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 Banking and Insurance
BILL: CS/CS/SB 926
INTRODUCER: Banking and Insurance Committee, Health Policy Committee, and Senator Albritton
SUBJECT: Licensure Examinations for Dental Practitioners
DATE: January 27, 2022
ANALYST STAFF DIRECTOR REFERENCE ACTION
1. Rossitto-Vanwinkle Brown HP Fav/CS
2. Schrader Knudson BI Fav/CS
3. RC
Please see Section IX. for Additional Information:
COMMITTEE SUBSTITUTE - Substantial Changes
I. Summary:
CS/CS/SB 926 revises dental licensure examination requirements for dentists and dental
hygienists to require applicants to demonstrate certain clinical skills on a manikin rather than a
live patient. The bill deletes the requirement that schools of dentistry wishing to offer licensure
examinations must have a plan to require dental students to possess medical malpractice
insurance in amounts not less than the amounts required to take the Florida licensure
examinations, to make adequate arrangements for patients who require follow-up care, and to
ensure that such students do not pose an unreasonable risk when conducting licensure exercises
on a live patient. The bill also repeals the authorization for the Board of Dentistry to require that
any person applying to take the practical dentistry or dental hygiene examination in Florida
maintain medical malpractice insurance in amounts sufficient to cover any incident of harm to a
patient during the examination.
The bill provides an effective date of July 1, 2022.
II. Present Situation:
The Practice of Dentistry
The Board of Dentistry (BOD) carries out the provisions of ch. 466, F.S., which establishes the
requirements for the practice of dentistry in Florida by dentists, dental hygienists, and dental
REVISED: BILL: CS/CS/SB 926 Page 2
assistants under the Dental Practice Act.
1
A dentist is licensed to examine, diagnose, treat, and
care for conditions within the human oral cavity and its adjacent tissues and structures.
2
A dental
hygienist provides education, preventive, and delegated therapeutic dental services.
3
Dental
assistants are persons who, under the supervision and authorization of a dentist, provide dental
care services directly to a patient, but who are not dental hygienists or licensed certified
registered nurse anesthetists.
4
Licensure as a dentist or dental hygienist requires passing
statutorily required licensure examinations.
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 four
national clinical testing agencies:
7,8
CDCA-WREB (Formerly the Commission for Dental Competency Assessments-Western
Regional Examining Board);
Council of Interstate Testing Agencies (CITA);
Central Regional Dental Testing Services, Inc. (CRDTS); and
Southern Regional Testing Agency, Inc. (SRTA).
Delaware administers its own exam while New York requires completion of a one-year
residency program for dentists.
9
Dentists
The requirements for dental licensure in Florida are found in s. 466.006, F.S. An applicant must
apply to the Department of Health (DOH) to take and pass the following examinations:
The ADLEX;
10
and
1
Section 466.004, F.S.
2
Section 466.003(3), F.S.
3
Section 466.003(4) and (5), F.S.
4
Section 466.003(6), 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 for Dental Students, available at https://www.ada.org/resources/licensure/student-
licensure (last visited Jan. 22, 2022).
8
The American Board of Dental Examiners, Inc., ADEX. What ADEX Does available at https://adexexams.org/about-adex/
(last visited Jan. 22, 2022).
9
American Dental Association, supra note 7.
10
Section 466.006, F.S. BILL: CS/CS/SB 926 Page 3
An exam on Florida laws and rules relating to dentistry.
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
Be 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
A 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 U.S. 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.
14
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 Jan. 22, 2022) 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.
14
Section 466.006(3), F.S. BILL: CS/CS/SB 926 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:
15
Graduated from a dental hygiene college or school that is:
o Board-approved;
o Accredited by the ADA CODA or by any other dental accrediting entity recognized by
the U.S. 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.
16
Dental and Dental Hygiene Examinations
The Legislature has authorized the BOD to use the ADLEX and the ADHLEX dental exams
developed by ADEX in lieu of an independent state-developed practical or clinical examination
for both dentists and dental hygienists.
17
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.
Dentists - 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 U.S. Virgin Islands.
18
The ADLEX clinical examination is
given in two formats:
The traditional format;
19,20
and
The Patient-Centered Curriculum Integrated Format (PC CIF).
