Foreign-Trained Dentists in the United States: Challenges and Opportunities

The aim of the present study is to review the licensing process and challenges faced by
foreign-trained dentists in United States (U.S.), and how incorporating foreign-trained dentists in
the dental workforce in the U.S. impacts the population’s dental care. Foreign-trained dentists must
complete additional training in a Commission of Dental Accreditation recognized program offered
by a U.S. dental school in order to be eligible for licensing. Foreign-trained dentists interested in
seeking employment in the U.S. face numerous challenges, including stringent admission processes,
high tuition costs, immigration barriers and cultural differences. Opening the U.S. dental profession
to foreign-trained dentists provides several advantages, such as increasing the diversity of dentists
in the U.S., expanding access to underrepresented communities, and enhancing the expertise of the
profession. Foreign-trained dentists are an important resource for a U.S. government seeking to build
the human capital base and make the most of global trade opportunities through a “brain gain”.
Increasing the diversity in the dental profession to match the general U.S. population might improve
access to dental care for minorities and poor Americans, reducing disparities in dental care.

1. Introduction
“Since I recognize that graduates of foreign dental schools, US citizens or not, might make a worthwhile
contribution to dentistry in this country . . . Still we must be careful to uphold standards of US
Dentistry—the best in the world—and, therefore, should take a good look at foreign-trained dentists
to be sure they measure up our standards before granting them licensure” [1].
This passage is extracted from an editorial published in the Journal of the American Dental
Association in the year 1977. This was the first article published in indexed literature that expressed
concerns regarding the professional role of foreign-trained dentists (dentists graduating from
institutions outside the United States (U.S.) and Canada) as dental/oral healthcare providers in
the U.S. This editorial also emphasized the superiority of the current U.S.-based dental education
system over dental institutions in many other countries [1]. Likewise, in the year 1982, Dr. Marvin
Rubin, Chairman of the Council on Education of The Dental Society of the State of New York, expressed
concerns regarding the licensure for foreign-trained dentists to practice clinical dentistry in the State
of New York. Rubin also presented a 5-year (1975 to 1980) dramatic data, that compared the rates of
failures in the clinical examination among U.S.-trained and foreign-trained dentists. The failure rate
among U.S.-trained and foreign-trained dentists, ranged between 1.34% and 6.44% and 66.1% and
80.9%, respectively [2].
The concept of professional self-regulation is based on the premise that members of a profession
possess specific standardized skills and competencies; which make the profession evaluate competence
and performance of its members. In this regard, it is an obligation for dental health professionals

to render services committed to the society [3]. The society’s trust in dental profession and the
provider is essential to sustain the social contract. Maintenance of certification and revalidation are
valid mechanisms to promote and maintain professional self-regulation [4,5]. In the U.S., several
associations claim to represent dentists, which include the American Dental Association (ADA),
American College of Dentists and the National Dental Association [6].
Licensure of foreign trained dentists created a debate in U.S. dentistry, raising concerns in
globalization, diverse workforce and access to care issues. Supporters of a diverse dental workforce
highlight the importance of foreign-trained dentists, valuing provider diversity and arguing increased
access to care for underserved populations [7]. On the other hand, concerns have been raised in terms
of patient safety and assurance of provider competence [8]. Nearly 3 decades ago, the Commission on
Dental Accreditation (CODA) passed a legislation that barred foreign-trained dentists from gaining
licensure (through a certification or clinical examination) to practice clinical dentistry in the U.S.
Instead, foreign-trained dentists were obliged to apply and successfully complete a 2- or 3-year dental
educational program in order to become licensed practitioners. These changes were introduced in
order to protect the public and ensure that international dentists were adequately trained to meet U.S.
standards [9–11]. Presently, licensing requirements for foreign-trained dentists in the U.S. are strict,
confusing, complex and are conferred by individual state licensing boards. This is very different when
compared with the rest of the world, where the federal governments set standards for dental education
and licensure [12].
With this conflicting background, the aim of the present study is to review the licensing process
and challenges faced by foreign-trained dentists in U.S. and how incorporating foreign-trained dentists
in the dental workforce in the U.S. impacts the population’s dental care. It is hypothesized that reducing
barriers for licensing to foreign-trained dentists can preserve population safety while improving
expertise and diversification of the U.S. dental workforce together with helping to reduce healthcare
disparities in the nation.

