Four Directions of Health Tourism

There are four recognized directions in which health tourism occurs (^{Labonté, 2013}):

North-North (between developed countries): This generally occurs among individuals residing in high-income nations. South-North (from developing countries to developed countries): This is the most traditional form and involves individuals with high purchasing power living in developing countries who seek medical care in developed countries with better facilities.

South-South (between developing countries): The most overlooked category, where individuals from developing nations travel to another developing country for medical services. Common destinations include Cuba, Yemen, Barbados, Jordan, and Mexico. North-South (from developed countries to developing countries): A newly emerging category where most services are provided by private entities in developing nations aiming to attract an underserved foreign market.

This study focuses on the last category, referring to individuals from developed countries visiting developing nations for dental health services. A notable example is Latin America, particularly Puerto Vallarta, which attracts clients from countries such as the United States and Canada. Medical Tourism in Latin America Medical tourism has been growing in recent years, capitalizing on the private healthcare infrastructure available in developing countries. In Latin America, nations such as Costa Rica, the Dominican Republic, Argentina, Colombia, Brazil, Panama, and Mexico have focused on attracting health tourists. These countries rank among the top destinations for medical tourism globally, according to Patients Beyond Borders and the ^{Medical Tourism Index (2020}; ^{Woodman, 2020}).

Dental medical tourism has positioned Mexico as the primary provider due to its proximity to a large market-the United States. This trend initially emerged in the Mexico-U.S. border region, where U.S. residents traveled south for dental care, particularly to cities such as Tijuana, Vicente Guerrero (Los Algodones), Nogales, and Ciudad Juárez. Later, dental medical tourism expanded to Mexico’s Pacific and Gulf beach destinations, including Cancún and Puerto Vallarta (^{Turner, 2009}; ^{Woodman, 2020}).

Other Latin American countries, including Argentina, Costa Rica, Peru, Colombia, and Brazil (Dental Innovation, n.d.; ^{Misch, 2020}), have also joined this global economic activity, where dental treatment and vacations are planned together. Lower airfare prices and reduced dental service costs in developing countries have facilitated and encouraged this type of tourism.

Ranking of Dental Medical Tourism Destinations Table 1 presents a ranking of the top countries attracting dental medical tourists, based on data from Universal Medical Travel, which manages 14 destinations for medical tourism. Mexico ranks first, while Costa Rica and Colombia rank sixth and eighth, respectively.

Despite these rankings, identifying a single most popular destination remains challenging. The ranking is often influenced by the origin of the website presenting the data. For example, a Costa Rican website may list Costa Rica as the most common destination, leading to biased results. However, one certainty is that all these destinations are equipped with cutting-edge technology to provide patients with the best possible experience.

Puerto Vallarta

Puerto Vallarta is a municipality located in the Costa-Sierra Occidental region of the state of Jalisco, on Mexico’s Pacific coast (Figure 2). The city began developing as a tourist destination in the 1960s, experiencing population growth (Table 3) due to national migration. This was a result of the March to the Sea Plan, proposed by Mexican President Adolfo Tomás Ruiz Cortines (1952- 1958), which aimed to alleviate demographic congestion in the central highlands by encouraging people to migrate to coastal areas (Gómez, 2017).

Subsequent development efforts continued under President Adolfo López Mateos (1958- 1964), who ordered the construction of the Compostela-Puerto Vallarta highway. Work began in February 1960 and was completed in March 1969, with the official inauguration by President Gustavo Díaz Ordaz in 1970 (Fernández & Correa, 2016; E. Gómez, 2017; J. M. Gómez, 2018; ^{Guzmán & Anaya, 2011}). Additional infrastructure developments included the construction of Puerto Vallarta’s airport, completed in 1962 (Fernández & Correa, 2016; E. Gómez, 2017; J. M. Gómez, 2018). In 1966, the first international flight from Mexicana de Aviación arrived, covering the Puerto Vallarta-Los Angeles route via Mazatlán (E. Gómez, 2017; J. M. Gómez, 2018). Meanwhile, the construction of the maritime terminal took place between 1968 and 1970.

Today, the marina can accommodate up to three cruise ships simultaneously (^{National Port System Administration of Puerto Vallarta, n.d.}).

Puerto Vallarta continues to experience population growth, making it one of Mexico’s leading cities in terms of both national and international immigration.

Figure 2. Geographic location of Puerto Vallarta, Jalisco, Mexico Source: ^{Statistical and Geographic Information Institute of the State of Jalisco (2018)}. 