21,22
15
Section 466.007, F.S.
16
See s. 466.007 (2)(b)1. and (3), F.S.
17
See ss. 466.006(4)(b) and 466.007(4)(b), F.S.
18
The Commission on Dental Competency Assessments, 2021 ADEX Acceptance Maps, Dental, available at
https://www.cdcaexams.org/ADEX-acceptance-map/ (last visited Jan. 22, 2022).Only New York and Delaware do not accept
the ADEX dental examination.
19
The Commission on Dental Competency Assessments, Dental (ADEX), available at https://www.cdcaexams.org/dental-
exams/ (last visited Jan. 22, 2022).
20
American Dental Association, supra note 7.
21
Id.
22
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 Jan. 22, 2022). 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: CS/CS/SB 926 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.
23
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.
24
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).
25
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;
26
Endodontics;
27
and
Periodontal Scaling.
The cost of taking the full dental ADLEX examination is $2,295 plus ancillary fees.
28
Dental Hygienist - The American Dental Licensing Examination (ADHLEX)
The ADHLEX examination is used in Florida and administered by the CDCA and the CITA. The
ADHLEX is designed for students about to complete dental hygiene training and graduate dental
23
Id.
24
Section 466.006(2)(b), F.S.
25
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 Jan. 22, 2022). 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.
26
Prosthodontics is the branch of dentistry concerned with the design, manufacture, and fitting of artificial replacements for
teeth and other parts of the mouth.
27
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.
28
See note 18. BILL: CS/CS/SB 926 Page 6
hygienists. Forty-seven states accept the ADHLEX examination; only Delaware, Georgia, and
Nebraska do not.
29
The ADHLEX examination is based on specific performance criteria used to measure clinical
competence. There are two skill-specific clinical and simulated clinical OSCE:
The Computer Simulated Clinical Examination (CSCE-OSCE); and
The Patient Treatment Clinical Examination (PTCE).
30
The CSCE-OSCE exam is designed to assess various levels of diagnosis and treatment planning
knowledge, skills, and abilities. Clinically-based questions are utilized through computer-
enhanced photographs, radiographs, optical images of study and working models, laboratory
data, and other clinical digitized reproductions.
31
The PTCE evaluates candidates on their clinical and judgment skills. Clinical skills include:
32
Detection and removal of calculus;
Accurate periodontal pocket depth measurements;
Tissue management; and
Final case presentation.
Judgment skills include:
Presenting an eligible patient;
Diagnostic-quality radiographs meeting all examination criteria; and
An acceptable case selection of teeth that meets all calculus requirements.
The non-patient version of this ADHLEX examination is called the Manikin Treatment Clinical
Examination (MTCE).
33
The cost of taking the full ADHLEX exam, both patient and manikin based, is $995.
34
Medical Malpractice Insurance for Examinees
As stated, Florida law currently requires dentist and dental hygienists to demonstrate competency
on a live patient during their licensure examination. Because of this, s. 466.0075, F.S., authorizes
the BOD to require that any person applying to take the examination to practice dentistry or
dental hygiene in Florida to maintain medical malpractice insurance in amounts sufficient to
cover any incident of harm to a patient during the clinical examination. Additionally, schools of
dentistry wishing to offer licensure examinations must have a written plan in place requiring that
dental student possess medical malpractice insurance in amounts not less than the amounts
required to take the Florida licensure examinations and to make adequate arrangements for
29
The Commission on Dental Competency Assessments, 2021 ADEX Acceptance Maps, Dental Hygiene, available at
https://www.cdcaexams.org/ADEX-acceptance-map/ (last visited Jan. 22, 2022).
30
The Commission on Dental Competency Assessments, Dental Hygiene (ADEX), available at
https://www.cdcaexams.org/dental-hygiene-ADEX-exam/ (last visited Jan. 22, 2022).
31
Id.
32
See note 28.
33
The Commission on Dental Competency Assessments, supra note 30.
34
Id. BILL: CS/CS/SB 926 Page 7
patients who require follow-up care as a result of procedures performed during the clinical
portion of the regional examination.
