All of your hard work in dental school boils down to the CDCA ADEX board licensure exam (no pressure 😅)! This year’s examination was particularly challenging, with the unexpected transition to the CompeDont Non-Patient Based Exam. I recently completed the CDCA ADEX Class 3 Restorative Exam on the new CompeDont tooth. Here’s my personal experience!
I was pretty anxious about the new CompeDont tooth. While I was confident that I could perform well on a natural tooth, I was uncertain of how the CompeDont tooth would compare. How will the tooth cut? Do I need to drill with water? Do I really need diamond burs? Will the tooth chip or fracture? What color and consistency will the caries be? Should I use a spoon excavator? How extensive will the caries be? Will I approach the pulp? Will I even know if I approach the pulp?! How tight will the contact be? Will I need to break contact? Will I be able to restore contact? Will my finishing burs damage the tooth? I could go on and on…
To prepare for the exam, I read the CDCA ADEX candidate manual, watched YouTube videos, and practiced #8-M on my Kilgore and Acadental typodonts. I did not have access to caries-simulated teeth, so I simply practiced ideal preps on conventional typondont teeth. I practiced 12 times during the 3 weeks leading up to my exam. Since our school’s clinic was closed due to COVID, I mounted my typodont to my deck furniture and worked outside (desperate times call for desperate measures)!
The Chief Examiner hosted a virtual orientation the night before our exam. He did a fantastic job answering our questions. You could tell that he genuinely wanted us to be successful. [By the way, this has been my experience throughout all portions of the exam. The examiners are friendly and supportive; they are not out to get you. Instead, they are genuinely rooting for your success!] During the orientation, it was clarified that each tooth is developed with a unique amount of caries and the radiographs provided were not specific to each tooth.
Typically, radiographs give the practitioner an idea of the location and extent of caries. In this case, I never looked at them! Frankly, I didn’t need to. When I received my tooth on exam day, I could immediately discern that it had a large carious lesion; it was far from ideal.
The caries in my tooth were evident as shadowing through the enamel. I illuminated the tooth with both a trans-illuminator and my loupe headlight. The trans-illuminator was overkill. I could clearly see the outline of the caries with my loupe headlight alone.
Before prepping, I noticed two “marks” on the facial surface of the tooth. I documented these “marks” in the notes section of the Progress Form and had these notations verified by a Clinic Floor Examiner (CFE) prior to prepping.
Prior to exam day, I had heard that the enamel of the CompeDont tooth was very hard to penetrate. I also heard it was best to use diamond burs with water. I had practiced with carbide burs and no water, so I stuck with what I had practiced. I didn’t want to switch my approach at the last minute. For me, this worked well!
Before prepping, I placed a fender wedge to protect the adjacent tooth. Obviously, the CompeDont tooth lacks flexible PDL fibers, so there was less “give” when placing the fender wedge. The proximal contact was broad and tight, so I separated the teeth gently by rotating a PFI instrument between the contact (using the same rotational motion I would to unlock a door with a key). We were warned that the adjacent teeth were NOT made of the same, hard material as the CompeDont tooth. Placing the fender wedge provided some insurance against having the bur ricochet off the hard CompeDont tooth, causing damage to the softer adjacent tooth.
I outlined my ideal prep with a mechanical pencil, then created the prep primarily using 330, 33 ½, and 35 carbide burs without water. I started at a speed of 5,000 rpm and never went beyond 20,000 rpm. Slow and steady wins the race!
Once inside, the caries were tactilely easy to distinguish from healthy tooth structure. Although the color of the caries was similar to the dentin, the lesion had a wax-like consistency. I could easily penetrate the lesion with an explorer and feel tug back.
After prepping to the ideal dimensions, I asked for 3 mods on the axial, facial, and gingival walls. They were all granted. In retrospect, I probably should have asked for a mod on the incisal wall as well. There was staining near the incisal that I removed, extending my outline to ~2.5 mm from the incisal edge. Luckily, the proximal contact was broad and I did not break incisal contact. This preventing me from having to completely restore contact (hallelujah)!
While removing caries, I did try using the spoon excavator with caution. I had heard that the CompeDont tooth easily chips with hand instruments. The tooth is so realistic that I actually forgot for a moment it was simulated, and used the spoon excavator with the same amount of force that I would on a natural tooth. Luckily, I quickly caught myself before causing any damage. I felt more comfortable using a #2 round bur on slow speed (approximately 5,000 rpm). I did not use an enamel hatchet or hoe.
Because I was working at a slow rate with caution, and the caries were quite extensive, I used way more time on the prep than anticipated. I had four hours to complete the entire procedure and spent approximately 2.5 hours on the prep.
By the time my final prep was checked, I had about 1 hour left for the restoration. Luckily, I breezed through it! The restoration was easy-peasy.
I used the same strategy to open the proximal contact (rotating a PFI) to place a mylar strip and wooden wedge. We were instructed to complete “normal” bonding procedures, including etch.
During the restoration, I used my Optibond Solo Plus adhesive sparingly because, while practicing, my composite finishing burs damaged the tooth surface. So, I didn’t want to have lots of flash to remove, in case the composite finishing burs would also damage the CompeDont surface. At the same time, I wanted to use enough adhesive for adequate bonding. I had heard horror stories of restorations popping right out of the prep!
To place the adhesive, I used the snowplow technique. Then, I used low viscosity conventional composite for the restoration. I found that the low viscosity composite flowed better towards the hard-to-reach facial extension. Some practitioners use flowable composite for this very reason, but I have occasionally created bubbles using flowable and wanted to play it safe for this high-stakes exam.
I finished my prep using composite finishing burs on a very slow speed (well below 5,000 rpm) and then polished with enhance points. There was no damage to the CompeDont tooth surface. I cleaned up the incisal embrasure with a #12 blade and cleaned up the gingival embrasure with a finishing strip. I did not need to re-establish proximal contact, as I never broke the incisal contact. Before submitting my final restoration, I gently “scrubbed” the tooth with a wet cotton roll and dried it with the air water syringe.
I completed the CDCA ADEX perio and class 2 exams on live patients before COVID. So, I have the unique ability to compare the live patient exam to my experience with the new CompeDont tooth!
Overall, I think the CompeDont exam is more ideal. There have been longstanding ethical concerns about treating live patients for the licensure exam. Plus, there was the added anxiety of whether the patient would show up and whether they would qualify medically! Further, the CompeDont exam eliminates a great deal of paperwork (patient consent, medical history), the use of a rubber dam, and anesthesia! This, in essence, gives you a little longer to complete the procedure.
Despite my initial concerns, I personally feel that the CompeDont tooth is very realistic! It cuts just like a natural tooth (yet, in my opinion, the DEJ and caries are easier to identify than a natural tooth).
If you are reading this in preparation for your own CDCA ADEX exam, I wish you lots of luck! I hope this review alleviates some of your anxiety. Take deep breaths, trust in your skills, and you will be successful!