The future need for dentists in the United States

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1 Pathways for Foreign-Trained Dentists to Pursue Careers in the United States Veerasathpurush Allareddy, B.D.S., M.B.A., M.H.A., M.M.Sc., Ph.D.; Satheesh Elangovan, B.D.S., D.Sc., D.M.Sc.; Romesh P. Nalliah, B.D.S.; Nithya Chickmagalur, B.D.S., M.D.S., D.M.D.; Veeratrishul Allareddy, B.D.S., M.S. Abstract: With the U.S. population growing ever more diverse and the need for dentists in many areas of the United States, there is increasing opportunity for foreign-trained dentists to pursue dental careers in this country. This article provides a broad overview of dental education and career pathways available for foreign-trained dentists in the United States. Educational opportunities include pursuing advanced standing dental degree programs and advanced graduate education (residency programs). Career pathways include working in academic and private practice settings. This article also describes the licensure and visa requirements foreign-trained dentists must satisfy to work legally in the United States. Dr. Veerasathpurush Allareddy is Associate Professor, Department of Orthodontics, The University of Iowa College of Dentistry & Dental Clinics; Dr. Elangovan is Assistant Professor, Department of Periodontics, The University of Iowa College of Dentistry & Dental Clinics; Dr. Nalliah is Instructor, Office of Global Health, Harvard ; Dr. Chickmagalur is an advanced graduate education student, Department of Developmental Biology, Harvard School of Dental Medicine; and Dr. Veeratrishul Allareddy is Associate Professor, Department of Oral Pathology, Radiology, and Medicine, The University of Iowa College of Dentistry & Dental Clinics. Direct correspondence and requests for reprints to Dr. Veerasathpurush Allareddy, Department of Orthodontics, The University of Iowa College of Dentistry & Dental Clinics, 801 Newton Road, Iowa City, IA 52242; ; Veerasathpurush-Allareddy@uiowa.edu. Keywords: dental education, dentists, academic career, private practice, foreign-trained dentists Submitted for publication 2/5/14; accepted 4/19/14 The future need for dentists in the United States is strong. Five thousand areas have been designated Oral Health Professionals Shortage Areas by the U.S. Department of Health and Human Services. 1 The aging U.S. population will increase the need for dentists in two ways: many older dentists will retire, and the larger cohort of older patients will need oral health care services. 2 In addition, the U.S. population is becoming increasingly diverse, 3 and individuals with limited English proficiency often have poorer health, 4 creating the need for health care practitioners with multilingual skills. To meet the need for more dentists, several new dental schools have opened in the last five years, and existing schools are expanding their class sizes. 5 However, there is also growing opportunity for foreign-trained dentists to pursue dental careers in this country. A previous article reviewed the types of advanced placement and other degree programs in the United States and Canada for foreign-trained dentists, comparing those programs and reviewing the similarities and differences between them. 6 In our article, we go a step further: our aim is to provide an overview of dental educational and career pathways in the United States for foreign-trained dentists, including work opportunities in private practice and academic dentistry and information on visa and licensure requirements. Advanced Standing D.D.S./ D.M.D. Education Of the sixty-five dental schools in the United States and Puerto Rico, twenty-five offer opportunities for foreign-trained dentists to acquire a full U.S. dental degree through abbreviated training in an advanced standing program. 7 Information about these programs appears in Table 1. Foreign-trained dentists typically enter these programs after basic science training in the traditional dental curriculum and before the clinical years. Entry requirements include passing scores on the National Board Dental Examination (NBDE) Part I and/or Part II and the Test of English as a Foreign Language (TOEFL), graduation from a foreign dental school, and prior transcripts. Several advanced standing programs also require that applicants undergo a psychomotor bench test, case presentations, and a formal interview as part of the application process. Most schools require that foreign school transcripts be evaluated by Educational Credential Evaluators Inc., World Education Services November 2014 Journal of Dental Education 1489

