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International dental program in Mexico raises questions

To be eligible for licensure in the U.S. or Canada, applicants in all states are required to be graduates of accredited predoctoral dental education programs, or have completed an advanced degree, certificate or two-year International Dentist Program at an accredited dental school.

That's why an advertisement in recent dental publications prompted a few members to contact the ADA for further clarity.

The ad promotes a "New International Dental Studies Program for Foreign-Trained Dentists" at the Universidad De La Salle Bajio in the city of Leon, Mexico: a "two-year program leading to California accredited dental diploma." The didactic training is in English, and clinical training in Spanish.

"Questions about how internationally-trained dentists are licensed to practice dentistry in the U.S. are not unusual," said Dr. Frank A. Maggio, chair of the ADA Council on Dental Education and Licensure. "States have different requirements, which leads to some confusion among dentists, and California's approach is different than any other state requirements."

What's different about California is a 1997 law that declared that the state's current process of licensing foreign-trained dentists—the Restorative Technique exam, also known as the "bench test"—was deficient. California enacted a new law (Assembly Bill 1116) that gave the California dental board the authority to determine whether international dental programs that apply for board approval are equivalent to similar accredited institutions in the U.S. Effective Jan. 1, 1998, the law enabled the dental board to approve dental education programs outside the U.S.

Like many states in recent years, California has been pressured to consider ways to license dentists trained outside the U.S. Dentistry is not unique in this regard—the state's medical board has approved several hundred medical schools located in 120 countries, and the nursing board already has the authority to approve nursing education programs in other countries.

On its Web site, the California Dental Association cites a number of sources that have lobbied for change, including legislators seeking an expanded workforce to treat underserved populations, the growing number of foreign-trained dentists seeking licenses to practice dentistry, and large clinics and group practices that rely on international graduates to fill available positions.

"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," the Web site reads. "And that requiring completion of a two-year U.S. program is a significant and unnecessary barrier to licensure."

All five dental schools currently accredited by CODA in California offer opportunities for internationally trained dentists to complete additional coursework. However, the Universidad De La Salle is not CODA-accredited.

What does this mean? In reality, the De La Salle International Dental Studies Program does not offer an immediate pathway to dental practice in California. Like all candidates for dental licensure in California, graduates of the International Dental Studies Program are required to pass the National Boards, Part I and Part II; pass a clinical licensure examination required by California (either the California licensure exam or the Western Regional Examining Board's); and pass background checks and jurisprudence exams.

Perhaps most importantly, graduates of De La Salle's international dentist program are only eligible for licensure in California.

"The International Dental Studies Program at De La Salle only exempts dentists from the Restorative Technique exam, which is the current path of licensure for internationally trained dentists," said Cathleen Poncabare, executive officer of the newly formed Dental Bureau of California in the state's Department of Consumer Affairs (which used to be the Dental Board of California before it was sunsetted June 30). "Applicants are not exempt from taking a clinical licensure exam to practice here. Completion of the program only makes them eligible for licensure in California, and only in California."

That would change if other states take measures like California did and recognize dental degrees from international programs or dental schools that are not CODA-accredited. "It is extremely difficult for state dental boards to do this with the present rules and regulations that are in effect," said Dr. Maggio.

Individual states have the authority to determine the educational credentials of candidates for dental licensure; in so doing, most defer to CODA accreditation. For the most up-to-date information on requirements, contact individual state dental boards.

The California legislature forced the dental board into the business of accreditation in 1997 when it approved AB 1116 as a way to recognize an equivalent dental education without requiring additional education for foreign graduates whose education had been verified and accepted as equivalent.

However, AB 1116 included language that allowed the board to contract with outside organizations to survey and evaluate international dental schools.

The dental board approached the ADA Commission on Dental Accreditation at the time to investigate the feasibility of contracting with CODA to evaluate programs, but at the time CODA did not have that type of organizational structure in place. Instead, the board used CODA accreditation standards to develop its own approval process regulations.

In 2005, the ADA House of Delegates approved a resolution that enables the ADA and CODA to begin providing fee-based consultation and accreditation to predoctoral international dental programs. Six international dental education programs are in the early stages of consultation with CODA.

Under California AB 1116, international dental programs can apply for approval with the dental board. The board granted provisional approval to Universidad De La Salle in August 2002 after the first site visit. Following its second site visit, De La Salle's five-year predoctoral dental education program received full certification in November 2004. The College of Dental Surgery in Manipal, India, has also applied and is in the process of being evaluated, said Ms. Poncabare.

AB 1116 calls for "periodic surveys and evaluations of all approved schools … to ensure continued compliance," adding that "each fully approved institution shall submit a renewal application every seven years."

With a law on the books giving the California dental board the authority to approve educational programs outside the U.S., De La Salle applied for approval for its new two-year international program in 2006. The International Dental Studies Program is not eligible for CODA accreditation, since CODA's current program only offers consultation and accreditation for predoctoral dental education programs similar to those offered in the U.S.

Dr. Brian Scott, president of the California Dental Association, said the CDA has taken a somewhat neutral stance on the Universidad De La Salle's predoctoral and International Dentist Programs. "In the approval process, the board sent a site visit team that provided a report to a technical advisory group in evaluation of the program, using the CODA process and following it to the letter," said Dr. Scott.

"Now that the Commission on Dental Accreditation has a process in place to accredit international dental schools, we hope the dental board will take the formal step of contracting with the commission," he added.

Dr. Luis Dominicis now serves as a member of the Advisory Committee to the Dental Bureau of California. De La Salle received board approval before his tenure on the committee; however, Dr. Dominicis is familiar with Universidad De La Salle because that's where he earned his dental degree 20 years ago.

"All of the students at De La Salle's California-approved track are U.S. citizens or legal residents of the United States, and they also happen to be bilingual," said Dr. Dominicis. "They know before they are admitted, and in fact are required to sign a disclaimer stating that they know this program is not CODA-approved. They are also informed that they will only qualify to get a license to practice in California once all licensure requirements for the state of California are met."

Two students from the California-approved track graduated from De La Salle in the spring of 2008, said Dr. Dominicis, and one has already passed all the required board examinations and is licensed and practicing in the state's largest community clinic, Clinica de la Raza. Dr. Dominicis added that this newly licensed dentist took the WREB exam, a clinical exam recognized by at least 30 states, but he is only able to practice in California because other states do not recognize De La Salle as an approved or accredited school.

With active predoctoral and international dentist programs, Universidad De La Salle expects to graduate 30 to 35 dentists a year within the next two or three years.

"The predoctoral program has already completed the survey to qualify to complete the self-assessment for joint ADA/CODA consultation, which is an initial step toward CODA accreditation," said Dr. Dominicis. "Their goal is ADA accreditation because that is the gold standard."

Dr. Dominicis believes that Universidad De La Salle is advertising its international dentist program in ADA publications to reach the many foreign-trained unlicensed dentists working in the U.S. in other workforce capacities. The ADA's Web site notes that internationally trained dentists who are not licensed to practice dentistry may find employment opportunities in dental industry or dental education, including dental manufacturing, dental supply or pharmaceutical companies, teaching or university-based research, dental assisting or dental laboratory technology.

"There are many Latino dentists who went to dental school in other countries but practice in the United States as dental assistants," said Dr. Dominicis. "This is a two-year program for them, with basically the same admission requirements as any other two-year program in the U.S., but only if they intend to practice dentistry in the state of California."