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Point of View: The 183 Million Forgotten by Dr. Alan Arturo Zarzar

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Point of View: The 183 Million Forgotten

From crisis to structural coherence

by Dr. Alan Arturo Zarzar
Point of view is an editorial space for original opinions, reflections, and thought-provoking commentary on trends shaping the profession.
The crisis we refuse to see
I have watched our profession drift toward a quiet crisis. Each year, millions vanish from the patient pool, clinics close for lack of staff, and qualified clinicians are locked out by rules that no longer protect the public—they protect a system that has forgotten its purpose.

Only 45% of Americans saw a dentist in 2022, leaving roughly 183 million Americans without preventive care.1,2 As of September 2025, the Health Resources and Services Administration identified 7,254 designated Dental Health Professional Shortage Areas affecting 61.5 million Americans, with only 32.8% of need met and 10,410 additional dentists required to eliminate the gap.5 This is not a debate or opinion; it is a matter of verifiable record.

Ohio mirrors the nation in miniature: 184 shortage designations, 2.62 million residents affected, and a need for 411 more dentists just to reach federal minimum service thresholds.5 These are not abstractions; they are counties, families, and lives without access to the basic human function of care.

I call this reality Economic Dental Disintegration—the chronic collapse of a health care infrastructure that silently erodes national productivity and public trust.


Education without preparation
Our dental education model is collapsing under its own contradictions. Tuition rises faster than inflation while clinical exposure shrinks. Graduates leave school heavily indebted but often under-experienced, entering a market that rewards procedural speed over diagnostic depth.

Faculty vacancies have increased 62% since 2019, and the pipeline is thinning.¹¹ New schools open without faculty to staff them, forcing programs to recruit international specialists who teach U.S. students but cannot practice alongside them because state licensure rules bar them from doing so. It is a system that confuses credentials with competence and blocks the very experts it depends on.

We can fix this. The Ohio Rural Service Dental Residency Program (ORSDR)—a concept proposal I authored and submitted for review to Governor Mike DeWine’s administration—establishes a two-year, paid, state-supervised residency model in Ohio’s rural shortage counties.¹³ The program pairs new graduates with experienced faculty and qualified foreign-licensed specialists under board and institutional oversight. ORSDR integrates training, licensure preparation, and community service into a single structure: Residents deliver care where access is limited, faculty gain support, clinics expand capacity, and patients receive the continuity of care they lack. It is a workforce, educational, and public health solution at the same time. More importantly, it establishes a scalable framework that other states can adapt without lowering standards or expanding risks.


A workforce shortage that isn’t
Critics argue there is no shortage of dentists—that this is merely an “access-to-pay” problem. They are half right. The crisis is not numerical; it is geographic. In many states, entire rural counties have no practicing dentist. In others, Medicaid participation hovers below 40%. Choice presumes the existence of an option; for millions, there is none.

Meanwhile, estimates suggest that as many as 100,000 foreign-licensed dentists are legally residing in the United States, yet fewer than 5% pursue licensure. These are not unvetted novices. Many hold graduate degrees, board eligibility, and years of specialty training in Commission on Dental Accreditation (CODA)-accredited programs. Yet under current rules, they may teach in our schools but cannot treat the patients they teach about. That is not protection; that is paralysis.


Ohio’s licensure turning point
On December 10, 2025, the Ohio State Dental Board convened an ad hoc committee to review a formal policy petition requesting reinstatement of limited specialty licensure (LSL)—a regulatory pathway Ohio itself authorized until 2019. The petition did not seek licensure for any individual applicant. It proposed restoring a specialty-restricted license applicable to a defined group of dentists: foreign-licensed clinicians who have completed two or more years of CODA-accredited specialty training in the United States and who would practice exclusively within that specialty scope, without authorization to perform general dentistry.

The rationale was straightforward. Ohio, like many states, trains specialty residents in CODA-accredited programs, relies on them as educators and clinical contributors, yet offers no licensure pathway that allows those specialists to practice within the very scope for which they were trained—unless they retrain in general dentistry through a separate path they may neither need nor intend to pursue. The petition sought to realign licensure authority with verified specialty education, existing statutory authority, and documented public health and workforce needs.

