Foreign-trained dentists licensed in the United States
Exploring their origins
Luciana E. Sweis, DDS and
Albert H. Guay, DMD
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ABSTRACT
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Background. The authors explored the origins of foreign-trained dentists seeking licensure in the United States.
Methods. The authors analyzed data received from the American Dental Association Department of Testing Services for candidates who took the National Board Dental Examinations (NBDE) Part II from 2002 through 2005. They also established proxies for the information they sought in lieu of existing direct data.
Results. A total of 4,136 candidates took NBDE Part II from 2002 through 2005. The greatest number of foreign-trained dentists originated from India, the Philippines and Colombia.
Conclusion. The greatest number of potential U.S. dental licensees are primarily from Asia, the Middle East and South America. However, precise studies need to be conducted to generate more exact data about foreign-trained dentists who practice in the United States.
Clinical Implications. The source of international dental graduates seeking licensure in the United States has implications for the licensure process and for the potential accreditation of foreign dental schools.
Key Words: Dental licensure; foreign dentists; accreditationAbbreviations: ADA: American Dental Association • CODA: Commission on Dental Accreditation • NBDE: National Board Dental Examinations
The United States has long attracted foreign students seeking advanced education in a wide variety of professional endeavors, including medicine and dentistry. Many foreign students return to their original countries to practice, but some stay in the United States and become licensed to practice here for a number of personal or professional reasons.
International dental school accreditation by the American Dental Association (ADA) Commission on Dental Accreditation (CODA) or by individual states continues to be a topic of discussion, particularly as it relates to licensure in the United States. As background information for international accreditation discussions, it is important to know which foreign dental schools account for the greatest number of graduates seeking licensure in the United States. Trends in this area are important to identify. For example, according to Mullan,1 "international medical graduates constitute between 23 and 28 percent of physicians in the United States." The largest group came from India (4.9 percent), followed by U.S. international medical school graduates (U.S. citizens who have gone abroad for medical education and returned to the United States to practice) (3.0 percent). The third and fourth largest groups came from the Philippines (2.1 percent) and Pakistan (1.2 percent), respectively. We drew these data from the 2004 AMA Physician Masterfile, a database maintained by the American Medical Association on all physicians in practice or in training in the United States.
Dentists trained in other countries who are seeking to practice in the United States also have affected dentistry. The concern over international accreditation as it relates to globalization and work force and access-to-care issues has become a part of the debate. Although there is a great deal of literature on the dental education of foreign-trained dentists, little is related to licensure. We conducted a PubMed search of the literature and found fewer than 10 articles on this subject; all of them were too specific to be of use in our study.
Dentistry has no central source of information on the number of dentists licensed in the United States who are graduates of foreign dental schools that are not accredited by the ADA Commission on Dental Accreditation.
We conducted this initial study to explore the origins of foreign-trained dentists seeking licensure in the United States. We hope this article will be a starting point in developing a reliable and current database that contains information about foreign-trained dentists who practice in the United States and tracks their experience in the United States.
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METHODS
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Unlike medicine, dentistry has no central source of information on the number of dentists licensed in the United States who are graduates of foreign, non–CODA-accredited dental schools. For that reason, we had to establish proxies for information about those dentists. Although proxy data are not precise, they provide the best available insight into the information sought and can reveal trends.
International dental school graduates who wish to obtain a license to practice in a state in the United States must begin the process by completing National Board Dental Examination (NBDE) Part I and NBDE Part II as they seek admission to a CODA-accredited dental school to obtain a dental degree or a certificate. We know the number of applicants and the non–CODA-accredited schools from which they obtained their dental degrees, as well as the number of graduates from international dental schools who were admitted to U.S. dental schools. From the combination of these data, we can obtain a good estimate of the number of international dental school graduates who most likely will seek a license to practice in the United States, the dental schools from which they were granted their dental degrees and their country of origin.
Several factors diminish the precision of the data:
- – Some international dentists who completed NBDE Part II did so without intending to seek licensure in the United States but instead for other reasons. We do not know the number of people in this category.
- – Some international dentists who obtain a dental degree from a CODA-accredited dental school do not intend to practice in the United States but wish to enhance their training and professional reputation in their home country or the country in which they practice. Directors of some international programs in U.S. dental schools estimate that a small percentage of their graduates are in this category.
- – The country of origin of every international dental school graduate cannot be accurately ascertained from the location of the dental schools from which they graduated, as some students receive their dental education outside of their native countries. We do not know the number of people in this category.
- – No estimate can be made of the number of U.S. students who received their dental degrees from non–CODA-accredited dental schools and returned to the United States for degrees from U.S. dental schools. International program directors at some U.S. dental schools indicate that this accounts for a small number of their students.