2 Table 1. Characteristics of advanced standing D.D.S./D.M.D. programs in the United States University & School Degree Offered Duration of Advanced Standing Program Number of Positions Minimum Entry Requirements: Standardized Tests Estimated Costs Loma Linda University D.D.S. 24 months TOEFL and NBDE Part I/Part II Total costs are $113,732 per year. Ostrow of the University of Southern California D.D.S. 24 months 32 TOEFL and NBDE Part I Total costs are $120,823 for year 1 and $110,573 for year 2. University of California, Los Angeles, D.D.S. 25 months 20 TOEFL and NBDE Part I Total costs are $116,947 for year 1 and $94,832 for year 2. University of California, San Francisco, D.D.S. 24 months 24 TOEFL and NBDE Part I Total costs are $123,561 per year. University of the Pacific Arthur A. Dugoni D.D.S. 24 months 22 TOEFL and NBDE Part I Total costs are $143,395 for year 1 and $135,237 for year 2. The University of Colorado D.D.S. 24 months 40 TOEFL and NBDE Part I Total costs are $96,370 for year I and $93,260 for year II. Howard University College of Dentistry D.D.S. 24 months 10 TOEFL and NBDE Part I/Part II Interested applicants should contact the school financial aid office. University of Florida College of Dentistry D.M.D. 48 months 2 TOEFL and NBDE Part I Tuition fee for nonresidents is $68,042 per year. Instrument, equipment, living, and Indiana University D.D.S. 24 months 24 TOEFL and NBDE Part I/Part II Total costs for nonresidents are approximately $99,000 per year. University of Illinois at Chicago College of Dentistry D.M.D. 24 months 40 TOEFL and NBDE Part I Tuition fee is variable depending on range of hours enrolled. University of Louisville D.M.D. 26 months Based on space availability TOEFL and NBDE Part I Nonresident tuition fee is $59,500 per year. Instrument, equipment, living, and Boston University Henry M. Goldman D.M.D. 24 months 75 TOEFL and NBDE Part I Tuition fee is $64,500 per year. Instrument, equipment, living, and Tufts University School of Dental Medicine D.M.D. 25 months TOEFL and NBDE Part I/Part II Total costs are $48,351 for year 1, $98,723 for year 2, and $91,803 for year Journal of Dental Education Volume 78, Number 11

3 University of Michigan D.D.S. 28 months 10 TOEFL and NBDE Part I Total costs are $124,258 for year 1 and $92,425 for year 2. Rutgers School of Dental Medicine D.M.D. 27 months 26 TOEFL and NBDE Part I and Part II Total costs are $103,218 for year 1 (including summer) and $76,135 for year 2. Columbia University College of Dental Medicine D.D.S. 30 months 2 TOEFL and NBDE Part I Total costs are $56,350 for first spring semester, $96,540 for year 2, and $95,871 for year 3. University at Buffalo D.D.S. 24 months 24 TOEFL and NBDE Part I Total costs for non-ny residents are $88,875 for year 1 and $87,910 for year 2. University of Oklahoma College of Dentistry D.D.S. 29 months 4 TOEFL and NBDE Part I Total costs are $10,000 for preliminary 16-week session, $155,160 for year 1, and $137,334 for year 2. University of Pennsylvania D.M.D. 24 months 30 TOEFL and NBDE Part I Total costs are $33,056 for preparatory program, $105,069 for year 1, and $101,862 for year 2. University of Pittsburgh D.M.D. 24 months 4 TOEFL and NBDE Part I/Part II Total costs for out-of-state students are $84,170 for year 1 and $75,067 for year 2. The Maurice H. Kornberg, Temple University D.M.D. 36 months 12 TOEFL and NBDE Part I Tuition fee is $60,690 per year. Instrument, equipment, living, and University of Puerto Rico D.M.D. 25 months 8 TOEFL and NBDE Part I Total costs are $77,736 for year 1 and $55,002 for year 2. Virginia Commonwealth University D.D.S. 28 months 10 TOEFL and NBDE Part I/Part II Total costs are $91,000 per year. University of Washington D.D.S. 26 months 5 TOEFL and NBDE Part I Total costs are $111,580 for year 1 and $106,580 for year 2. Marquette University D.D.S. 36 months Varies TOEFL and NBDE Part I Tuition is $51,880 for nonresidents. Instrument, equipment, living, and Note: Total cost is the amount (including tuition, other fees, equipment and instrument costs, and living expenses) provided by the school s financial aid office. There is no uniformity in how costs are reported by schools, so applicants are advised to contact the schools for the most updated information. Most schools require that foreign school transcripts be evaluated by Educational Credential Evaluators Inc., World Education Services Inc., or Josef Silny & Associates Inc. Some of the schools also require a psychomotor bench test as part of the admissions process. Source: Data were obtained from American Dental Education Association (ADEA) CAAPID SM Directory ( The website of each dental school was visited to obtain financial data. Both accessed: February 5, November 2014 Journal of Dental Education 1491