2. Materials and Methods
The focused question addressed was: What are the licensing pathways and challenges faced by
foreign-trained dentists in U.S. and their impact to the dental care of the U.S. population? In order to
identify studies relevant to the focused question, a structured literature search without language or
time restriction, up to and including May 2018, was conducted using the PubMed (National Library of
Medicine), Scopus, OVID and Web of Science data-bases. All levels of available evidence, including
original studies (prospective and retrospective), review articles, commentaries and letters to the editor
were sought. The following Medical Subject Headings (MeSH) were used: (1) dentists, (2) education,
(3) United States, (4) licensure. Other related non-MeSH terms were used to identify additional
studies exploring foreign-trained dentists in U.S.: (5) foreign, (6) trained and (7) international. Boolean
operators (OR, AND) were used to combine the key words mentioned above: (a) 1, AND 5 OR 7, AND 6,
AND 3; (b) 1, AND 5 OR 7, AND 6, AND 2 OR 4. After the initial electronic search, the reference
lists of the studies identified were hand-searched to identify further potentially relevant studies.
In order to analyze the included articles, a qualitative methodological approach was used, rather than
a quantitative method, due to the nature of the focused question and the studies available in the
literature [13].

. Pathway to Licensing
Foreign-trained dentists must complete additional training in a CODA accredited program offered
by an U.S. dental school in order to be eligible for licensing. There are three different educational pathways to licensing , including

3.2.1. Advanced Standing Programs
Foreign-trained dentists are allowed to gain acceptance in the second or third year of dental
school, and acquire a degree in dentistry in the U.S. (Doctor of Dental Surgery (DDS) or Doctor of
Medicine in Dentistry (DMD)) after completing 2 or 3 years of undergraduate study. Approximately
896 foreign nationals were admitted in 2016 in U.S. dental schools, including first-year students and
advance standing programs [25].
The number of U.S. dental schools offering educational programs for foreign-trained dentists
have increased substantially in the past years. According to the ADA, 32 of the 65 dental schools
in U.S. offer advanced standing programs for foreign-trained dentists. Application requirements
include passing scores of: (a) Test of English as a Foreign Language (TOEFL), (b) National Board
Dental Examination (NBDE) Part I and Part II, and (c) transcripts from dental school evaluated by
independent educational credentialing institutions. Additional requirements include psychomotor
bench tests, case presentations and personal interviews [8,9,22].
3.2.2. Specialty Training Programs
These allow U.S.-trained and foreign-trained dentists to combine residency post-doctoral training
with research training in specific specialties of dentistry. The ADA recognizes 9 dental specialties:
(a) Dental Public Health, (b) Endodontics, (c) Oral and Maxillofacial Pathology, (d) Oral and
Maxillofacial Radiology, (e) Oral and Maxillofacial Surgery (OMFS), (f) Orthodontics, (g) Pediatric
Dentistry, (h) Periodontology and (i) Prosthodontics. The duration of these specialty training programs
may vary from 2 to 6 years depending on the program. For example, OMFS programs are a minimum
of 4 years; however, 6 years OMFS programs are completed together with a Doctor of Medicine
Program. For licensing of foreign-trained dentists, only a limited number of states (such as Texas
and Virginia) accept successful completion of a clinical specialty program instead of an U.S. dental
degree [22].
3.2.3. Advanced Post-Graduate Education Programs
These include 1-year or 2-year residencies: General Practice Residency (GPR) and Advanced
Education in General Dentistry (AEGD). There are also advanced programs in non-ADA-recognized
specialties such as (a) Dental Anesthesiology, (b) Cosmetic Dentistry, (c) Orofacial Pain, (d) Oral
Medicine, (e) Operative Dentistry, (f) Gerodontology and (g) Special Needs Dentistry [22].
Though these programs are ADA credited, they remain unendorsed for specialization. These programs
usually grant a certificate of completion (not a DDS or DMD degree) which may satisfy only licensure
eligibility requirements in the state where the program is located, or be recognized only by a limited
number of states [9]. Several dental schools do not accept foreign-trained dentists into their programs
due to state policies, and only applicants graduating from a U.S. based dental school are eligible for
application [22]. Application requirements include passing scores of: TOEFL, NBDE Part I and Part
II, transcripts from dental school (evaluated by independent educational credentialing institutions),
grade point average, class ranking, and letters of recommendation.
Following completion of the aforementioned educational requirements, foreign-trained dentists
need to complete the regional dental examination required by the State. There are 5 regional testing
agencies in U.S.: (a) the Western Regional Examining Board (WREB), (b) Central Regional Dental
Testing Service (CRDTS), (c) Commission of Dental Competency Assessment (CDCA) (formerly known
as North East Regional Board (NERB) of Dental Examiners), (d) Southern Regional Testing Agency
(SRTA), and (e) Council of Interstate Testing Agencies (CITA). Depending upon the state-defined
regulations, additional requirements may be warranted, which include (a) jurisprudence exam, (b) laws
and ethics exam, and (c) background check [22,23].