The Beginning of Professional Dental Training in Mexico

In Mexico, the earliest recorded instance of a commercial dental practice dates back to 1823, when a French-born individual, Dr. Guillermo Parrot, became the first to advertise his services as a dental surgeon (Díaz, 2008). After the end of Mexico’s War of Independence, Parrot promoted his services in the newspaper Águila Mexicana, offering medications to whiten and preserve teeth (^{Alvarado, 2014}; Díaz, 2008).

The Beginning of Professional Dental Training in Mexico

Due to increasing demands for quality in dental services, Mexico saw the need to accredit dentists, as the profession was not yet regulated in the country. Eugenio Crombé became the first foreign dentist accredited in Mexico (^{Alvarado, 2014}; Díaz, 2008). Years later, in 1854, the first Mexican candidate, Mariano Chacón, was examined for dental accreditation.

He had acquired his dental knowledge through an apprenticeship system, learning from foreign dentists in their clinics (^{Alvarado, 2014}). As a result of this mentorship system, Margarita Chorné y Salazar became the first accredited female dentist in Mexico in 1886 (Díaz, 2008).

In terms of professional training, Eduardo Clay Wise and Tobía Núñez pioneered efforts to establish a formal dental education program in 1880.

They submitted a petition to the Ministry of Justice and Public Instruction requesting a facility for a Dental School in Mexico, emphasizing its necessity (^{Rodríguez, 2007}).

By 1887, the first edition of the journal Arte Dental was published, and a dental society was established, reinforcing the significance of dentists in Mexico (^{Rodríguez, 2007}). As part of these efforts, various associations and private dentists requested the creation of a dental school in 1896, though multiple failed attempts were made to establish it (^{Alvarado, 2014}; ^{Rodríguez, 2007}).

In 1898, Dr. Charles Aubrey Young published the first issue of Revista Dental Mexicana to unite and update the dental community, aiming to establish a new dental society involved in dentist certification (^{Alvarado, 2004}). At the time, certification was handled by medical professionals with limited expertise in dentistry, leading the society to request that experienced dentists serve on the examining board. The curriculum for the dentistry program was modeled after training programs in the United States and Europe (^{Alvarado, 2004}; ^{Rodríguez, 2007}).

In 1900, Francisco Pastor Artigas attended a dental congress in Paris on behalf of President Porfirio Díaz to obtain the curriculum from the Paris Dental School. This curriculum served as the foundation for the Mexican dental program, which was implemented in 1901 at the Consultorio Nacional de Enseñanza Dental (CNED). The curriculum was officially approved by presidential decree in 1902, published in the Diario Oficial (^{Rodríguez, 2007}).

After more than 20 years of efforts to establish university-level dental education, classes at CNED began on January 1, 1904, under the jurisdiction of the School of Medicine at the Universidad Nacional Autónoma de México (UNAM). The school was formally inaugurated on April 19 of the same year, marking the beginning of formal dental education in Mexico.

As of 2022, Mexico has 222 higher education institutions offering programs in dental and oral health sciences.

These institutions collectively provide 2,255 academic programs: 1,032 at the undergraduate level and 1,223 at the postgraduate level, including specializations, master’s, and doctoral degrees (^{DataMéxico, 2023}).

Objective

The objective of this research was to describe the professional and technological development of dental practitioners in Puerto Vallarta, Mexico.

Sample Description

The study was based on a sample of 21 dentists, representing 12% of the total registered dental professionals in Puerto Vallarta as of November 2023 (^{INEGI, 2024}). The key characteristics of the sample are as follows:

The results indicate that most of the participating dentists were young adults (see Table 4).

Business Landscape of Dental Practices in Mexico

In Mexico, 95% of businesses are classified as microenterprises or sole proprietorships, according to the 2019 Economic Census (^{INEGI, 2019}). These are businesses with between 1 and 10 employees, including the owner.

Among the dental practices surveyed in this study, 90% of respondents identified as sole proprietors, while the remaining 10% were registered as civil associations or corporate entities.

Regarding the year in which dentists were able to establish their own practices or clinics-achieving financial self-sufficiency-the distribution is as follows:

One key aspect of dental practice in Puerto Vallarta is collaborative work among dentists. To provide comprehensive dental health services, practitioners often collaborate, referring patients to specialists when necessary or sharing equipment. In some cases, specialists travel from Guadalajara to Puerto Vallarta to offer their services. In dental clinics, multiple specialists associate to meet the diverse treatment needs of their patients.

