Clinical Examination Choices

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Emily R. Holt, MHA, RDH, CDA, EFDA, a clinical associate professor of dental hygiene at the University of Southern Indiana in Evansville, explains what dental hygiene students should consider when selecting a clinical exam. 

Dental hygienists who worked through the past year likely encountered experiences unlike any other time in history. The demand for dental hygienists rose as more clinicians decided to leave the profession instead of returning to work during a pandemic. Opportunities for employment opened up across the country. In my own sector in Southern Indiana, there seemed to be a shortage of dental hygiene substitutes based on the amount of communication I received from those needing help. Adding insult to injury, there were lengthy delays in getting licensure for new graduates. College campuses were restricted on providing direct patient care due to the risk of transmitting and contracting novel coronavirus infections, so clinical examinations were modified. 

While already in the works by several testing agencies, implementation of a manikin-based clinical exam seemed to save the day. It allowed campuses to offer clinical exams with lower risk of spreading COVID-19. In states like Indiana, the dental board temporarily removed a patient or manikin-based examination as a requirement for licensure. While the removal of the clinical exam may have been welcomed at the moment, it may have lasting consequences. 

One reason for concern is how this affects license transferability from state to state. Applying for a license in another state is required when working across state lines. Most states have their own licensure requirements and do not simply grant a new dental hygiene license to an individual who is licensed in another state. In 2019, Arizona became the first state to offer license reciprocity, but other states have been slow to jump on the bandwagon. Let’s talk briefly about why it is important to research which clinical exam benefits you the most.

Transferability of Clinical Exams Between States

With the introduction of the manikin-based clinical exam in 2020, those seeking licensure have more to consider when registering for regional board exams. The manikin exam is offered by four of the five regional testing agencies, including the Commission on Dental Competency Assessments (CDCA), Council of Interstate Testing Agencies (CITA), Central Regional Dental Testing Service, and Western Regional Examining Board.  Southern Regional Testing Agency only offers the patient-based clinical exam currently. The manikin exam has many advantages to the patient-based exam, but state dental boards have not unanimously agreed on accepting it. Some agencies are choosing to only accept the manikin exam for the duration of time the state is under a state of emergency due to the pandemic. Others are only accepting it until a specific time, such as the end of 2021. While the manikin exam is likely here to stay, how are those who are registering to take a clinical exam supposed to predict if it will be advantageous to take a patient-based exam compared to a manikin exam? 

Some resources are available to assist students in the decision-making process between the two types of clinical exams. While the American Dental Association (ADA) governs administration of the written licensure examination for dental hygiene, it only provides guidance on clinical examinations for dentists. The American Dental Hygienists’ Association (ADHA) is one of the organizations to turn to for this type of information in our field. However, I found that the ADHA’s posted document is more than 5 years old. So much has changed over those 5 years, which makes the document only useful as a springboard. If I were selecting which regional board or type of clinical exam to take, I would still search through several sources to find answers to my questions based on the outdated content on the ADHA table.

A state-of-the-art resource is the ADEX acceptance map on the CDCA’s website: This map shows a breakdown of which states accept the ADEX clinical exam, which ones only accept ADEX patient-based exams, and which ones accept ADEX manikin exams. It is customizable for the information you are trying to find. The ADEX clinical examination is administered by the CDCA and CITA regional boards. Compared to other clinical dental hygiene exams, it is accepted by the greatest number of states and jurisdictions.1 Only three states do not accept the ADEX clinical exam: Nebraska, Georgia, and Delaware. Reviewing this map can put you one step closer to deciding which clinical exam to take. 

Identifying State Specific Requirements

The licensure process is an expensive one, so it is wise to avoid errors in exam selection. Regional clinical exams range from $975 to $1,625 before adding on facility fees and travel expenses. The testing agencies may offer a reduced fee for those who take both the patient-based and manikin clinical exam. For example, the CDCA charges a discounted fee of $300 to take the patient-based clinical exam after a student has already completed the manikin exam. This would only be necessary if obtaining a subsequent license in a state that does not recognize the manikin exam.  

As a dental hygiene educator, I prepare students for the licensure process. In addition to orienting them to the license requirements in our state, I share some simple directions on identifying state-specific licensure requirements for any state. The ADA compiled a listing of each state’s dental board website, which is available at:  

These websites indicate which regional board is accepted by the agency. If an update is not posted about the acceptance of manikin clinical exams, an email to the contact person listed on the site will get the ball rolling.


While some may say adding the manikin clinical exam creates more confusion to the selection process, I feel it is a long overdue addition to our profession’s licensure requirements. Not only does the manikin exam put everyone on an equal playing field, but it also allows the individual seeking licensure to focus solely on skill performance. The manikin exam removes the need for radiographs, local anesthesia, control of herpetic lesion outbreaks and hypertension, and even the expense of paying someone to sit as your patient. With continued implementation over the next few exam cycles, I hope to see its acceptance grow across our nation.


  1. American Board of Dental Examiners. Candidates. Available at: Accessed February 6, 2021. 
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