Comprehensive Solutions Strategy Addressing the American Dental Association Resolutions 401, 413, and 514B

A Response to the ADHA’s Rejection Letter—Safeguarding Licensure to Uphold Professional Quality and Trust

To:

Erin Haley-Hitz, RDH, BSDH, MS, FADHA, MAADH
President, American Dental Hygienists’ Association (ADHA) 2024-2025

Dr. Brett Kessler, DDS
President, American Dental Association (ADA) 2024-2025

Dear President Haley-Hitz and President Kessler,

I write to you with deep respect for your dedication to upholding the highest standards within the dental profession and for your efforts in addressing the multifaceted challenges of Oral Health Inequality that our nation faces today. The recent ADA Resolutions 401, 413, and 514B have sparked significant dialogue within the dental community. My intention is to contribute my perspective, rooted in decades of clinical practice, dental education, and policy advocacy, and to offer strategic and comprehensive solutions that align with our shared mission to enhance Oral Health for All Americans.

Background Context and Urgency

The U.S. is currently experiencing a severe Oral Health Crisis, highlighted by the following facts:

• 130 million Americans lack access to dental care annually.
• A shortage of over 50,000 dental providers, disproportionately impacting rural and underserved areas.
• Systemic barriers that hinder the effective integration of highly skilled, foreign-trained dentists already residing in the U.S.

This crisis requires bold, innovative, and balanced policies that prioritize Patient Safety, Professional Integrity, and Public Health Equity.

Integration of Interdisciplinary Collaboration

Strengthening interdisciplinary collaboration through partnerships between dental professionals, public health experts, and community leaders is essential for creating more cohesive, community-oriented dental care solutions. This strategy leverages diverse expertise and enhances the effectiveness of oral health initiatives, ultimately benefiting patients and communities across the nation.

Oral Care Must be Included as an Indivisible Part of Primary Care

• Every American should receive two dental cleanings a year, regardless of insurance coverage.
• These cleanings should adhere to the PerioClean™ Preventive Dental Hygiene AirPowerWash Protocol, an innovative and patient-centric approach designed for preventive care. PerioClean™ is a competitive alternative to the patented (GBT) – Guided Biofilm Therapy protocol by EMS Dental but without the obligation to buy into EMS’s expensive product line to use the term or market the service to patients. PerioClean™ is available for use and application by all dentists and hygienists without any product usage conditions or required additional credentialing. It is trademarked by Dr. Alan Arturo Zarzar to support and enhance the dental profession.
• This shift will establish a new standard for preventive oral health and overall well-being.

American Standards

While calibration to American Standards is often justified, it is equally essential to recognize the rigorous training that foreign-trained dentists, particularly those from (Latin America), undergo. These professionals complete five years of dental school followed by an additional year of universal community residency to obtain their dental license. On average, Latin American graduates accumulate double the clinical chair-time patient training compared to their U.S. counterparts (upon graduation). In contrast, U.S.-trained dentists complete four years of undergraduate education and four years of dental school without mandatory community residency. This stark disparity in clinical patient care training experience highlights the need for Reform in the U.S. Dental Education System to align with international best practices. It is important to frame this as a necessary evolution, not a critique, ensuring that this Advancement is viewed as an opportunity for growth.

Despite being highly qualified, foreign-trained Latino Dentists frequently encounter a lack of respect and recognition for their skills. The misconception that they are undertrained persists due to comparisons with a minority of U.S.-trained dentists who have had the opportunity to pursue advanced specialty education. While these U.S. specialists often achieve notable expertise, the majority of general dentists from Latin America do not have access to such continuous education opportunities, either at home or in the U.S. This comparison inadvertently reinforces an inaccurate narrative regarding the competencies of foreign-trained dentists.

In Latin America, the concept of ‘Whole Person Dental Care’—where oral health is integrated into a patient’s overall wellness—has been deeply embedded in cultural and community practices for decades, predating its adoption in the U.S.

Personal Perspective

I am uniquely positioned to address these global disparities in dental education. My academic journey includes two years of college at Arizona State University, five years of dental school in Bolivia, and an additional full-time year in community residency. I have earned multiple one-year diplomates in oral surgery and dental implants from Bolivia, Spain, and the U.S., along with a specialty degree in oral surgery from Chile. My qualifications also encompass a dual two-year master’s degree in Periodontics & Prosthodontics from Barcelona, Spain, and another two-year master’s degree in Implant Dentistry from Bolivia. However, due to exorbitant transcript fees and an arduous credentialing process, I was compelled to choose which degrees to submit for U.S. recognition. I opted for my DDS from Bolivia and dual master’s from Spain to align with practical realities.