4 Inc., or Josef Silny & Associates Inc. Scholarships and tuition support for these programs are limited, with no financial support available in most schools. Unfortunately for foreign-trained dentists considering such programs, the number is currently decreasing. The most common reason we have heard for closing advanced standing programs is that many dental school curricula are evolving into interconnected, continuous programs that fully integrate medicine, dentistry, and biology. These integrated programs do not allow for advanced standing students to begin the clinical programs in a seamless fashion. Foreign-trained dentists are still invited to apply to those dental schools on an advanced standing basis, but they have to participate in the entire four years to graduate with a U.S. dental degree. Apart from the advanced standing programs, some dental schools also offer faculty D.D.S./D.M.D. programs for full-time faculty members who are foreign-trained. Currently, there is no available list of schools that provide this option. A faculty D.D.S./D.M.D. option is usually negotiated at the time of the job interview and offer. These programs vary depending on the school and are usually tailor-made to meet the needs of the individual pursuing this option. Advanced/Graduate/ Residency Education Most foreign-trained students can also apply to graduate residency programs in the United States. Currently, there are nine American Dental Association (ADA)-recognized dental specialties in the United States: dental public health, endodontics, oral and maxillofacial pathology, oral and maxillofacial radiology, oral and maxillofacial surgery (OMS), orthodontics and dentofacial orthopedics, pediatric dentistry, periodontics, and prosthodontics. 8,9 Residency programs vary from two to six years, depending on type of degree. OMS programs are a minimum of four years; six-year OMS programs are completed concurrently with an M.D. (Doctor of Medicine) program from affiliated medical schools. All other residency programs are a minimum of two years in duration. Residency programs are typically completed in conjunction with earning a master s or doctoral degree. Advanced programs are also offered in such non-ada-recognized dental specialties as dental anesthesiology, dental implantology, geriatric/special needs, operative dentistry, and oral medicine. The duration of these residency programs varies between one and four years, depending on concurrent master s or doctoral degree programs. One- or two-year General Practice Residency (GPR) and Advanced Education in General Dentistry (AEGD) programs are also available in some dental schools and other academic institutions. Most of the graduate programs require that applicants complete a D.D.S. or D.M.D. program at a Commission on Dental Accreditation (CODA)- accredited dental school, and some state-supported dental schools do not take any foreign-trained dentists into their programs due to state policies. However, a few programs accept foreign-trained dentists who have obtained a D.D.S./D.M.D.-equivalent from dental schools outside North America. Other entrance requirements are school- and specialty-specific and include such factors as scores on the NBDE Part I and/or Part II, Graduate Record Examination (GRE, conducted by the Educational Testing Service), and TOEFL for non-native speakers of English, undergraduate grades/scores/grade point average, class ranking (if available), dean s letter, and letters of reference (usually from at least three individuals who are knowledgeable about the applicant s academic credentials, clinical work, research abilities, and long-term career goals and objectives). Though not an absolute requirement, it helps if applicants have experience in research, community activities, teaching, and leadership. Since foreign dental schools vary widely in terms of grading criteria, several U.S. residency programs require that applicants have their foreign dental school transcripts evaluated by independent evaluators knowledgeable about educational credentials. Some U.S. dental schools and residency programs also require that applicants be eligible for obtaining a full clinical license in order to pursue a clinical specialty residency program, while others require that applicants obtain a resident/limited license/permit. Six types of residency programs (AEGD, dental anesthesiology, GPR, OMS, orthodontics, and pediatric dentistry) participate in the Postdoctoral Dental Matching Program administered by National Matching Services, Inc. for selecting students. According to the program website, for the matriculating year of 2014, the number of residency spots available through the matching program varied from a low of twenty-seven for dental anesthesiology to a high of 619 for GPR programs ( dentres/aboutstats.html). The numbers of applicants in 2010 to 2014 who gained admission to programs, 1492 Journal of Dental Education Volume 78, Number 11

5 Table 2. Number of students from U.S. and foreign dental schools matched to six types of postdoctoral dental residency programs, General Advanced Oral and U.S./Foreign Practice Education in Maxillofacial Pediatric Dental Dental School Residency General Dentistry Surgery Dentistry Orthodontics Anesthesiology 2014 U.S Non-U.S U.S Non-U.S U.S Non-U.S U.S Non-U.S U.S Non-U.S Note: Dental anesthesiology was not included in Source: National Matching Services Inc. Postdoctoral dental matching program: statistics for applicants (years 2010 to 2014). At: natmatch.com/dentres/aboutstats.html. Accessed: February 4, broken down into U.S. and foreign dental school graduates, are shown in Table 2. AEGD programs had the highest proportion of foreign-trained dentists (18.9 percent) followed by orthodontics (16.1 percent). Since not all dental schools participate in the matching program, the number of positions available probably exceeds those shown in the table. Academic Careers For foreign-trained dentists pursuing advanced standing predoctoral or specialty training in the United States, academic dentistry is one of the options to consider upon graduation. In 2000, a study reported that close to 66 percent of U.S. dental academicians were more than fifty years of age, suggesting retirements will lead to increased job opportunities in the next decades. 