3.3. Challenges
Foreign-trained dentists interested in seeking employment in the U.S. face numerous challenges,
including: stringent admission processes, high tuition costs, immigration barriers and cultural
differences [22,26,27].
3.3.1. Admission Process
The available openings for foreign-trained dentists in the different educational programs are
limited, which leads to very competitive and stringent admission processes. Table 3 summarizes the
number of applicants between 2014 and 2018 who gained admission into residency programs which
participate in the Postdoctoral Dental Matching Program

3.3.2. Tuition Costs
Traditionally, U.S. public universities have 2 tiers of pricing: rates for state residents and
for non-residents. However, some institutions have introduced a third, higher tier specifically
for students coming from abroad. It is argued that higher tuition rates are necessary to pay for
services that international students use exclusively or more intensively than others, such as the
monitoring and reporting requirements to the federal government (F-1 and other non-immigrant visas,
the Student and Exchange Visitor Information System (SEVIS)); and other services to a population of
non-native English speakers, including the International Students and Scholar Office [27]. This same
argument can be extrapolated to dentistry, where foreign trained dentists pay higher tuition than U.S.
trained dentists [16]. For example, the projected tuition and fees for the 2-year international dentist
program at University of Colorado for the class of 2019 is $157,260 USD ($78,630 USD each year);
whereas, the yearly rates for Colorado residents and non-residents are $36,205 USD and $61,508 USD,
respectively [28]. Similarly, the 2-year International Dentist Program for foreign-trained dentists in

University of Buffalo requires the payment of $75,000 USD for a mandatory continuing education
summer program in addition to the academic year tuition [29]. A similar scenario occurs with
post-doctoral programs. For example, in Eastman Institute for Oral Health (EIOH) at University
of Rochester, the annual tuition fee for a foreign-trained dentist in the 2-year AEGD program,
is $15,000 USD; whereas, those residents graduated from a U.S. or Canada dental school receive
an annual stipend of approximately $51,000 USD [30].
Furthermore, it is pertinent to mention that additional to tuition fees, travelling, relocation
and living expenses in the city of the program must be also added to the total costs [9].
Moreover, scholarships, loans and financial support to foreign-trained dentists are limited [10].
3.3.3. Immigration Barriers
In addition to licensure requirements, a foreign-trained dentist are required to be a permanent
resident, citizen, or have a valid legal visa of the U.S. in order to practice [22]. Nonimmigrant visas
(such as the F-1 student visa) are given under the condition that after gaining the special skill, the visa
holder should return to their home country to serve their nation. The U.S. does not offer a direct path
to permanent immigration for foreign students; sponsorship by an U.S. employer is required [10].
The H-1B visa program allows U.S. companies to employ foreign workers in different areas requiring
theoretical or technical expertise. In 2017, 1169 H-1B applications were filled by dental offices. The top
five companies applying for H-1B visas for dentists were: Western Dental Services, Dental Dreams,
Maverick Family Dental, Jdc Healthcare, and Perfect Dental; to fill positions in only five states:
California, Connecticut, Massachusetts, Pennsylvania and Texas. These five companies combined,
account for 11.2% of total dental applications [

3.3.4. Cultural Differences
Foreign-trained dentists differ from U.S. dental students in terms of cultural values, previous
personal and professional life experiences, and maturity (as they are often older with families) [9,32].
These factors, including psychological and socio-cultural adjustment, may result in additional
challenges to foreign trained dentists to fit in the U.S. dental school environment, affecting their
academic performance [9].
3.4. Opportunities
Opening the U.S. dental profession to foreign-trained dentists provides several advantages.
For example, foreign-trained dentists increase the diversity of dentists in the U.S., expand access to
underrepresented communities, and enhance the expertise of the profession [7,19,22,33].
3.4.1. Underserved Communities
The U.S. Department of Health and Human Services has designated 5000 Oral Health Professions
Shortage Areas [22]. Communities with high proportions Hispanic and African American residents
are 4 times more likely to have a shortage of physicians, regardless of community income [34]. It has
been suggested that having more foreign-trained dentists could impact dentist practice patterns by
offering increased access to rural or undeserved areas; however, there is no strong evidence to support
this statement [21,25]. A recent study reported that 44% of clinically Hispanic dentists primarily treat
undeserved patients at their practice [19]. Moreover, it has also been reported that minority dentists
were two times more likely to accept new Medicaid patients compared with white dentists [33].
3.4.2. Diversity
Disparity between the proportions of African Americans, Hispanics and American Indians
in the general U.S. population and the nation’s dental profession, has been extensively reported
in the literature [7,19]. These minority groups represent approximately 30% of U.S. population;
Dent. J. 2018, 6, 26 8 of 10
however, only comprise 6% of the dental workforce [15,17]. In the year 2016, foreign-trained dentists
working outside academic settings represented 5.6% of the U.S. dental workforce [25]. Studies have
suggested that the presence of minority healthcare professionals is imperative to meet healthcare needs
of minority communities [17,34]. However, there is not available evidence reporting that minority
healthcare professionals of any origin are more likely to serve any minority community

