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More discussion about the DDH Compact

Commentary: What’s in the fine print of the DDH and AADB Compacts?

April 16, 2024
Here's more conversation around the Dental and Dental Hygienist (DDH) Compact. Educate yourself through the RDH articles to determine where you stand on the issue. This latest is from the executive director of CRDTS.

As the executive director of the nationally recognized dental and dental hygiene testing agency Central Regional Dental Testing Service (CRDTS), I turn to various resources for information regarding the dental and dental hygiene profession and specifically clinical licensure examinations. As a well-respected and reputable publication, RDH magazine is one that is closely followed by CRDTS and the many dental hygiene professionals I have the pleasure of working with.

In recent months there have been a couple of articles regarding two separate dental and dental hygiene compacts that have been or are intended to be introduced into legislation soon—the Dental and Dental Hygiene Compact (DDH Compact), which the Council of State Governments facilitated the drafting of in partnership with the ADA and the ADHA, and the AADB Dental and Dental Hygiene Compact (AADB Compact).

Both compacts claim the driving force is increased portability for dental and dental hygiene professionals. While CRDTS supports portability, we cannot support a compact that risks the safety and welfare of the public or violates anticompetitive laws and restricts trade in the process. Neither of these compacts benefit the profession without compromising the standards and the authority of state dental boards.

We encourage you to educate yourselves about the fine print and what the enactment of either or both compacts will mean for the future of the dental profession. Lowering the standards and requirements set forth in state laws for clinical licensure examinations, sacrificing the authority of state dental boards to determine what requirements are acceptable for licensure in each state, and restricting exam options for candidates actually thwarts the stated purpose of the compacts.

For instance, if portability and increased access to dental health care was truly the motivation for the AADB Compact, it would recognize all clinical licensure exams that are currently accepted in each state. Instead, the AADB Compact requires passing the American Board of Dental Examiners (ADEX) exam to be eligible to receive a compact license as of January 1, 2024.1 Not only does this raise questions regarding anticompetitive and trade restriction laws, but it also means the AADB is dictating to state dental boards and legislators what clinical licensure examinations are acceptable.

In most states, the state dental boards are responsible to ensure that clinical licensure examinations accepted as a pathway toward dental or dental hygiene licensure meet the requirements set forth by law. Thus, if a state determines that the ADEX exam does not meet the requirements and applicants are required to take an exam other than the ADEX exam to qualify for licensure, then under the AADB compact, those licensees will not be eligible for compact privilege. Consequently, by requiring a specific exam rather than accepting all nationally recognized exams, the AADB is effectively hindering the very purpose cited for the compact.

For example, the Nebraska State Board of Dentistry determined that the CRDTS exam is the only acceptable exam in Nebraska for clinical examinations initiated after November 1, 2022.2 Hence, professionals licensed after January 1, 2024, in Nebraska will not be eligible for compact privilege under the AADB Compact. Simply put, by eliminating candidates who are licensed in a state that requires an exam other than the ADEX exam, the AADB is impeding the goal it claims to be working toward.

This contradiction begs the question as to the motivation behind such a requirement. Ultimately, if portability and access to care is the point of a compact, then it would follow that all exams vetted and accepted in the US would qualify a licensee for compact privilege under the AADB Compact.

Unfortunately, the DDH Compact that triggered the AADB to develop its own compact has already been introduced and lobbied to legislators, in many cases without knowledge or support from the very professionals who are charged with upholding the state’s licensing laws—the state dental boards. It has been passed by the state legislature in five states as of April 1, 2024, and is pending in 11 other states. The most disturbing thing about the DDH Compact is that it risks diminishing the current standards for licensure set forth by law to ensure the safety and welfare of the public. For more than half a century, nearly every state has required a psychomotor hand-skills component as part of clinical licensure exams, whether given by a third party or by the state.

The DDH Compact allows for exams that do not include a psychometric hand-skills component and, worse yet, for licensure with no clinical exam at all. The DDH Compact states that to obtain a Compact Privilege, the licensee shall “… have successfully completed a clinical assessment for licensure” and defines clinical assessment as “… examination or process, required for licensure as a dentist or dental hygienist as applicable, that provides evidence of clinical competence in dentistry or dental hygiene.”3 This means that the Dental Licensure Objective Structured Clinical Exam (DLOSCE) will be an acceptable pathway toward licensure under the DDH Compact.

The DLOSCE is a written-only exam developed and administered through the Joint Commission on National Dental Examinations (JCNDE), a Commission of the American Dental Association (ADA), which is a partner in the development of the DDH Compact. The DLOSCE (and the Canadian OSCE) are accepted in only a handful of US jurisdictions, and for very good reason; those exams do not include a psychomotor hand-skills assessment.

In fact, even in the states that accept the DLOSCE or the Canadian OSCE, some still require that candidates complete a hand-skills assessment in addition. Because of the lack of psychomotor hand skill assessment, the DLOSCE has not been an acceptable exam in most the US, and while the DDH Compact does not openly identify it, the DLOSCE will be an acceptable pathway toward compact privilege through the DDH Compact.

Beyond the written-only exams that do not cover the requirements of most of the US jurisdictions, there are now one or two states that allow licensure upon graduation from a CODA-accredited program with no clinical licensure examination. Thus, if a state requires a clinical licensure exam for licensure but also participates in the DDH Compact, they will have to issue a compact privilege in their state to those who have not taken a clinical licensure exam. Compromising the standards for dental and dental hygiene licensure that have been in state laws for more than 50 years is not the way to accomplish the goal of increased portability and access to care.

The dental professionals serving their state dental boards have understood the importance of the psychomotor hand-skills assessment for decades. If the DDH Compact is enacted (it requires seven states to pass legislation), then states that elect to participate may be welcoming dental professionals who would not otherwise qualify for licensure in their state, effectively opening the door to a dangerous path for the profession and negatively impacting the safety and welfare of the public.

CRDTS supports increased portability for dental and dental hygiene professionals but cannot support either of these compacts as currently written. We hope you will join us in opposing the DDH Compact and the AADB Compact and work with us and state dental boards to find a more effective and fair solution to increased portability for dental professionals that will not compromise the competency testing standards or risk public safety.


1. Dentist and dental hygiene compact. Accessed April 1, 2024. https://ddhcompact.org/

2. American Association of Dental Boards Interstate Dental and Dental Hygiene Licensure Compact. Accessed April 1, 2024. https://aadbcompact.org/

3. Nebraska Department of Health and Human Services/Licensing Board Meeting Agendas & Minutes. Accessed April 1, 2024. https://dhhs.ne.gov/licensure/Pages/licensing-home-page.aspx

Richael Cobler is a business professional with more than 30 years of experience in legal, compliance, and business administration. She has been the executive director of CRDTS since 2021 and has developed a passion for oral health care and for maintaining the high standards of competency assessments as a pathway toward licensure.