Systemic Challenges

In many U.S. states, the system mandates that, despite extensive credentials, I must take the dental hygiene board exam as a protocol to become eligible for further re-education. Candidates are then required to complete an additional two years in a CODA-accredited dental hygiene program to qualify for dental hygiene licensure (except in Florida). The same requirement applies to dental licensure, where taking the dental board exam serves as an eligibility step before completing a comparable two-year CODA-accredited Advanced Standing International Program, a Specialty Program, or a (1 to 2-year) GPR/AEGD residency. This process incurs significant debt and represents only a preliminary step toward full licensure. This underscores the true educational disparities that exist, not where they are often presumed. This issue extends beyond my personal experience; it affects thousands of highly skilled professionals. This is the broader point that must be addressed.

Detailed Analysis and Strategic Solutions for Each Resolution

I. Removal of Faculty-to-Student Ratios in Dental Hygiene Programs (Resolution 401)

Proposed Solution: Rather than reducing faculty oversight by removing faculty-to-student ratios, the solution lies in increasing the number of competent faculty members. This can be effectively achieved by integrating foreign-trained dentists who bring substantial clinical and academic expertise into faculty positions.

Temporary Licensing for Faculty: Implement temporary faculty licensing for qualified foreign-trained specialists (e.g., those with master’s degrees in Periodontics, Oral Surgery, etc.) to serve as faculty and program directors. Denying these highly qualified professionals teaching opportunities due to the absence of a dental and dental hygiene license, despite their advanced degrees and extensive experience, is counterproductive and restricts educational potential.

Rationale: Enhancing the number of skilled faculty, instead of reducing supervision, upholds and even elevates educational standards while addressing faculty shortages. Leveraging foreign-trained dentists’ diverse backgrounds and clinical knowledge enriches dental hygiene programs (and related dental programs), ensuring comprehensive and high-quality training and oversight.

Addressing Licensure Barriers for Teaching Positions: A significant barrier in obtaining a teaching license is the common requirement for proof of employment or a letter of intent to hire before licensure is issued. This creates a dilemma where highly qualified applicants are overlooked due to recruiters’ lack of awareness or automated systems that filter out unlicensed candidates. To solve this, dental boards should issue conditional Dental Teaching Licenses in advance, which activate upon employment. This proactive step would simplify the hiring process, make recruitment more efficient, and create logical pathways to needed teaching roles.

Highlighting Mutual Benefits: The proposed integration of foreign-trained professionals aligns with the ADHA’s commitment to upholding high educational standards and maintaining patient safety. By ensuring that skilled practitioners contribute to dental programs, this strategy meets the dual goals of quality training and faculty augmentation.

Alignment with ADHA’s Concerns: This solution respects and reinforces the ADHA’s emphasis on solid oversight and quality assurance in dental hygiene education. It presents a path that enhances faculty capabilities without compromising the integrity of the training standards.

II. Allowing Dental Students to Practice Dental Hygiene Without State Licensure (Resolution 413)

Firm Opposition: Allowing dental students to practice dental hygiene without state licensure is fundamentally unacceptable! Students must complete their training, graduate, and obtain the appropriate licensure before participating in any clinical practice.

Core Principle: EVERYONE NEEDS A LICENSE!

STUDENTS MUST COMPLETE THEIR EDUCATION, GRADUATE, AND OBTAIN LICENSURE BEFORE PRACTICING.

Reasoning: This policy is vital for ensuring patient safety, maintaining professional integrity, and upholding the practice standards necessary to protect public health. Licensure represents a commitment to competency and readiness, key aspects that safeguard patient welfare and the reputation of the dental profession.

Highlighting Mutual Benefits: This approach underscores the importance of consistent standards for all practitioners, supporting a well-trained workforce, and reinforcing public trust in dental services. Ensuring dental students meet licensure requirements before practicing enhances the quality of care and professional accountability.

Alignment with ADHA’s Concerns: This stance aligns seamlessly with the ADHA’s commitment to preserving high licensure standards, thereby maintaining the quality of education and patient care. Upholding these standards ensures that both current and future dental professionals meet the rigorous criteria necessary to foster trust and defend the profession’s integrity.

