International Dental Graduates

Introduction

California and other states continue to face pressure to issue licenses to international dental graduates.  One source of pressure is the community of international dental graduates.  Another source is the group of legislators and other policy makers who view this pool of trained professionals as a partial solution to improving dental care access among the underserved.  Yet another advocacy group is the large clinics and group practices that, in recent years, have relied heavily on the availability of international graduates to fill available positions.

Licensing authorities and organized dentistry face the challenge of ensuring international graduates meet the same standards for licensure as U.S. graduates.  Those standards currently include completion of an accredited dental education program, passage of Parts I and II of the National Board Dental Examinations (NBDE), and passage of a state or regional clinical examination.  Successful completion of one year of an accredited postgraduate program, with certain conditions, is an optional route to initial licensure in California, New York, Washington, Connecticut and Minnesota.  While California in the last decade has changed the licensure process for international graduates to ensure equivalency of education, there are complaints that available space in international dental programs (IDPs) at California schools is inadequate.  There are also concerns that some international dental education programs may be equivalent to a U.S. Commission on Dental Accreditation (CODA)-accredited dental program, and that requiring completion of a two-year U.S. program is a significant and unnecessary barrier to licensure.

CDA supports efforts to help international graduates practice dentistry in this country without establishing other standards for education, licensure, or practice that are less than standards required of U.S. graduates.

Background

All state and territorial licensing authorities require passage of Parts I and II of the National Board Dental Examinations.  Almost all licensing authorities require passage of a state or regional clinical examination.  Almost all states require completion of an accredited dental education program.  Accredited Canadian programs are considered equivalent to accredited U.S. programs.  A few states allow licensure for graduates of non-CODA accredited programs who have completed a CODA accredited ADA-recognized advanced education program.

California

Demographics of internationally-trained dentists residing in the state are unknown, e.g., number, country of origin, years in practice, years in U.S.  The Center for California Health Workforce Studies reported in 2004 that more than 400 international graduates sought services from the recently established Welcome Back Centers.  Over 60 percent of the centers’ clients are from Spanish-speaking countries.

Beginning in the mid-1970s, California offered a unique pathway to licensure for international graduates:  Passage of a restorative technique (RT) exam performed on a typodont would qualify the applicant to take the state licensure exam, without additional education at an accredited school.  Subsequent legislation in 1992 (AB 192 – Tucker) placed some limitations on the RT exam by requiring applicants who failed to pass the exam three times to obtain an additional two years of education at an accredited dental school before being eligible again.

Despite those modifications, concerns grew within the dental profession that the RT exam was not always providing an accurate snapshot of a candidate’s skills, and discussions began on moving toward a uniform licensure standard for all applicants.  Extensive negotiations between CDA leadership, ethnic dental societies, the Dental Board, and key legislators resulted in the passage of AB 1116 (Keeley) in 1996.  The new law established a process for Dental Board approval of international dental schools, eliminated the RT exam as of January 1, 2003, required all graduates of non-Board approved schools to obtain an additional two years of education at an approved school, and allowed all licensed dentists to append the letter “D.D.S.” to their names regardless of their actual degree title.  Subsequent legislation extended the implementation date to January 1, 2004.

Although AB 1116 allowed the Dental Board to approve non-CODA accredited schools, the intent has always been for the board’s process to mirror CODA’s to the greatest extent possible.  In fact, the Dental Board approached CODA about the possibility of contracting with it to evaluate foreign schools.  CODA’s organizational structure at the time prevented the possibility of contracting. Nevertheless, the board utilized CODA accreditation standards in developing their own approval process regulations, and the board has since consistently included former CODA members in its site visits to applicant schools. 

As the deadline for phase-out of the RT exam approached, concerns grew that the Dental Board simply did not have the resources to provide every applicant their required three RT exam opportunities.  Further negotiations led to the enactment in 2004 of AB 1467 (Negrete-McLeod), which extends the deadline for RT exam passage to December 31, 2008, only for those applicants who have passed the national board exam and otherwise met all other qualifications by December 31, 2003. 

Since the passage of AB 1116, only two international dental schools have completed the application process for Dental Board approval.  Universidad De La Salle Bajio, located in the city of Leon in Mexico, received its approval from the board November 2004.  The school has reserved five slots within their dental school class for students to enroll in the California Dental Board approved curriculum.  One of the prerequisites for this program is an undergraduate degree from a university in the United States.   The Dental Board also is considering an application from the College of Dental Surgery in Manipal, India.  A site visit was conducted in 2005, and the application remains active.