Although each state establishes its own requirements for licensure, the ADA Department of State Government Affairs, which monitors licensure requirements, is unaware of any states that do not require the completion of NBDE Parts I and II for licensure. Although the exact number of NBDE candidates who seek licensure in the United States is not known, we assume that a relationship between the number of candidates taking the examinations and the number who will seek licensure in the United States exists and that the numbers move in the same direction; that is, the greater the number of candidates, the greater the number seeking licensure.
Notwithstanding these limitations regarding the precision of the data we analyzed and the proxies we chose, we can draw general conclusions and identify some trends from these data until more exact data are available.
The ADA Department of Testing Services provided data for candidates who took NBDE Part II from 2002 through 2005 and indicated on their test applications that they had graduated from a non–CODA-accredited dental school. These applicants’ credentials were evaluated by Educational Credential Evaluators (ECE) (Milwaukee)—a service used by the ADA Joint Commission on National Dental Examinations to determine eligibility of foreign-trained candidates to take the NBDE2—and the applicants had successfully completed NBDE Part I. The ECE report provided verification that the candidates had graduated from recognized dental education programs in a foreign country and that the curriculum included the content areas covered in the examination.
Not all international dental school graduates who complete NBDE Part II wish to practice dentistry in the United States. A number of non-immigrant students wish to attend a postgraduate training program and then return to their country of origin, and others decide to practice outside the United States.
Some foreign-trained dentists who took NBDE Part II during the years we studied were enrolled in a program at a CODA-accredited institution that granted a dental degree or in a state-approved supplemental education program (usually two to three years). Some of these candidates indicated on their test applications that they were students at the CODA-accredited institution rather than the foreign dental school from which they received their dental degrees, making locating their ECE report information difficult. To overcome this problem, we cross-referenced data from NBDE Part II with NBDE Part I information, using names, addresses, graduation dates, school, country of origin or other information that could help us identify these people.
To refine the data further, we counted candidates only once even if they took the examination more than one time in a year. We excluded candidates with inaccurate or unidentifiable dental school information or if they had the same name as another candidate.
We also obtained data from the Survey Center in the ADA Health Policy Resources Center. We obtained the total number of international dental school graduates who were admitted to U.S. dental schools from various survey reports on dental education conducted by the American Dental Association Survey Center. For comparative purposes, we also obtained information from the Survey Center on the total number of foreign-trained dentists who graduated from training programs in accredited dental schools in 2003. 3
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RESULTS
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A total of 24,113 people (domestic and foreign) took NBDE Part II from 2002 through 2005. Through the selection process we described, we identified 4,136 people who were foreign-trained.
The 12 countries that were the source of the highest number of dentists are listed in Table 1
. The greatest number of NBDE Part II candidates during the study period received their dental degrees from dental schools in India (25.8 percent), followed by dental schools in the Philippines (11.0 percent) and Colombia (5.8 percent). Ninety-six countries around the world each supplied less than 4.0 percent of the remainder of the candidates.
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TABLE 1 Top 12 countries of origin of National Board Dental Examination Part II foreign-trained candidates, 2002–2005.*
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For the four years we evaluated, the international dental school that provided the most international dental school graduates was the University of the East, Manila, Philippines (169 candidates), followed by Centro Escolar University, Manila, Philippines (151 candidates), and Bangalore University, India (116 candidates). The 15 schools that supplied the greatest number of candidates are listed in Table 2.
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TABLE 2 Top 15 international dental schools attended by National Board Dental Examination Part II foreign-trained candidates, 2002–2005.*
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Candidates in our study graduated from 478 dental schools in 100 countries. The dental schools from which the five highest percentages of candidates graduated are listed in Table 3 for each of the years we studied. International dental school graduates were 7.6 percent of those who graduated from U.S. dental schools in 2003, as indicated in Table 4 (American Dental Association Survey Center, 2003–04 Survey of Dental Education, unpublished survey data).
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TABLE 3 Top five international dental schools attended by National Board Dental Examination Part II foreign-trained candidates, 2002–2005.*
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According to various Surveys of Dental Education, (American Dental Association Survey Center, Surveys of Dental Education, unpublished survey data) the number of foreign-trained dentists enrolled in predoctoral dental programs in the United States decreased approximately 50.0 percent since 1993, with relatively stable levels since 1997.4 The number of these international dental school graduates is listed by year of admission in Table 5 (page 224).
We found that there was a trend of decreasing numbers (a 46.4 percent reduction) of foreign-trained dentists taking NBDE Part II from 2002 through 2005 (Table 6, page 224).
