This study compared higher education dental undergraduate student performance in online assessments with performance in traditional paper-based tests and investigated students' perceptions of the fairness and acceptability of online tests, and showed performance to be comparable. The project design involved two parallel cross-over trials, one in Year 3 (n = 132) of the dental curriculum, one in Year 5 (n = 134). A total of 266 students undertook related tests of the same knowledge base in both online and traditional paper formats. Order of presentation of the test form was randomized. One hundred and thirty-two students in Year 3 additionally completed questions concerning their perceptions of the acceptability and fairness of the online examination process. Focus group discussions were held with groups of students (n = 30) from both Year 3 and 5 to explore their perceptions of the online format. The online tests were created using the commercial software package MaxExam (Bristol, UK). The results were analysed using repeated measures analysis of variance (ANOVA) with the order of presentation being entered as a variable in the analysis. The results of the study showed that for both Years 3 and 5 students there was a high degree of consistency in performance between the two versions of the tests, although a minority of students performed better in the online version of the test. Over 70% of students rated the online test as acceptable, and 90% felt that the online format did not disadvantage them even in a 'high-stakes' situation. From these results, we conclude that online assessment does not confer any disadvantage to students. Students perceive such assessment to be both fair and acceptable, and to have some advantages over the traditional paper-based methods of assessment.