Among the interviewed dentists, most covered between one and six specialties in their practice through collaborative partnerships. The three most common specialties were endodontics, periodontics, and third molar surgery. When a required specialty was not available, 86% of respondents stated that they referred the patient to a trusted colleague.

Professional Development of Dental Practitioners in Puerto Vallarta

Like all healthcare fields, dentistry requires accredited professional training and continuous education. In addition to earning a university degree and specializing in at least one field, dental practitioners must stay updated on new technologies, materials, and innovations.

Table 4 outlines the years in which the interviewed dentists completed their professional training and their respective specializations. The majority obtained their degrees from the University of Guadalajara. Among the three dentists who studied between 1960 and 1969, financial and logistical challenges were significant, as they noted in their interviews.

At that time, the road connecting Puerto Vallarta to Guadalajara had only recently been completed under the Costa Program led by Governor Agustín Yáñez (1952-1958). Families in Puerto Vallarta rented homes in Guadalajara to accommodate students who pursued their education in the city.

However, few dental graduates returned to Puerto Vallarta to practice their profession, as seen in Table 4.

Notably, all interviewed dentists had at least one specialization, 38% held two specializations, and 29% had more than two specializations. The most common areas of expertise were implantology, oral rehabilitation, and endodontics. Additionally, five of the respondents had completed at least one specialization abroad.

All interviewed dentists agreed that ongoing training and professional development are essential, and they personally finance these costs.

Additionally, 53% of respondents were members of the Puerto Vallarta College of Dentists, an association that organizes courses, diploma programs, and other professional development events for its members.

Technological Advancements in Dental Practice in Puerto Vallarta

Technological advancements play a crucial role in modern dental practice. In addition to acquiring furniture and equipment, dentists must stay up to date with new techniques associated with these innovations. During interviews, dentists highlighted two main benefits of continuing education and specialization:

They gain access to the latest technology as part of their training.

Their work becomes easier and more efficient through the use of new tools and techniques.

Regarding the origin of most dental technology used in Puerto Vallarta, the distribution is as follows:

Based on the technological level and services available in the dental offices and clinics of the interviewed practitioners, a categorization of these practices was developed, as presented in Table 5.

According to the interviews, 14% of dentists offer basic-level services, 71% operate at an intermediate level, and 14% provide advanced- level services. This classification of technological and service levels in Puerto Vallarta’s dental offices and clinics highlights the high quality of available dental services. Additionally, when combined with the significantly lower costs compared to the United States and Canada, these factors help explain the increasing trend of dental medical tourism in Puerto Vallarta.

Regarding materials used for treatments, repairs, and dental reconstructions, dentists source them from local, state, national, and international suppliers:

Dental laboratories play a crucial role in completing dental procedures, particularly for reconstructive purposes. Their primary function is the design and fabrication of dental materials, such as implants, crowns, veneers, and splints. Some dental clinics operate their own in-house laboratory, but 81% of the interviewed dentists rely on local dental laboratories, while 14% use laboratories in Guadalajara.

Dental Services for Foreign Patients

As an international tourist destination, Puerto Vallarta offers unique advantages that make it attractive to individuals looking to combine vacations or recreational activities with health tourism. This phenomenon is described by ^{Connell (2006)} as “Sea, Sun, Sand, and Surgery.

Puerto Vallarta perfectly fits this concept, as it not only provides high-quality health services-particularly dental services-but also allows tourists to enjoy beaches and warm weather in one of the world’s most famous vacation spots. Among the interviewed dentists, foreign patients account for an average of 46% of their clientele per clinic. Most foreign patients seek implantology, oral rehabilitation, and dental cleaning services, which serve both aesthetic and functional purposes.

The United States and Canada are the main countries of origin for foreign patients. However, there has been a growing influx of patients from South America, Asia, and Europe. To accommodate these international visitors, most dentists have made an effort to ensure at least one staff member speaks English.

None of the interviewed dentists directly work with foreign health insurance companies, but 86% stated that they assist patients by filling out insurance forms or compiling their dental records so they can seek reimbursement from their insurance providers.

Many tourists and foreign residents willingly pay for dental services out of pocket, even if their insurance does not cover them, as the cost is significantly lower than in their home countries. The most in-demand advanced dental procedures among foreign patients include endodontics, oral rehabilitation, implantology, and maxillofacial surgery.