AB 1945 (Firebaugh), signed into law in 2002, was promoted by its sponsors (a coalition of primary care clinics) as a way to improve access to care in underserved areas by allowing up to 30 physicians and 30 dentists from Mexico to practice in those clinics for a three-year period.  CDA opposed the bill on the basis that it was inconsistent with ongoing efforts to establish uniform standards for dental licensure in California.  Although clean-up legislation, AB 801 (Diaz), was enacted in 2003, further widening the eligibility of dentists from Mexico for the program, to date there has been no further movement to actually implement the pilot program.  AB 1045 made the implementation of the pilot program contingent upon availability of a non-state funding source, which has not materialized to date.

International Dental Programs (IDPs)

According to the ADA, there are 32 CODA accredited predoctoral programs that may accept international dental graduates with “advanced standing.”  Additionally, a few schools offer certificate programs to international graduates that may allow them to apply for licensure in specific states.  In California, international graduates who complete a minimum two-year program at a state-approved dental program are eligible to take the California clinical exam.  All five California dental schools plus Universidad De La Salle Bajio have state-approved international dental programs.  The program at De La Salle is taught entirely in English.

Although it is estimated that between 250 and 300 candidates have taken the RT exam annually with almost all passing the exam within four attempts, no data was kept on how many candidates were licensed in California through the RT exam route.  Therefore, no comparison can be made with the number of international dental graduates who complete IDPs.

California-approved IDPs
Students accepted annually

De La Salle

30

Loma Linda

20

UCLA

12

UCSF

24

UOP

16

USC

32

Canada

The National Dental Examining Board of Canada (NDEB), in the mid-1990s, did examine and evaluate the worth of assessing international dental graduates’ educational credentials.  It found that the process used by some assessment services did not establish educational equivalency based on standards but rather on a comparison of years of study. It also found the evaluation process to be very difficult and prone to error.  Since 2000, Canada’s process of licensing international dental graduates is similar to California’s process of requiring candidates to complete a two-year educational program prior to taking the final licensure exam.  Since implementing the additional educational requirement, the NDEB has learned that this process is perceived as a significant barrier to graduates from Western Europe, Israel, Hong Kong, Australia, and New Zealand.  The Commission on Dental Accreditation of Canada has been requested to investigate the possibility of establishing reciprocal agreements similar to the one with its U.S. counterpart, with other accrediting organizations; to investigate the possibility of accrediting international dental programs; and to consider revising the accreditation standards of the qualifying programs to allow flexibility.

Trends, Recent Actions and Programs

When legislation allowing the state to accept results of the Western Regional Exam Board (SB 1865 -Aanestad) was introduced in 2004, ethnic dental societies expressed concerns that international dental graduates might not be allowed to take the WREB exam, or would not have the same opportunities as California graduates to practice in other states after passing the WREB.  WREB information indicates that exam applicants need only document that they have met their state’s qualifications for taking the state exam to be eligible for the WREB.

Accreditation

After examining how other U.S. organizations work with international educational programs, CODA developed a plan to make available fee-based consulting services and evaluation, in conjunction with accreditation, to international dental schools.  The plan was implemented January 2007.  CODA also adopted the following policies:

Documents were developed and provided to the 12 programs that expressed a continuing interest in CODA’s consultation and accreditation services. The 12 programs are located in the following countries: Australia, Columbia, India, Korea, Mexico, Peru, Saudi Arabia, South Africa, Sweden and Turkey.

CODA has a reciprocal agreement with the Commission on Dental Accreditation of Canada (CDAC).  The agreement was recently expanded to include accreditation standards for two-year certificate programs for international dentists effective March 1, 2007.  CODA continues to meet with the Mexican National Council on Dental Education, meeting twice in 2007.  Representatives of both organizations continue to believe the Mexican Predoctoral Accreditation Guidelines and Procedures need considerable revision to achieve comparability with CODA and CDAC accreditation standards.

Welcome Back Centers

Funded by the California Endowment, the mission of the Welcome Back Centers is to build a bridge between the pool of internationally trained health workers living in California and the need for linguistically and culturally competent health services in underserved communities.  Centers are located in San Francisco, Los Angeles, and San Diego, and offer counseling, support, and educational programs to internationally trained physicians, nurses, and dentists.  In addition to orientation and support in obtaining the appropriate professional credentials and licenses for their profession, clients are presented with alternatives to consider, for example choosing a different health occupation offered through a community college or focusing their skills and experience in the areas of health care management or research.

Because the actual number of internationally-trained health care professionals living in California is not known, the centers continue to gather data to learn the number of these health professionals in California, and what have been the barriers that professionals have experienced in trying to practice their profession or enter the health care delivery sector. The centers seek to engage their clients in identifying solutions and making policy recommendations that address the barriers they have experienced. 

Other Health Professionals

The trend in medicine, nursing, and pharmacy is to establish national organizations to assess and test international graduates. Licensure of internationally-trained health professionals follows a pattern:  (a) assessing educational equivalence to U.S. or state standards; (b) passing English language proficiency standard; (c) meeting national professional competency standards; and (d) passing individual state background checks and jurisprudence exams. 

 

References

 

September 2007