10 Academic dentistry provides opportunities to teach dental students in didactic, clinical, and laboratory settings. Apart from teaching, dental faculty members are involved in a wide range of activities such as designing and conducting independent and/or collaborative research, performing community service, reviewing articles submitted for publication, and conducting patient care. The exposure to a variety of activities on a day-to-day basis and the supportive work environment are often cited as major reasons for pursuing academic careers. 11,12 Other advantages of being in academia include staying constantly updated, working at the cutting edge of the profession, learning from peers who are experts in their areas, and working in an interdisciplinary environment. Academic careers carry many other benefits from secure salary to excellent insurance and retirement plans. On the other hand, salary limitations compared to private practice, work pressure, gender bias, length of academic training, and educational debt have been cited as barriers to entering academia. 13 Foreign-trained dentists enrolled in advanced standing or residency programs frequently obtain educational loans to complete their training. Even though some tuition waiver programs and support from specialty foundations are available for dentists intending to pursue a full-time academic career, foreign-trained dentists sizable loan burdens often make it impossible for them to pursue this pathway unless they have attended a tuition-free college. In 2013, Nalliah et al. reported a trend of reducing interest in pursuing full-time academic careers in Massachusetts as educational debt increased. 14 It could be argued that foreign-trained dentists, therefore, November 2014 Journal of Dental Education 1493

6 have an advantage when seeking academic careers in U.S. states that facilitate the process by which dentists from other countries can practice and teach in university settings. However, the movement of foreign-trained dentists into academia (or other fields of dentistry) in the United States represents a loss of highly qualified dentists in foreign countries. A large number of dentists come to the United States from developing nations seeking better opportunities for themselves and their families. The loss of such individuals from developing nations has been reported in medicine, 15,16 but needs to be empirically examined in dentistry. If this does occur, the resulting brain drain can affect those areas that need dentists the most. Specialty training is not essential to work in an academic setting. Foreign-trained dentists who graduate from a CODA-accredited advanced standing dental program can teach predoctoral dental students, but those trained as specialists in a CODA-accredited graduate program can teach both predoctoral and postdoctoral students. Although we have heard individuals say in recent years that graduation from a CODA-accredited dental school is necessary to gain an academic position, we are aware of several schools that have hired highly qualified foreign-trained dentists as full-time faculty members and for senior-level academic positions. If a foreign-trained dentist is in one of the dental specialties, being board-certified is an added advantage that further enhances one s opportunities. Board certification is a process by which a dentist trained in a specialty goes through a series of rigorous examinations to demonstrate exceptional expertise in that field. Depending on the nature of the appointment, academic jobs in dentistry can be broadly divided into two tracks: non-tenure and tenure. Non-tenuretrack appointments are usually clinical positions in which the primary responsibility will be didactic and clinical teaching. With a few exceptions, non-tenuretrack positions usually have minimal or no research requirements. Tenure-track appointments provide the opportunity for a faculty member to become tenured, which ensures the individual s position for the long term. Faculty members on the tenure track are required to pursue independent and/or collaborative research projects and are expected to publish their research findings on a regular basis. Tenure-track appointments in dentistry may be further divided into research-intensive tenure-track and clinical scholartrack positions. In the research-intensive track, research occupies the bulk of one s activities, with little or no time devoted to clinical teaching or