Cognitive alignment and assessment validity in a high-stakes dental specialty examination: A Bloom’s taxonomy-based analysis

Background: In high-stakes postgraduate examinations, the cognitive complexity of assessment items is central to evaluating advanced clinical reasoning and decision-making competencies. Alignment between examination content, cognitive demand, and competency based educational frameworks is essential for assessment validity. This study evaluated the cognitive structure of pediatric dentistry questions in the Turkish Dental Specialty Examination (DUS) using Bloom’s revised taxonomy and examined their alignment with curricular expectations. Methods: A retrospective cross-sectional analysis was conducted on 127 officially released pediatric dentistry questions administered between 2012 and 2021. Each item was independently classified according to Bloom’s revised cognitive levels. Curriculum relevance and scientific accuracy were rated using a 5-point Likert scale. Inter rater reliability was assessed using weighted Cohen’s kappa. Associations between cognitive level and curriculum relevance were analyzed, and temporal trends across examination years were explored. Results: Questions were predominantly concentrated at the Understand and Apply levels, with fewer items categorized at the Analyze level. No questions were classified at the Evaluate or Create levels. Although lower- and higher-order cognitive skills appeared proportionally balanced when dichotomized, higher-order items largely reflected procedural application rather than advanced analytical or evaluative reasoning. No significant temporal progression toward greater cognitive complexity was observed. Curriculum relevance ratings were high overall but showed no significant association with cognitive level. Conclusions: This high-stakes specialty examination predominantly assesses lower- and intermediate-level cognitive processes, with limited representation of advanced higher-order thinking. The findings indicate potential blueprint misalignment with postgraduate competency expectations and underscore the need for deliberate integration of higher cognitive-level items to strengthen assessment validity.