During the ad hoc committee discussion, the petition was framed primarily through the lens of individual licensure eligibility rather than as a prospective, system-level policy proposal, and while the committee indicated verbally that the request was unlikely to advance, no written finding or published minutes had been issued at the time of this writing.

Ohio’s experience is not unique. Across the country, specialty-trained dentists—including those educated in CODA-accredited U.S. programs—remain underutilized, while emergency departments absorb preventable dental disease and underserved communities continue to lack care. When regulatory bodies default to procedural defensiveness rather than evidence-based reconsideration, stagnation becomes policy by omission.

The lesson from Ohio is not that reform is unnecessary, but that meaningful reform cannot originate solely within the walls of a licensure board. Solutions of this scale require executive leadership, academic partnerships, and legislative engagement to align public protection with workforce realities.

Board-level licensure decisions alone cannot resolve that gap. Neither can isolated academic programs nor ad hoc policy petitions. What is required are formally structured, service-based models that operate at the intersection of public health, graduate education, and state oversight: models capable of producing measurable access outcomes while preserving patient protection and regulatory integrity.

Several states have begun experimenting with such approaches through residency-based service programs, rural training tracks, and public-academic partnerships designed to deploy clinicians where need is greatest while maintaining clear accountability. These models warrant rigorous evaluation, economic analysis, and policy scrutiny—not as alternatives to licensure reform, but as complementary mechanisms that can inform it.

Ohio now stands at a turning point—not because a petition was denied, but because the process revealed where real decision-making authority must reside if access to dental care is to be addressed with the seriousness, structure, and accountability the crisis demands.


The economic lens
The United States spends $3.9 billion each year on emergency-room visits for preventable dental disease³ and loses $45 billion in productivity to oral-health-related lost workdays.4 Those dollars buy nothing lasting, just temporary pain relief, antibiotics, and lost wages.

Redirecting even a fraction of current emergency room spending into structured, supervised residency programs in shortage areas could fund thousands of training positions, expand access, and reduce long-term costs.

The same budget that currently bandages emergencies could build capacity, reduce deficits, and revitalize local economies.


The false divide: Foreign vs. American
The rhetoric that pits foreign-trained against U.S.-trained dentists is as false as it is destructive. Competence knows no passport. The majority of foreign specialists teaching in U.S. dental schools already meet the same CODA standards as their American counterparts. They publish in our journals, mentor our students, and serve our communities—only without the legal ability to treat patients outside campus walls. That contradiction does not protect patients; it punishes them.

Debt is not a qualification. Competence is demonstrated through verified education, supervised performance, and outcomes—not tuition cost. Licensure exists to safeguard the public, not to reward those who incurred the highest tuition. If we equate competence with cost, we invert the profession’s ethics.


Inertia over action
In 2008, U.S. Army Colonel Donn Grimes warned that the dentist shortage was becoming a national security risk.¹² Seventeen years later, we are still debating definitions while the problem worsens. Faculty vacancies multiply; clinics close; millions wait.

Claims that “183 million Americans chose not to go” ignore the data. As of 2025, 7,254 Dental Health Professional Shortage Areas affect 61.5 million people, many of whom lack any economically viable option for care. Patients cannot “choose” what does not exist.5

Nothing in these proposals lowers standards. Supervised licensure-track rural residencies, portfolio verification, and conditional service licenses are tighter forms of accountability than the current binary exam gate. Licensure protects the public, not lenders. The economics are simple: We already spend billions to do nothing; we can spend less to build something that works.

Whether you believe this is an access problem or an apathy problem, the measurable outcome is the same—tens of millions without care, clinics closing, and faculty vacancies multiplying. If half of us believe in one cause and half in another, the rational approach is to pilot both solutions and measure which works. That is how science and policy advance.