III. Foreign-Trained Dentists to Practice Dental Hygiene Without State Licensure (Resolution 514B)

Critical Enhancements to the Resolution:

1. Differentiated Pathways: It is essential to recognize that not all foreign-trained dentists possess the same qualifications. Foreign-trained general dentists should be exempt from taking the dental hygiene board exam and have their degrees recognized, as the role of a dental hygienist often does not exist in Latin America. In these regions, general dentists are trained to perform both dental and dental hygiene duties. However, exemption from the exam does not imply practicing without a license—EVERYONE NEEDS A LICENSE. Thus, foreign-trained general dentists should be granted a two-year temporary dental hygiene license. During this period, their performance should be evaluated, and if satisfactory, they should receive full licensure. This structured approach ensures that foreign-trained applicants move through a transparent path toward permanent licensure after a successful evaluation period.
2. Foreign-Trained General Dentists Applying for Dental Licensure: Foreign-trained general dentists who wish to obtain a full dental license should still be required to take the dental board exam to demonstrate their competency according to U.S. standards. This ensures consistency in maintaining professional standards across the board.
3. Foreign-Trained Dentists with Specialty or Master’s Degrees: Recognize the advanced qualifications of foreign-trained dentists who possess specialty degrees or master’s degrees. These professionals should be exempt from the dental board exam and issued an immediate two-year temporary license to practice within their specialty. This policy acknowledges their high-level training and experience, facilitating their integration into the U.S. dental workforce. After the initial two-year period, a performance evaluation should determine their eligibility for full licensure.
4. Temporary Licensure with Prioritization:
   • Prioritize Foreign-Trained Dentists Already Residing in the U.S.: Priority should be given to foreign-trained dentists with viable migratory status (e.g., green card holders). This ensures that policy changes benefit those who are already contributing to U.S. society before considering overseas applicants seeking entry.
   • U.S. Citizens Over Non-Citizens: U.S. citizens who are foreign-trained dentists should receive priority in licensure pathways and job placement. This approach mirrors reintegration policies for U.S. military veterans transitioning to civilian roles and ensures American citizens can use their expertise to address gaps in underserved communities, aligning with national workforce and public health goals.
5. Structured Testing with Refund Incentives: Implementing a refund policy for board exam fees would reinforce candidates’ commitment to preparation. Candidates who pass the dental or hygiene board exams should receive a full refund. Additionally, upon passing, they should be granted temporary licensure and directed to serve in underserved areas, helping to address workforce shortages and distribute care more equitably.

Alignment with ADHA’s Concerns: This proposal underscores that all practitioners, irrespective of their training background, must meet high standards of practice. By ensuring that everyone holds a license, this approach aligns with maintaining patient safety and professional excellence, which supports the ADHA’s commitment to quality and public trust.

IV. Addressing Concerns About Professional Job Security

Clarification: There is no risk of American-trained and U.S.-licensed dentists or hygienists losing their jobs to foreign-trained professionals. The ADA should play a key role in regulating the placement of foreign-trained, temporary-licensed dentists, ensuring their deployment is focused on designated Health Professional Shortage Areas (HPSAs) and underserved communities. This targeted approach helps fill critical gaps in care without impacting existing job security for U.S.-trained practitioners.

Embracing Foreign-Trained Contributions: Foreign-trained dental professionals should be integrated and respected as valuable members of the dental workforce, not viewed as second-tier practitioners. Their skills and expertise must be recognized and celebrated as essential components in addressing the broader dental care crisis. Such integration fosters collaboration and enriches the overall quality of oral care provided to patients.

Highlighting Mutual Benefits: By positioning foreign-trained professionals in underserved areas, this strategy supports the shared mission of improving access to dental care. It allows U.S.-trained practitioners to maintain their positions while leveraging the unique skills of foreign-trained dentists to bridge gaps in coverage, fostering an inclusive and effective dental care system.

Alignment with ADHA’s Concerns: This approach reassures stakeholders of the commitment to protecting the American-trained dental workforce. At the same time, it acknowledges the importance of filling oral care gaps in a way that enhances public health and upholds professional standards. Such measures are aligned with the ADHA’s focus on balancing workforce security with the pressing need for comprehensive dental care solutions.

V. Comprehensive Approach to Licensure and Residency

1. Differentiating Skill-Qualified and License-Qualified:

a) The term “American Ego,” as mentioned in my article—Oral Health for All Americans: Making America Healthy Again, refers to the flawed perception that foreign-trained dentists are less skilled than their U.S.-trained counterparts. This assumption is both inaccurate and detrimental. Dental education and practice in many regions worldwide are more advanced and comprehensive than commonly believed.

b) The current licensure system is often perceived as overly focused on bureaucracy, burdening candidates with costly exam fees and additional years of re-education that result in unnecessary debt. Reforming these aspects can pave the way for a more equitable and efficient pathway for skilled foreign-trained professionals.