patient care, whereas clinical scholar-track faculty members usually pursue clinical practice and research activities on a roughly equal basis. Based on the job description, dental faculty members will be involved in research to varying degrees. The research focus areas in dentistry can be generally divided into oral biology research, public health/health outcomes research, and patientoriented research. Oral biology is a broad term that involves biological research focusing on areas such as oral immunology, cariology, biomaterials, tissue engineering, and molecular biology. Public health and health outcomes research in dentistry primarily focuses on population-based studies and policy development specific to oral conditions. In patientoriented research, patients form the vital component of the study. Testing a newly approved dental material for safety and efficacy for patients with dental caries is a good example of a patient-oriented clinical research project. In many cases, faculty dentists have the opportunity to practice general dentistry or their specialty within the dental school where they teach. However, there are wide variations among states and dental schools regarding the requirements foreign-trained dentists must satisfy to practice. Massachusetts, Iowa, and Illinois allow foreign-trained dentists who have academic appointments to practice in intramural faculty practice clinics for a limited number of days with a faculty permit. Even within one state, we know of one dental school that allows full-time faculty members who are foreign-trained dentists with full licensure to practice extramurally, while another does not allow full-time faculty members to practice extramurally. California allows faculty members to practice within the dental school but regulates the process, requiring that foreign-trained dentists be full-time faculty members who teach four days a week and are allowed to practice only one day a week. Other states like Nebraska do not allow foreign-trained dentists to practice. Foreign-trained dentists who have graduated from an advanced standing dental program in the United States are automatically eligible for dental licensure upon passing the state-specific licensure exam. However, foreign-trained dentists who completed only a specialty program in the United States are often required to obtain a university-specific faculty dental permit to see patients in dental school clinics. Not all dental schools offer a faculty permit to practice and may require full dental licensure Journal of Dental Education Volume 78, Number 11

7 In the ten-year period from 1998 to 2008, the number of full-time dental/clinical science faculty members in the United States remained fairly constant, ranging from 4,215 filled positions in academic year to 4,636 in On the other hand, the number of filled full-time biomedical sciences faculty positions dropped from 933 filled positions in to 663 in Open positions in academic dentistry are advertised with free access on the American Dental Education Association (ADEA) s DentEdJobs ( dentedjobs.aspx), as well as at dental conferences, general dental journals such as the Journal of Dental Education and Journal of Dental Research, and the journals and websites of dental specialties. Faculty positions in dentistry are also listed on the Academic Keys website ( seeker_search.php) and on the job search site of The Chronicle of Higher Education ( levitae.com/job_search/new). Working in Private Practice in the United States To work in private practice after completion of a dental degree from a non-coda-accredited dental school, foreign-trained dentists need to pursue a pathway to licensure either by completion of an advanced standing dental degree (two- or three-year programs) or a degree in one of the specialty programs. 18,19 The only pathway that is accepted nationwide is the completion of an advanced standing dental degree. Only a limited number of states accept successful completion of a clinical specialty program in lieu of a dental degree. 19 Requirements for initial licensure are statespecific, but often include successful completion of both parts of the NBDE, advanced standing degree (D.D.S. or D.M.D.) from a CODA-accredited dental school or successful completion of a CODA-accredited graduate program in one of the nine recognized specialties, plus successful completion of all parts of a regional dental licensure exam like those given by the Western Regional Examining Board (WREB), North East Regional Board of Dental Examiners (NERB), Central Regional Dental Testing Service (CRDTS), Southern Regional Testing Agency (SRTA), or Council of Interstate Testing Agencies (CITA). In addition, almost all states require passing a jurisprudence exam or laws and ethics exams before final issuing of the dental license. Almost all states at this time also require a comprehensive background check, fingerprint clearance, history of any personal or medical problems that may impair the ability to practice dentistry, and information regarding