/ (last visited Mar. 18, 2021).
19
American Dental Association, Licensure Pathways, available at https://www.ada.org/en/education-
careers/licensure/licensure-dental-students/licensure-pathways (last visited Mar. 18, 2021).
20
See note 18.
21
American Board of Dental Examiners, Inc., ADEX Patient Centered Curriculum Integrated Format (PC CIF), ADEX
available at https://ADEXexams.org/wp-content/uploads/2016/06/ADEX-Patient-Centered-Curriculum-Integrated-Format-
PC-CIF-2.pdf (last visited Mar. 19, 2021). The PC CIF format focuses on patient care needs, rather than the candidate's
examination. The examination itself is identical to the ADEX Licensing Examination for initial licensure in dentistry.
BILL: SB 1366 Page 5
The traditional format uses a clinical manikin and patient-based examinations administered in a
single sitting at the end of a dental student’s senior year by a testing agency or individual state. It
is for those students who have elected not to take the PC CIF or for those who have already
graduated from dental school.22
The PC CIF is an alternative to the traditional format. The PC CIF option is offered by the
CRDTS, CITA, CDCA, and SRTA, but not the WREB. The PC CIF allows dental students to be
examined in sections, during the fourth year of dental school. With the PC CIF, the manikin-
based clinical examinations are administered late in the junior year or early in the senior year,
and the clinical patient-based examinations are administered during the senior year. Only
students or graduates of schools accredited by the ADA CODA or the Commission on Dental
Accreditation of Canada may take the ADLEX PC CIF clinical examination.23
All other candidates (including international graduates) must apply through a state’s dental board
in the state or jurisdiction where they wish to practice for permission to take an examination for
licensure only in that state or jurisdiction.
The ADLEX examination series includes computer simulations and clinical examinations
performed on patients and manikins and is an Objective Structured Clinical Examination
(OSCE).24 There are five skill-specific components including a high-fidelity computerized OSCE
testing a candidate’s ability to apply knowledge to the care of patients. The five areas are:
 Diagnostic Skill Examination;
 Restorative – Anterior and Posterior;
 Prosthodontics;25
 Endodontics;26 and
 Periodontal Scaling.
The cost of taking the full dental ADLEX examination is $2,295 plus ancillary fees.27
22
Id.
23
Section 466.006(2)(b), F.S.
24
National Institute of Health, US National Library of Medicine, Oman Med J. 2011 Jul; 26(4): 219–222, Objective
Structured Clinical Examination: The Assessment of Choice, available at
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3191703/ (last visited Mar. 18, 2021). The Objective Structured Clinical
Examination is a versatile multipurpose evaluative tool that can be utilized to assess health care professionals in a clinical
setting. It assesses competency, based on objective testing through direct observation. It is precise, objective, and
reproducible allowing uniform testing of students for a wide range of clinical skills. Unlike the traditional clinical exam, the
OSCE could evaluate areas most critical to performance of health care professionals such as communication skills and ability
to handle unpredictable patient behavior.
25
Prosthodontics is the branch of dentistry concerned with the design, manufacture, and fitting of artificial replacements for
teeth and other parts of the mouth.
26
Endodontics is the branch of dentistry concerning dental pulp and tissues surrounding the roots of a tooth. Endodontic
treatment, or root canal treatment, treats the soft pulp tissue inside the tooth.
27
See note 18.
BILL: SB 1366 Page 6
The Western Regional Examining Board Examination (WREB) – Dental
The WREB dental examination is fully accepted in 21 states28 with 16 other states accepting
successful results only in support of initial licensure.29 The WREB does not require membership
as a pre-requisite for utilization of its dental and dental hygiene examinations. The WREB does
not require the passage of Part I and Part II of the national dental boards prior to taking the
WREB clinical examination and does not administer state-specific jurisprudence examinations.30
The 2021 WREB dental examination consists of the following sections:31
 Operative;
 Endodontics; and
 Comprehensive Treatment Planning (CTP).
The WREB offers optional sections in prosthodontic and periodontal, if required by the state in
which a candidate is applying for initial licensure.
The operative section is performed on either a live patient or a simulation performed on a
manikin. The candidate may complete up to two procedures to demonstrate competence on the
Operative section.
Patient Operative:
 A Class II restoration – Composite or Amalgam; and
 If required:
o Direct Class II Composite or Amalgam restoration; or
o Direct Class III Composite restoration.
Simulation Operative: A Class II and Class III preparation and restoration procedure must be
completed.32
The endodontics section is completed on simulated teeth for both the patient-based and manikin
formats. Candidates are required to place and maintain the manikin in correct patient treatment
position and remain articulated in correct vertical dimension. Candidates have three hours to
complete their treatment and postoperative radiographs. Candidates are required to perform the
following endodontic procedures:
 Anterior – Graded on access and condensation; and
 Posterior – Graded on access only.
28
Western Regional Examining Board, About Us, States Accepting WREB, available at https://wreb.org/about-us/ (last
visited Mar. 18, 2021). Alaska, Arizona,