US Dental License for Foreign Trained Dentists


Sunday, November 11, 2018

WREB Clinical Exams

WREB - Western Regional Examining Board / Dental Exam

Western Regional Examining Board
Western Regional Examining Board

WREB serves as one of the clinical exam requirements needed for getting the license in many US states, after the educational requirement (2-yr program) and the written exam requirement (NBDE). I will try to summarize here the key points that you need to know, from my own experience with WREB, from the official WREB publications, and from the advice of my school professors and WREBs own floor examiners. Since specific exam requirements are subject to change, I will try not to go into details discussing those requirements, you can always read the candidate guide for specifics. As always, it's difficult to guarantee the accuracy of all of the information listed here, at all times, so I strongly encourage you to read the WREB candidate guide very carefully to make sure that you understand all aspects of the exam.

To pass the WREB exam: a minimum of 75 points for the overall score, and at least 55% in any section.

I. Operative Section:

Two different restorative procedures on patients that you provide. Worth 48 points.

A. Operative Exam Issues:

1. Unacceptable patient/case submission will result in a 3 points deduction; you can be penalized twice per procedure for a maximum deduction of 6 points per procedure. Be careful.

2. Bevels are not required on Class II composite restorations.

3. Automatic Failure: you don't want to do any of the following sins:
(a) Caries remaining in prep.
(b) Prep of wrong tooth.
(c) Prep of tooth without approval.

4. Modification Requests: Cut ideal prep before asking for modifications.

5. Rubber dam: required for grading and for modification requests; not required for procedure.

6. MO preps on mandibular first bicuspids are not allowed.

7. Posterior Class II teeth require pretreatment bitewing & PA film.

8. Avoid stained pits and fissures if possible because they may be graded as caries remaining which translates into automatic failure: e.g.,
(a) you are prepping a #14 MO, you are responsible for the distal occlusal pit (the entire occlusal surface). If the distal occlusal pit is carious, you must restore it, and it will be graded as part of your Class II prep score, even if it was restored as an individual prep due to tooth structure conservation indications.
(b) If there is buccal or lingual pit caries, you should not restore them until you have requested a prep modification. You will be automatically failed for prepping without a request, but you will also be failed for leaving caries if you ignore them!

9. Class III composite:
(a) Must be unrestored proximal surface with caries at least to the DEJ or beyond.
(b) If there are lesions on both M & D proximal surfaces, both lesions must be done.
(c) Should be an ML or DL prep; MF or DF preps can be done but must be justified.
(d) Gingival margin must be in enamel.
(e) Restoration must extend into the contact.
(f) Temporary fillings are not allowed in adjacent tooth.
(g) Tooth must be vital; preps in RCT teeth are not allowed.
(h) Teeth with veneers are unacceptable.

10. Indirect pulp caps: If you are within ½ mm of the pulp, you may make a note to the floor examiner requesting to do an indirect pulp cap. You must know how close you are to the pulp; you may take a radiograph to ascertain this. The trick is to know for sure you are only ½ mm of the pulp.

B. Common Problems:
1. Tooth not in occlusion.

2. Caries not to DEJ or deeper.

3. Caries not on proximal surface with adjacent contact.

4. Over- or under-treatment proposed on diagnosis.

5. Submitting backup patients without doing your own diagnosis: We heard about candidates who have requested to treat teeth that have been extracted, to treat lesions that were already treated by another candidate on the exam, etc!

II. Periodontal Treatment:

Root planing and scaling on a patient that you provide. Worth 8 points. Periodontal exam failure is the least common problem.

A. Common Problems:

1. Insufficient calculus on quadrant; automatic 3 point deduction for a rejected quadrant.

2. Soft tissue damage.

III. Endodontics Section: 

Endo treatment on two extracted teeth. Worth 16 points. Endodontic exam failure is the most common reason for having to repeat the WREB exam.

A. Endodontics Exam Issues:

1. Caries cannot violate the pulp chamber.

2. Radiographs must show the entire tooth from incisal edge to root apex; use double film packs and take both B-L and M-D views.

3. Chipped teeth are acceptable as long as the damage does not compromise your access design and form.

4. Rubber dam must be used.

5. Only the canal you specify will be graded in the posterior tooth, but you may fill more than one of the canals.

6. If your tooth breaks, put all pieces in a bag and have the floor examiner make a note. Avoid this by keeping the teeth moist in water or glycerin.