malpractice pertaining to dentistry. A few states require background clearance through a third party, which may take several weeks to a few months. If the foreign-trained dentist holds a license in any state in the United States or any other country, verification of such a license is often required unless the foreigntrained dentist is a refugee or asylum seeker. In addition to the licensure requirements, all foreign-trained dentists must have valid legal visa status in the United States or be a legal permanent resident or citizen of the United States in order to practice. Obtaining a legal work visa is often a long and cumbersome process, which requires adequate planning on the part of the potential employer and the foreign-trained dentist. Additional qualifications must frequently be met to justify the reason for hiring a foreign-trained dentist instead of a U.S. dentist; some of these include advertising the position statewide and nationwide and meeting the comparable minimum wage requirements based on qualifications and work intended to be performed while on duty. All these processes may take several months to a year to complete successfully. One of the additional recent challenges has been a lack of an adequate number of work visas, which are issued by the United States Citizenship and Immigration Services (USCIS; www. uscis.gov/). This number is usually around 70,000 visas with an additional 20,000 for candidates with master s or higher degrees that were completed in the United States. The beginning of acceptance dates for these visas has traditionally been April 1 for visas beginning October 1, at the start of the USCIS fiscal year. Over the last several years there have been more applicants than visas available, so a lottery system is in place to select candidates. Foreign-trained dentists may also work on an Optional Practical Training Status, which ranges from twelve months (for most degrees) to thirty months (for STEM degrees) depending on the individual s field of study. Conclusion This article has provided a broad overview of dental educational and career pathways available for foreign-trained dentists to pursue in the United States. Educational opportunities include pursuing advanced standing dental degree programs and November 2014 Journal of Dental Education 1495

8 advanced graduate education (residency programs). Career pathways available include working in academic and private practice settings. Both licensure and visa requirements must be met in order to work in the United States. REFERENCES 1. U.S. Department of Health and Human Services, Health Resources and Services Administration. Oral health workforce. At: workforce.html. Accessed: January 24, U.S. Census Bureau. Age and sex composition: At: Accessed: March 13, U.S. Census Bureau census shows America s diversity. At: Accessed: January 28, Flores G, Tomany-Korman SC. The language spoken at home and disparities in medical and dental health, access to care, and use of services in U.S. children. Pediatrics 2008; 121(6): American Dental Education Association ADEA official guide to dental schools. Washington, DC: American Dental Education Association, Boorberg NB, Schönwetter DJ, Swain VL. Advanced placement, qualifying, and degree completion programs for internationally trained dentists in Canada and the United States: an overview. J Dent Educ 2009;73(3): American Dental Association. DDS/DMD programs. At: Accessed: January 28, American Dental Association. Dental specialties. At: Accessed: January 28, American Dental Association. Specialty definitions. At: Accessed: January 28, Haden NK, Beemsterboer PL, Weaver RG, Valachovic RW. Dental school faculty shortages increase: an update on future dental school faculty. J Dent Educ 2000;64(9): Trotman CA, Haden NK, Hendricson W. Does the dental school work environment promote successful academic careers? J Dent Educ 2007;71(6): Shepherd KR, Nihill P, Botto RW, McCarthy MW. Factors influencing pursuit and satisfaction of academic dentistry careers: perceptions of new dental educators. J Dent Educ 2001;65(9): Rushton VE, Horner K. Academic dentistry. J Dent 2008;36(7): Nalliah RP, Howell TH, Allareddy V. Educational debt is having a ripple effect on access to care in Massachusetts. J Mass Dent Soc 2013;62(3): Dowling PT, Bholat MA. Utilizing international medical graduates in health care delivery: brain drain, brain gain, or brain waste? A win-win approach at University of California, Los Angeles. Prim Care 2012;39(4): Hagander LE, Hughes CD, Nash K, et al. Surgeon migration between developing countries and the United States: train, retain, and gain from brain drain. World J Surg 2013;37(1): American Dental Association, Survey Center survey of dental education: faculty and support staff, volume 3. Chicago: American Dental Association, American Dental Association. State licensure for international dentists. At: Accessed: January 28, American Association of Dental Boards. State map index. At: Accessed: January 28, Journal of Dental Education Volume 78, Number 11