In the present study, from the perspective of periodontics residents, interest in undertaking a graduate periodontics program is shared among U.S and international graduates. Overall, the majority of respondents stated that interest in implantology, previous exposure to periodontal procedures, interest in improving periodontal surgery skills, a good relationship with periodontics faculty, the residency curriculum, advanced program features and faculty reputation as factors that attract dental graduates in selecting an advanced periodontics program. One of the top influential factors was previous exposure to periodontal procedures. This result is in agreement with our previous study, which was reported in the opinion of periodontics department chairmen that specialty clinic rotations and elective courses increase student interest in applying to advanced periodontal education . However, there were differences between U.S. and international graduates in terms of background and factors that influenced them to commit to further education in periodontics, such as debt, dental work experience, a good relationship with predoctoral faculty, advance training cost, and location.
In the U.S., the average educational debt for a dental student was $292,000 in 2019 . This is in agreement with the present study, where a significantly higher proportion of U.S. dental graduates, had educational debts greater than $150,000 as compared to international graduates. According to the present survey, in comparison to American graduates, international graduates tend to be older and have more work experience as a general dentist prior to attending a periodontics program, which may contribute to their having less debt. Furthermore, international graduates frequently have financial support from their home country’s government for higher education. In agreement with the present study, student debt [3, 4, 8, 10], program cost  and location [12, 13] have been reported as significant factors that influenced the students’ decision to specialize in dentistry. In the U.S., the average income for general dentists is lower than that of dental specialists . However, American students may be drawn to this career choice by the ability to enter the workforce earlier. Interestingly, in our previous study, from the perspective of program chairmen, the offering of a stipend does not affect the number of applications to the periodontics programs . Perhaps the increasing numbers of international students in dental higher education over time may be due to the fewer financial responsibilities compared to the U.S. graduates’ financial burden.
In the present study, in comparison to international graduates, U.S. graduates reported that a good relationship with the pre-doctoral faculty had a positive impact on developing interest in a periodontics program. This result ties with a previous study wherein it was found that strong faculty student interaction tended to foster interest in a career in periodontics . In agreement, prosthodontics residents reported that advice from predoctoral mentors was an important influential factor in choosing prosthodontics as a career . However, in a Saudi Arabian study, students reported that the influence of family members in the dental profession are of high importance in a selection of a specialty . This variance in opinions among international and American graduates may be influenced by differences in cultural backgrounds. For example, it has been reported that prestige is an important influential factor on choosing a specialty for Turkish, Saudi and Iranian dental graduates. However, it is not an essential factor for western dental graduates, such as British and Danish [6, 17,18,19]. Interestingly, in the present study, international graduates reported that completion of a periodontics program was one way to obtain a dental license to practice in the United States. Also, approximately 30% of international graduates had plans to practice in the United States. Completion of a CODA accredited specialty program is one of the three educational pathways in order to be eligible for licensing in the U.S. . Perhaps, given the decreased amount of debt, international graduates may have more disposable revenue than domestic graduates, and may consider dental specialization in the U.S. as a financial opportunity to earn a higher income as a specialist.
There were limitations to this study. Not all residents in all U.S. programs could be reached, since their contact information was not accessible through the AAP directory website, which is meant to have residents’ contact information. The low response rate (28%) could be partially explained by residents’ main focus on completion of their residency program, by the workload needed to successfully fulfill all of a program’s requirements, and by a potentially outdated list of e-mail addresses in the AAP directory. However, given the small sample, this study identified interesting and informative factors that describe the choice differences between U.S. and international graduates in selecting periodontal programs. A post-hoc power analysis revealed power ranging from 53.3 to 95.8% for dichotomous variables and 65.8% to 80.5% for continuous variables that were analyzed to detect differences between US and International graduates in this study. Studies with small sample size could potentially reveal important characteristics that could be expanded with larger studies and may be included in systematic reviews [21, 22]. Further studies with larger samples are required to increase the power to detect and better understand the differences in influencing factors between U.S. and international graduates’ interests in advanced periodontal education.