7. Be careful not to break the tooth during lateral condensation. If this happens, a score of 3 is the highest possible if all else is well done.

8. Scoring is 0 – 5: 3 indicates minimum competence; a score of 4 on one of the two teeth does not offset a score of 2 on the other tooth – both must be 3 or above.

B. Common Problems:

1. Tooth mounted in wrong arch or backwards in socket.

2. Tooth not in occlusion.

3. Apex putty is not a minimum of 2mm from the base material.

4. The posterior tooth does not have at least two canals.

5. Non-diagnostic radiographs are submitted or no pretreatment duplicate films are submitted.

6. Time management; going overtime with live patient exam.

7. Submission of wet and/or unfixed radiographs.

8. Taking too many radiographs to get that one “perfect” film – film needs to be diagnostic, not perfect.

IV. Periodontal Diagnosis: 

Computer simulation exam. Worth 8 points.

V. Prosthodontics: 

Computer simulation exam. Worth 8 points.

Common Problems: with both CSW Exams (they are administered at the same time):

1. Waiting too long to make the exam appointment, Exam must be taken no more than 45 days before or 3 days after sitting for the clinical exam.

2. Not taking 2 pieces of ID that match the registered name.

VI. Patient Assessment & Treatment Planning - PATP: 

Case-based written exam. Worth 12 points.

A. PATP Exam Issues:

1. Patient cases are used, both adult and pedo cases (Photographs, radiographs, patient information sheet & health history (same forms that WREB requires), caries status and risk assessment are provided.

2. Candidate has 1 hour to treatment plan 1 case:
(a) Exam seeks evidence of good basic treatment planning skills, keep it simple.
(b) Treatment plan only for what you are given, don't read things into the case that do not exist.
(d) Develop an appropriately sequenced treatment plan.
(e) Use of common abbreviations is allowed. Try though to stick to the ones in the official candidate guide.

B. PATP Common Problems

1. Searching for things that are not readily evident in the provided case materials.

2. Poor handwriting.

3. Not keeping it simple, again, do not overtreat or get fancy.

VII. Dental Assistants: 

One of the best things that you could do is to hire an assistant to help during the exam, an experienced dental assistant is better, and one who has been involved in a WREB exam is even better, this can save you a lot of time before and during the exam. It's worth investing in.

VIII. Finding Patients: 

You have to find your own patients for the exam, I encourage you to start looking for patients as early as you can, give yourself plenty of time ahead so you don't get caught up. Although luck has a lot to do with finding "the right patient" there are several things you can do to improve the odds:

A. Screen your own patients that you already see at the school, you will be surprised sometimes how you can find lesions that were not diagnosed before.

B. Offer free screenings to friends, family, etc. Or you can even extend the offer to your local area (schools, church, etc) provided that you can handle the masses that will respond to the offer (this might be better handled by a large group of volunteer students working together).

C. You could offer potential patients incentives to help them commit to showing up for your exam, I have seen several incentives offered, from powered toothbrushes, to cold hard cash.

D. Ask local dentists, especially alumni of your school to help in referring patients who might be good candidate for the exam.

E. If all fails, and you are desperate, you can always resort to patient finding agencies that specialize in locating candidates for the WREB exam, that can be very pricy, but I've seen some of my friends utilize this approach very successfully.

IX. General Information:

A. Be familiar with the regulations before the exam.

B. Be familiar with the needed paperwork beforehand.

C. Pay attention during the orientation, and ask questions if you need to.

D. Know the scoring criteria.

E. Patient selection is very important, the examiners want to see that you can diagnose properly, they do not want to reject patients, but they must if your patient does not meet the criteria. Also make sure the patient’s health is acceptable, they have no TMJ problems, not an anxious patient, etc.

F. Time management is important, especially for the endo exam, do not start late! Endo and PATP exams are timed, none of the others are, but pay attention to your time. Perio patient must be treated the same day they are accepted.

G. You may anesthetize the patient before being submitted for approval.

H. Do not ask the floor examiners to sit and look at your prep until you have cut the ideal prep, they will ask you if it is ideal before they sit down. Do not fish!

I. Candidates will not be penalized for equipment failures; if there is more than a 15 minute delay, the candidate will be compensated. Make sure you notify the floor examiner as soon as you notice the malfunction.

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