3.4.3. Expertise and Experience
Incorporating foreign-trained dentists might benefit U.S. training programs by increasing maturity,
diversity and different perspectives on healthcare [22]. Similarly, foreign healthcare providers
contribute to academics and research enhancing the U.S. medical system [16]. Approximately 13.1% of
dentists working in U.S. academic settings in 2016 were identified as being foreign-trained. A significant
rise compared with 2002 and 2009, where foreign-trained dentists in academia were estimated to be
3.3% and 9.1%, respectively [25].
4. Discussion
From the literature reviewed, it is noteworthy that foreign-trained dentists face numerous
challenges to practice in the U.S. In order to become licensed, dental professionals must complete
additional training in a CODA accredited program offered by a U.S. dental school. Although the
number of U.S. dental schools offering educational programs for foreign trained dentists have increased
substantially in the past years, the available openings are limited, which leads to a very competitive
admission process. Therefore, in order to promote diversity in dental professional education and
practice, effective ways to identify and address “unconscious bias” in admissions and recruitment
processes are needed. It is hypothesized that increasing the number of foreign-trained dentists might
help to develop awareness and ability among all dental providers to respond to patients with different
values or culture. It is necessary to shift from a “cultural competence” to a real cultural proficiency
and cultural humility. Diversity is essential to academic and professional excellence. A significant
amount of learning occurs through informal interactions among individuals who are of different races,
ethnicities, religions and backgrounds. Moreover, cultural competence cannot be effectively acquired
in a relatively homogeneous environment. Dental programs must create an environment that ensures
an in-depth exchange of ideas and beliefs across gender, racial ethnic, cultural and socioeconomic lines.
For example, EIOH at the University of Rochester, is unique among academic health centers in the U.S.
Despite the absence of an undergraduate dental school, the institution offers a variety of postdoctoral
educational opportunities for U.S.-trained and foreign-trained dentists. Demographic information for
EIOH residents and postdoctoral dental fellow population for the period 2017–2018 was obtained from
the Registrar Office at EIOH. In total: 140 trainees, including 65 U.S.- and Canada-trained dentists,
65 foreign-trained dentists, two graduate students (Master of Science candidates) and eight preceptors.
In terms of citizenship, 67 (47.8%) trainees were non-resident aliens; whereas, 73 (52.2%) trainees were
U.S. Citizens or Permanent Residents; out of which 21% were from historically under-represented
groups (specifically African American and Hispanic). The current trainee population represents
39 different countries (including the U.S.) and 19 different states of U.S.
Immigration and economic barriers also represent a significant limitation for foreign-trained
dentists. In order to complete an educational program in U.S., international dentists need to request for
an F1 or “student” visa. This visa presents strict work restrictions for the student. Moreover, students
are usually non-eligible for a social security number; do not have access to scholarships and loans,
and have higher tuitions compared with U.S. students/dentists. Therefore, it is necessary to develop
financial aid programs to reduce the financial barriers for minority dental students and foreign
trained dentists in order to increase their access to dental programs and expand the dental workforce.
Furthermore, after completing the educational programs, foreign-trained dentists must be legal
permanent residents, citizens, or have a valid legal U.S. visa in order to practice. It is noteworthy
that there is a need of a migratory reform, shifting toward a model of “skilled-based immigration”,

similar to Canada and Australia; where professionals with higher skills and competences are offered
permanent residency. U.S. current policy prioritizes family reunification and set quotas for the most
highly skilled immigration categories; whereas, Canada’s skill-based immigration is consistent with
its continuing prospect of nation-building through human capital accumulation. This immigration
process allows three-times the level of per capita immigration as the U.S. has, while at the same time
maintains a stable and relatively high public tolerance to immigration.
5. Conclusions
Foreign-trained dentists are an important resource for a U.S. government seeking to build the human
capital base and make the most of global trade opportunities through a “brain gain”. Increasing the
diversity in the dental profession to match the general U.S. population might improve access to dental
care for minorities and poor Americans, reducing disparities in dental care. Further qualitative research
is needed in this regard