2. Proposal for Expanded Residency Programs:

a) Residency Program Expansion and New Locations:

• Community Health Centers in HPSAs: Expand residency programs by integrating dental residency slots into community health centers located in Health Professional Shortage Areas (HPSAs). This expansion would include adding dental chairs and residents to centers that currently do not provide dental services, bridging a critical care gap in their region.
• New Dental Care Centers in HPSAs: Establish new dental care centers in underserved HPSAs to address the substantial lack of dental care. Foreign-trained dentists can play a vital role in staffing these centers, providing essential care, and mitigating the dental provider shortage.

b) Dental Hygiene Residencies for Foreign-Trained Dentists: Create residency programs that allow foreign-trained dentists to work and demonstrate their competencies in practical, residency-style environments. This initiative will benefit communities in need while giving foreign-trained dentists the chance to prove and showcase their skills.

c) Fair Residency Compensation: Addressing the disparity in residency stipends is essential. Current stipends for dental residents often lag behind wages for less demanding jobs, such as delivery drivers, who receive higher pay and benefits. By improving residency compensation, these programs become more attractive, drawing skilled professionals to serve in underserved areas. This also provides foreign-trained dentists with an opportunity to prove their qualifications and contribute meaningfully, fostering respect and professional recognition for their expertise.

Highlighting Mutual Benefits: Expanding residency programs and improving compensation will benefit the dental profession by filling workforce gaps with well-qualified practitioners. These measures will strengthen public health initiatives, ensuring high-quality care for underserved communities.

Alignment with ADHA’s Concerns: This approach supports the ADHA’s goal of maintaining high standards while addressing workforce shortages. Structured residency programs provide a controlled environment for foreign-trained professionals to demonstrate their competencies, aligning with the ADHA’s commitment to patient safety and professional excellence.

3. Continuing Education Emphasis: Emphasizing continuing education for both U.S.-trained and foreign-trained professionals ensures that all dental providers remain up-to-date with the latest best practices and evolving standards. Continuous learning supports the integration of new knowledge and technology, maintaining high-quality patient care and professional competence. This strategy fosters collaboration and ensures that all practitioners, regardless of training background, can contribute to a unified standard of excellence.

VI. A Call to Unity and Collaboration

As NBC anchor Lester Holt wisely signs off, “Please take care of yourself and each other!” This simple yet profound statement embodies what we, as licensed U.S.-trained and yet-to-be-licensed, foreign-trained dentists, must embrace to move forward and address the oral health crisis we face today.

When we hear, “Let’s stay out of each other’s business,” it often originates from a place of past hurt or fear. However, now, more than ever, we need to unite. We do not need to stand divided or view one another as competition. We must respect and honor those who are licensed, U.S.-trained professionals, recognizing the hard work, dedication, and sacrifices that have earned them their professional standing.

Simultaneously, we must empower skilled, foreign-trained dentists who are waiting for a coherent, practical path to licensure—one that respects their qualifications, provides fair compensation, and avoids unnecessary re-education and debt.

Protecting professional boundaries for their own sake does not solve the more significant issue: the staggering lack of access to dental care for millions of Americans. This crisis is not about job security or undermining qualifications; it is about coming together to address the needs of the 130 million Americans who lack essential dental care, including basic cleanings.

We, foreign-trained dentists, are neither undertrained nor inexperienced. We are prepared and committed to being a part of the solution. Perhaps the most significant challenge we face is not the oral health crisis itself but the indifference that divides us. Uniting our efforts could be the first step toward achieving Comprehensive Dental Access for All Americans and overcoming the divisions that prevent us from seeing one another’s value and shared purpose.

I encourage you to reflect on this and consider the potential impact of collaboration over division. Are you with me in this endeavor?

“Pride will keep you from the Purposes of GOD.” – Pastor Mike Cameneti, Faith Family Church, Canton, Ohio.

VII. Final Considerations

Both the ADA and the ADHA have made commendable strides in upholding professional standards and advocating for improved oral health. However, neither can single-handedly address the full complexity of our current Oral Health Crisis, as detailed in my article—A Path to Oral Health Equity. By integrating the outlined proposals, we can forge a balanced, forward-thinking strategy that prioritizes patient safety, professional integrity, and national health equity.

At its core, addressing this crisis comes down to a simple reality: we need more “skilled-qualified” professionals to meet the demand for dental care. The ongoing debates about not being “licensed-qualified enough” only serve to delay necessary action. Without an expanded and diverse workforce, even the most well-funded initiatives will not achieve their potential. Structural reform is no longer optional; it is essential.

Highlighting Mutual Benefits: These proposals not only address the gaps in dental care but also create opportunities for collaboration and growth. The integration of foreign-trained professionals can complement the existing workforce and strengthen public health outcomes, fostering trust and cooperation within the dental community.

I encourage both associations to carefully review these outlined recommendations and the supporting documentation embedded within my published articles, and collaborate on policies reflecting our shared commitment to a healthier nation. Only through effective and comprehensive collective action can we build a sustainable, inclusive dental care system that ensures Dental Access for All Americans.

Sincerely,

Dr. Alan Arturo Zarzar
DDS, MS, FAAIP, MAAIP

Zarzar@DrZarzar.com