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DISCUSSION
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The decreasing number of international dental school graduates enrolled in CODA-accredited dental schools is in accord with recent trends at other U.S. universities. An article in USA Today 5 cites increasing U.S. tuitions; immigration issues after Sept. 11, 2001; the changing nature of higher education; and heightened competition from the rest of the developed world as some of the reasons for the more than 3.0 percent drop in foreign student enrollment since the 2001–2002 academic year. This trend also is discussed at length in a Fact Brief published by the Institute for the Study of International Migration at Georgetown University.6 The Fact Brief presents basic indicators on foreign students drawn from three major sources: the U.S. Department of State’s data on foreign student visas, the Institute of International Education’s Open Door reports on foreign student enrollments and the Council of Graduate Schools surveys of graduate schools.
Although the precision of the data in our study is compromised by the lack of exact data as we described earlier, the general observations and trends emerge clearly and most likely would not change with more precise data. More and better data would expand the scope of the information that could be gathered from future studies.
Unlike medicine—in which international medical school graduates constitute approximately one-quarter or more of the physician work force in the United States—the reliance on international dental school graduates in dentistry was not as significant for the years we analyzed, though some states are looking toward foreign-trained dentists to help with the access-to-care crisis, particularly with underprivileged groups. For example, according to the ADA Department of State Government Affairs, California and Minnesota have given their dental boards authority to approve foreign dental schools that do not have CODA accreditation for the purpose of licensing their graduates in those jurisdictions. The California dental board has approved one non–CODA-accredited school, but the Minnesota dental board has not yet done so. California has enacted legislation that would allow 30 Mexican dentists and 30 Mexican physicians to practice in that state in underserved Hispanic areas without a California license. This act also requires that California dental schools develop a curriculum for and provide remedial education to that group in a number of areas. It also requires that private money fund the program. No private funding has been identified, and the program has not been implemented.
With the international accreditation issue gaining increased awareness, it is especially important to evaluate adequately the international dental schools that educate the greatest number of dentists who seek licensure in the United States.
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CONCLUSION
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Studies need to be conducted to identify the exact number of foreign-trained dentists who practice in the United States in the areas of clinical practice, research, teaching, etc. In addition, information concerning the NBDE success rate of graduates from various dental schools—managed within the Family Educational Right to Privacy Act’s limitations on information gathering and sharing—could be of value in understanding the educational statuses of foreign dental schools and serve as an impetus for improving dental education around the world.
In medicine, state medical boards want to be assured that graduates of foreign medical schools have acquired the skills to practice medicine independently. The information gathered from the tracking of international medical schools’ records by the Federation of State Medical Boards indicates that some state medical boards have created lists of foreign schools from which they will not license graduates.7
The field of dentistry continues to be affected by international dental school graduates who look to the United States for promising professional opportunities. As with international medical school graduates, the leading sources of foreign-trained dentists seeking these opportunities are primarily from Asia, the Middle East and South America. During the period we studied, the schools producing the greatest number of potential U.S. licensees changed order annually in regard to number of NBDE Part II candidates, but they remained near the top of the list.
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FOOTNOTES
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Dr. Sweis was the Hillenbrand Fellow 2005–2006, American Dental Association, Chicago, when this article was written. She is a clinical assistant professor, Department of Oral Medicine and Diagnostic Sciences, University of Illinois at Chicago College of Dentistry.
Dr. Guay is the chief policy advisor, American Dental Association, 211 E. Chicago Ave., Chicago, Ill. 60611, e-mail "guaya{at}ada.org". Address reprint requests to Dr. Guay.
The views expressed in this article are not necessarily those of the American Dental Association or its subsidiaries.
The authors acknowledge the valuable assistance of the American Dental Association’s Division of Education and Licensure, particularly Ms. Anne Koch, and the ADA Survey Center in gathering data for this study.
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REFERENCES
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- Mullan F. The metrics of the physician brain drain. N Engl J Med 2005;353(17):1810–8.[Abstract/Free Full Text]
- American Dental Association. International dentists: Frequently asked questions. Available at: "www.ada.org/prof/prac/licensure/faq.pdf". Accessed Feb. 27, 2006.
- American Dental Association Survey Center. 2003–04 Survey of dental education: Volume 2—Tuition, admission and attrition. Chicago: American Dental Association; 2005.
- American Dental Association. Annual report on dental education: Dental school admissions supplement. Chicago: American Dental Association; 1994.
- Marklein MB, Slavin B. USA losing its advantage drawing foreign students. USA TODAY; Jan. 6, 2006:10A.
- Georgetown University. Fact brief: The reason for concern? Trends in the numbers of foreign students in science and engineering through 2005. Available at: "www.georgetown.edu/sfs//isim/Publications/SloanMaterials/Fact1_1,%20declines%2005.pdf". Accessed July 9, 2006.
- Croasdale M. Quality concerns spur scrutiny of many Caribbean medical schools. American Medical News Jan. 16, 2006:1–2.
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ABSTRACT
METHODS
