The Future of Clinical Assessment in US Dental Education: Competency-Based or Entrustable Professional Activities?

In the late 1990s, US dental education embraced competency-based education (CBE), replacing time- and procedure-based requirements with an outcomes-oriented approach centered on demonstrated abilities and readiness for independent practice. Nearly three decades later, entrustable professional activities (EPAs) is emerging as an assessment framework. Do EPAs represent a new paradigm for dentistry, or are they an extension of assessment principles already embedded in competency-based dental education (CBDE)? This paper examines the similarities and differences between CBDE and entrustable professional activities-based education (EPABE), with particular attention to terminology, assessment methods, decision-making, and the evidence required to demonstrate compliance with US predoctoral dental education standards. CBDE commonly assesses competencies, defined as knowledge, skills, and professional behaviors, through discrete examinations, simulations, structured clinical assessments, or patient-based competency examinations. These methods can establish whether a learner performs a defined task at an acceptable level, but assessments conducted at a single point in time may provide limited evidence of consistency, adaptability, judgment, or sustained performance across clinical contexts. EPABE assesses authentic, integrated professional activities through repeated observation in the clinical workplace. Entrustment decisions address the level of supervision a learner requires and are informed by longitudinal evidence of reliable performance, including technical skill, clinical judgment, efficiency, communication, and professionalism. Unlike many competency assessments, entrustment is dynamic: It may be maintained, withdrawn, or re-established as performance changes. EPABE therefore requires assessment systems capable of aggregating and displaying sequential performance data to support defensible decisions about readiness for independent practice. We argue that EPAs offer a clinically grounded evolution of competency assessment but should not be viewed as a universally sufficient method. Infrequent, unpredictable, or high-risk activities may be better assessed through simulation, case-based methods, or other summative approaches. Hybrid assessment models that combine longitudinal workplace-based observations with targeted high-stakes assessments may provide the most valid, feasible, and CODA-aligned evidence of predoctoral dental graduates' readiness for practice.