Early on, the ADA publicly supported mandatory CE with a position statement adopted by the House of Delegates in 1973.⁸ This position statement recommended that each state dental board consider requiring dentists to show evidence of CE as a condition of reregistration of their licenses.⁹ The ADA Principles of Ethics and Code of Professional Conduct embodies this philosophy: "The privilege of dentists to be accorded professional status rests primarily in the knowledge, skill and experience with which they serve their patients and society. All dentists, therefore, have the obligation of keeping their knowledge and skill current."¹⁰

The decision to require CE for relicensure was controversial.^1,11,12 Dental leaders debated whether such a step really would lead to an improvement of practitioner competence^11,12 and whether the quality of dental CE programs in general would serve this purpose at all.^1,13 Despite a lack of evidence of the effectiveness of the measure,^14–16 state dental boards continued with implementation of CE programs. While other approaches used to ensure continuing competence have been discussed,¹⁷ no state legislature has moved beyond requiring anything other than CE for relicensure.

From the beginning, state dental boards made some distinctions about the acceptability of CE credits. For instance, some state dental boards set minimums, maximums or both for clinical and nonclinical credit hours. Others required a minimum number of credit hours on certain subjects, such as infection control, child abuse and HIV/AIDS. Another categorization divided CE credits into those earned through independent-study and on-site courses. Since computers and the Internet are used to deliver independent-study courses, their increasing adoption by dentists intersects with state relicensure requirements.

While independent-study courses have been available for a long time, the use of computers and the Internet for this purpose is relatively new. The potential use of information technology for CE in the health professions was identified in the 1967 Report of the National Advisory Commission on Health Manpower,¹⁸ which stated, "New data processing techniques utilizing computers and adaptations of various teaching devices ... should be fully exploited as media for programs of continuing education."

With the growth of the Internet and its application to dentistry, interest in using it for CE had grown significantly.^19,20 The educational quality of early offerings appeared to be questionable,²¹ which led the ADA’s Standards Committee on Dental Informatics to develop the American National Standards Institute (ANSI)/ADA Specification 1001, Guidelines for the Design of Educational Software.²² This standard was approved by ANSI in 2002. Compliance with ANSI/ADA Specification 1001 is a recommendation in the ADA’s Continuing Education Recognized Provider (CERP) guidelines.

State relicensure requirements typically impose on several aspects of Internet- and computer-based educational materials:

– recognition of courses similar to traditional CE courses could be subjected to topical restrictions (such as clinical or nonclinical);

– the number of hours that can be accumulated through independent study could be limited;

– some state dental boards could require that the sponsor obtain separate approval for computer-based courses;

– state dental boards could handle in-state computer-based courses differently from out-of-state courses.

The last comprehensive review of CE requirements for relicensure was published in JADA in 1975.²³ At that time, six states required CE, and 28 were considering requiring mandatory CE. The number of CE hours required ranged from four per year (over a five-year period) in North Dakota to 30 per year (over a three-year period) in Kansas. At that time, eight ADA constituent societies had instituted their own CE requirement for membership, and others were considering it.

We conducted a survey of state licensing boards’ CE requirements for relicensure and examined whether those requirements contained specific language about computer-based CE courses. We designed the study to compare requirements on a quantitative and a qualitative basis among the 50 states.

The results of our survey may be of interest for policy-making bodies in dentistry such as state dental boards, the American Dental Association, and component and local dental societies that may require comprehensive information about CE and relicensure for developing policies and strategic plans. CE providers such as dental schools, companies and private institutions also may benefit from the information in this article. Dental practitioners can gain a comprehensive overview of CE requirements in their home states and other states.

	METHODS

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We obtained a list of dental boards in the 50 states and the District of Columbia from the American Association of Dental Examiners’ Web site ("www.aadexam.org"). We sent a letter to the administrative director of each dental board requesting information about requirements for initial licensing and license renewal for general dentists. We also asked them to send specific information regarding requirements for CE hours, such as regulations regarding clinical and nonclinical CE hours, independent-study courses and CE provider (such as ADA CERP and Academy of General Dentistry [AGD]) accreditation).

After one month, most of the dental boards had responded in writing, usually by sending copies of their applications for a dental license and pertinent dental statutes for their states. Several dental boards responded by e-mail and included addresses for their Web sites with complete source information. Thirteen states did not respond to the initial letter, and we then contacted them by telephone.

After gathering the raw information, we reviewed the various state dental statutes in detail to extract the following information:

– license renewal period;

– total number of CE hours required per renewal period;

– limits for the acceptance of CE hours on clinical and nonclinical topics, and hours accumulated through on-site and independent-study courses;

– other types of activities that would qualify for CE hours, such as holding a faculty position, presenting a paper or a table clinic, and publishing a scientific paper;

– other requirements for CE topics, such as cardiopulmonary resuscitation (CPR), infection control, medical emergency and identification of abuse.

Forty-five of the 50 states and the District of Columbia required continuing education credits for relicensure.

We entered the extracted information into a spreadsheet program and summarized it descriptively. In combination with data from the ADA’s Distribution of Dentists in the United States by Region and State, 1999,²⁴ we calculated the demand for the total number of state-mandated CE hours in the United States per year. We present these results in the following section.