Five steps toward integration
  • Modernize residency pathways. Permit supervised licensure-track rural residencies within shortage areas to count toward state licensure under defined conditions, as proposed by Ohio’s ORSDR pilot.
  • Incentivize service, not location. Tie conditional licenses to defined service commitments in designated rural counties or community clinics, aligning workforce deployment with public need.
  • Credential by competence. Replace binary exam gates with portfolio-based assessments and outcomes audits verified by board-licensed supervisors.
  • Fix the faculty pipeline. Empower qualified foreign-trained specialists who already teach in U.S. programs to obtain limited specialty practice licensure, stabilizing faculty teams and strengthening training environments.
  • Link workforce to economic policy. Recognize oral health as infrastructure by redirecting existing health care spending toward care delivery models that keep patients out of emergency departments and workers productive.

Managing the predictable pushback
Some will say this is socialism; others will say it is cheap labor. Neither is accurate. This is economic patriotism—an effort to use resources we already have to serve the people we are already failing.

Others will fear competition. But the reality is that no U.S. graduate is being replaced; they are being promoted to supervisors, educators, and leaders in a system that finally pays them to teach and to lead.

The greater risk is doing nothing until corporate and government actors define solutions without us. Dentistry has a narrow window to act from a position of strength rather than react.


Dental justice as a public duty
I have spent a career moving between the operatory, the classroom, and the policy table. I have seen what happens when good people stay silent because the truth is uncomfortable.

Our profession was built on service, not self-preservation. Systems that fail to correct themselves are eventually corrected from the outside. Dentistry still has the opportunity to choose reform grounded in evidence, competence, and service.

If we refuse to integrate competence into care, then what is our plan for those who have none?

I believe our profession stands at a crossroads. Either we reform ourselves, or the system will be reformed for us. I know which path I will take. And I hope my colleagues, in Ohio and across America, will walk it with me.

The most profound form of discrimination is the unequal access to health care.

Join the Conversation!

References
1. American Dental Association Health Policy Institute. National trends in dental care use, dental insurance coverage, and cost barriers. September 2024.
2. U.S. Census Bureau. Migration drives highest population growth in decades. Dec. 19, 2024.
3. CareQuest Institute for Oral Health. Dental care in crisis: Tracking the cost and prevalence of emergency department visits for non-traumatic dental conditions. Aug. 13, 2025.
4. CareQuest Institute for Oral Health. The hour of need: Productivity time lost due to urgent oral health needs. Feb. 2, 2024.
5. Health Resources and Services Administration, Bureau of Health Workforce. Designated health professional shortage areas statistics: Designated HPSA quarterly summary (as of Sept. 30, 2025). Oct. 1, 2025.
6. Health Resources and Services Administration, Bureau of Health Workforce. State of the U.S. health care workforce, 2024. November 2024.
7. CareQuest Institute for Oral Health. Out-of-pocket snapshot: Adults with dental and medical care coverage. April 2024.
8. American Dental Association Health Policy Institute. The U.S. dentist workforce: 2025 update. August 2025.
9. American Cancer Society. Key statistics for oral cavity and oropharyngeal cancers. 2025.
10. Ohio Administrative Code. Rule 4715-18-01. Effective Feb. 4, 2019.
11. American Dental Education Association. Faculty vacancy trends and implications for dental education. Journal of Dental Education. Published online Sept. 10, 2024.
12. Grimes D. Shortage of dentists as a national security risk. U.S. Army War College. March 15, 2008.
13. Zarzar AA. Ohio Rural Service Dental Residency Program (ORSDR): Concept proposal. Unpublished manuscript.

Author Bio
Alan Arturo Zarzar Alan Arturo Zarzar, DDS, MS, FAAIP, MAAIP, is an Ohio-based periodontist, oral surgeon, graduate educator, and immigrant U.S. citizen. An advocate for workforce and licensure reform, he authors on modernization of practice pathways, faculty development, and rural dental care access. His work as a policy strategist and reform architect bridges academia, regulation, and community service.

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January 2026
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