35
III. Effect of Proposed Changes:
CS/CS/SB 926 amends s. 466.006, F.S., confirming that the ADLEX is the practical examination
for dentists in Florida and revising the required minimum examination requirements to eliminate
the requirement for use of live patient(s) for two restorations, the demonstration of periodontal
skill with calculus,
36
and the demonstration of restorative skills, which requires the candidate to
complete procedures performed in preparation for a cast restoration. The bill requires the
candidate to use a manikin that has typodont teeth,
37
including one with simulated caries, as
approved by the CDCA.
The bill amends s. 466.0065, F.S., deleting the requirement that dental schools wishing to offer
dental licensure exams to students have a written plan to comply with the following
requirements:
A dental student must possess medical malpractice insurance in amounts not less than the
amounts required to take the Florida licensure examinations;
Adequate arrangements must be made for patients who require follow-up care as a result
of procedures performed during the clinical portion of the regional examination; and
There may not be any evidence in a student’s academic record suggesting that the student
may pose an unreasonable risk to any live patient required for the clinical portion of the
examination.
CS/CS/SB 926 amends s. 466.007, F.S., to require that dental hygienists taking the ADEX
licensure examination to demonstrate skills within the dental hygiene scope of practice on
manikin that has typodont teeth with simulated dentition and calculus as approved by the CDCA,
instead of a live patient.
The bill also repeals s 466.0075, F.S., which authorizes the BOD to require that any person
applying to take the practical dentistry or dental hygiene examination in Florida to maintain
medical malpractice insurance in amounts sufficient to cover any incident of harm to a patient
during the clinical examination.
The bill provides an effective date of July 1, 2022.
35
Section 466.0065(2)(c) and (e)
36
Dental caries is a process of demineralization of tooth enamel, leading to destruction of enamel and dentin, with cavitation
of the tooth. Decayed and infected teeth can be the source of other infections throughout the body, and decayed or missing
teeth can interfere with proper chewing of food, leading to nutritional deficiencies or disorders of digestion. Called also tooth
decay. The Free Medical Dictionary, Dental Caries, available at https://medical-
dictionary.thefreedictionary.com/dental+caries (last visited Jan. 22, 2022).
37
A typodont is a model of the oral cavity, including teeth, gingiva, and the palate. A typodont is an educational tool for
dental and hygienist students, allowing them to practice certain dental procedures on the plastic teeth of a model before
actually performing the procedures on live patients. The Free Medical Dictionary, Typodont, available at https://medical-
dictionary.thefreedictionary.com/typodont (last visited Jan. 22, 2022). BILL: CS/CS/SB 926 Page 8
IV. Constitutional Issues:
A. Municipality/County Mandates Restrictions:
None.
B. Public Records/Open Meetings Issues:
None.
C. Trust Funds Restrictions:
None.
D. State Tax or Fee Increases:
None.
E. Other Constitutional Issues:
None.
V. Fiscal Impact Statement:
A. Tax/Fee Issues:
None.
B. Private Sector Impact:
The bill will probably reduce the cost of taking the licensure examinations for both
dentists and dental hygienists as many often must pay patients large sums for patients to
appear at examinations.
C. Government Sector Impact:
None.
VI. Technical Deficiencies:
None.
VII. Related Issues:
None.
VIII. Statutes Affected:
This bill substantially amends the following sections of the Florida Statutes: 466.006, 466.0065,
and 466.007. BILL: CS/CS/SB 926 Page 9
This bill repeals section 466.0075 of the Florida Statutes.
IX. Additional Information:
A. Committee Substitute – Statement of Substantial Changes:
(Summarizing differences between the Committee Substitute and the prior version of the bill.)
CS by Banking and Insurance on January 25, 2022:
The CS revises the type of manikin that may be used in an ADEX Dental Hygiene
Examination to be one with typodont teeth with simulated dentition and calculus.
CS by Health Policy on January 13, 2022:
The CS makes technical corrections to the bill relating to required demonstration of a
prospective dentist’s periodontal skills, by replacing “caries” with “calculus,” and makes
a technical correction to a prospective hygienist’s required demonstration of skills, by
adding “calculus” to those requirements.
B. Amendments:
None.
This Senate Bill Analysis does not reflect the intent or official position of the bill’s introducer or the Florida Senate.