While we took great care to ensure that the reported data were correct and current, this article is not intended to be a substitute for a specific review of a practitioner’s home state dental practice act regarding compliance with relicensure requirements. Practitioners are advised to obtain a copy of their state dental practice act to ensure that they comply with current requirements.

	RESULTS

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As of Dec. 31, 2002, 50 states and the District of Columbia responded to the survey—a response rate of 100 percent. Forty-five of the 50 states and the District of Columbia (88 percent) required CE credits for relicensure. Colorado, Connecticut, Vermont, Wisconsin and Wyoming did not require CE. For the jurisdictions that mandated CE, Table 1 shows the number of total CE credits required for each renewal period, the renewal period, the average number of credits required per year, and the Web site address at which state dental board regulations can be found.

View this table: [in this window] [in a new window]   TABLE 1 SUMMARY OF CE* REQUIREMENTS BY JURISDICTION.

Approximately 165,000 U.S. dentists are professionally active. Using data from the ADA survey Distribution of Dentists in the United States by Region and State, 1999,²⁴ we calculated the total demand for state-mandated CE hours in the United States per year to be approximately 2.8 million hours.

As Table 2 shows, 10 states (22 percent of the jurisdictions requiring CE) stipulated a minimum number of clinical CE hours per year. Dental practice acts typically define clinical CE as CE directly related to patient care. For instance, courses on sterilization and infection control, pharmacology, dental materials and dental procedures generally are included in this category, while courses focusing on practice management, personal finances, and billing and insurance processing are not.

Thirty of the 46 jurisdictions that required CE (65 percent) limited the number of hours that could be accumulated by independent-study courses, which included computer- and Internet-based courses. The limits ranged from zero to 14 hours per year, or from zero to 50 percent of the total hours per year. Eight states specifically mentioned computers or the Internet as options for independent-study courses. Most others used terms ranging from the generic (for example, "home study" or "correspondence courses") to the specific (for example, "videotape" and "audiotape") to describe independent study.

Practitioners had a variety of other options that allowed them to earn CE credit. Several states awarded CE credit for holding a faculty position, 17 for presenting a paper, 10 for publishing a scientific paper, and seven for presenting a table clinic.

Several states also required a certification or that a course be completed in a special subject area. By far the most common of those requirements was certification in CPR, which was mandated in 28 states. Eight states required that a course in infection control be completed, one state required that a course on medical emergencies be completed and another required that a course on the identification of abuse be completed. In our review of state dental statutes, we found that many other ways of obtaining CE credit were available. For instance, Missouri awarded nonclinical credit for attending dental board meetings and 50 hours of CE credit for obtaining diplomate status through board certification in an ADA-recognized specialty.

Specific information regarding independent-study courses in the state dental statutes was provided rarely. Massachusetts, for instance, defined self-instruction courses as home study courses, correspondence courses, educational television and audiocassettes. The last two types of courses describe the media used to deliver them, not the course type. Therefore, it is unclear whether a computer-based course or a journal article with test questions would be included as self-instruction courses.

Some state dental statutes explained what criteria a course would have to fulfill to be accepted for CE. For instance, the Commonwealth of Massachusetts Regulation 234²⁵ stated that a CE program must require attendance; be at least one class hour (50 minutes) in length; be conducted by an instructor qualified by education, experience or both; and retain a written course description. Furthermore, it stated that provisions should be made for evaluation of the participants’ attainment of the course objectives. Most states referred to the ADA CERP²⁶ or AGD²⁷ guidelines instead of listing specific criteria. Notably, some states required a review of independent-study educational materials before they could decide whether the materials were appropriate for CE credit.

	DISCUSSION

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This survey showed that CE requirements have evolved into a common characteristic of dental licensing in the United States. We found that only five states had no CE requirement. Dentists in most states are required to complete approximately 20 CE hours per year for relicensure. Twenty states have implemented requirements regarding the number of clinical CE hours, nonclinical CE hours or both. Many states allow for a variety of other ways to obtain CE hours, such as holding a faculty position, publishing a scientific paper, and presenting a paper or a table clinic.

Independent study in its many forms—such as correspondence courses, journal articles with test questions, CD-ROM–and Internet-based courses, and live Internet chat sessions—plays an important role in the acquisition of CE credits for relicensure. Other than mentioning that computer-based interventions are acceptable for independent-study CE, however, state dental practice acts are not explicit about the quality of such offerings. The discussion regarding the quality of CE offerings is not new.¹ Given the low educational quality of some of the online courses,²¹ it may be prudent to consider how electronic CE offerings to the profession could be improved. ANSI/ADA Specification 1001, Guidelines for the Design of Educational Software²² is the only comprehensive set of quality guidelines applicable to computer-based CE courses. State dental boards may want to consider how this framework could be integrated into a quality assurance mechanism for CE courses, and how the educational effectiveness of these and other forms of CE could be enhanced.

	CONCLUSIONS

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Computer-based instruction, especially in CE, is a work in progress. Continual monitoring of state-of-the-art technology and its educational effectiveness is necessary to ensure that it becomes a valuable CE tool for the profession.