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Is Residency Worth It? by Dr. LeRoy Horton

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Dentaltown Magazine 

Exploring the benefits, challenges, and long-term outcomes

by Dr. LeRoy Horton

As the interviewer shuffled through the papers of my application pensively, he looked up at me with a seemingly puzzled expression. His head tilted in confusion and, in an even tone, he uttered, “I am not sure we have anything to teach you.” I was surprised at this statement, let alone the setting—this was an interview for my potential acceptance into this director’s periodontal residency program. Luckily for me, I had fielded this question many times over in the lead-up to my interviews. As I sought advice on my decision to leave general practice to become a specialist, many of my friends and mentors seemed equally confused as to why I would upend a 12-year career and essentially start over.

By all measures, I was very accomplished. I owned two successful dental offices and boasted a career as what we call a “super GP,” or a general dentist that offers a wide range of advanced treatments. However, as I admired the specialists that I learned from over the years, I also envied their in-depth knowledge of their respective fields and their ability to weave the history of scientific literature into sound practice philosophies.

I felt my apparent success implied a depth of knowledge that I increasingly realized I did not truly have, at least not nearly to the level of these instructors I learned from. The separation I felt between these specialists and me also made me acutely aware of the gap between me and recent graduates I was hiring at the time. This stratification solidified my desire to pursue a long-term structured program of continued training.


Confidence vs. competence
When fourth-year dental students approach graduation, there appears to be a disparity in their expressed confidence to practice and their post-graduation plans. The limitations of learning in a dental school setting at the predoctoral level are obvious by their choices. According to a survey by the American Dental Education Association in 2024, 93% of graduating students reported feeling as if they had the clinical skills to begin practice in general dentistry. This stands in contrast, however, to the 36% of them who were planning to pursue advanced education. This means one out of three students made the decision to enhance their skillset, with more than 50% of this number seeking either a general practice residency or an advanced education in general dentistry.1

These numbers are consistent with previous years and could easily be interpreted as roughly 15% of dental students feeling as if they need more training or supervised practice. In contrast, almost 40% of their fellow students, according to an eight-year study by Shaikh et al., have family members in the dental field who could provide resources and guidance if they immediately entered the workforce.2

For the rest of us that did not go into post-doctoral programs, the question must be asked: Were we as good as we thought we were? We can possibly provide insight into that, especially in the day and age of technological advances. Sadid-Zadeh et al., in a study assessing digital impressions, showed that 50% of preparations had undercuts, unsupported enamel, or unacceptable finish line quality. In addition, 80% of premolars, 95% of first molars, and 91% of second molars had 20 degree or more taper instead of the ideal 7–16 degree, and overall, 46% of the preparations had areas of poor marginal quality.3

This is not a judgment on general dentistry. In the realm of specialty treatment, we also know that advanced training and experience matter. If we compare long-term tooth survival rates after root canal treatment by endodontists to general practitioners, a multicenter study by Alley et al. showed a difference of almost 10% (98.1% vs. 89.7%).4 As for implantology, Morris et al., in a multicenter study looking at more than 2,900 implants, found the survival rate of implants placed by inexperienced practitioners was 73.0% compared with 95.5% by implant specialists.5 To further press the point of the importance of advanced training in terms of outcomes, Abei et al., comparing casts from orthodontist to general dentist completed cases, found a significantly lower ABOI score for the specialists (a grading system in which the lower the score the better the alignment).6

These consistent demonstrations of the differences in outcomes are not to assert that general dentists are not highly skilled nor that they shouldn’t do advanced treatments. Conversely, it is to emphasize the need for continued training over the lifetime of one’s career.

The value of residency
Residencies, whether for general dentistry or specialty, offer a highly structured and supervised learning experience. Ranging from 12 to nearly 60 months, these programs are a combination of continued didactic education, preclinical and clinical experiences, literature review, examinations, and a supervised performance of increasing case complexity.

Students do not simply to learn the “how,” but become proficient in addressing the five “W” questions.
  • Who are we treating and what about them makes them unique systemically, psychologically, and socially?
  • What are the needs and desires they present with?
  • When is the appropriate time for care and specifically the proper sequence?
  • Where should this patient be treated? Is this a case for your office? A colleague? Or even a combination with a collaborative effort?
  • Why are you doing this or these treatments? Do you have and understand the body of knowledge that dictates your diagnoses and clinical decisions?

When it comes to patient care, this deeper level of understanding is easier to attain in a structured environment. As a general dentist for years, I attempted to learn bits and pieces in between the hustle and bustle of running two businesses while seeing a caseload 10 times that of dental school setting per day, without being held accountable daily to anyone but myself. However, in residency the caseload is usually much lower, which allows for a more intentional and effective implementation of new skills and practice philosophies. This experience is reinforced by the consistent accountability one has to their attendings and their didactic exams.

General dentistry is arguably one of the most difficult positions to hold. Both coach and quarterback, offense and defense—overall leader of patients. However, to be competitive in a growing market, general dentists are performing more and more advanced treatments to generate income and attract patients. The most obvious example is probably orthodontics in the form of clear aligners. Industry reports show that as of 2021, 52% of general dentists provide orthodontic treatment, with 45% of that in the form of clear aligners, and 19% with traditional braces with brackets.7

As we have established that advanced training is tied to patient outcomes, there is a sound argument for long-term structured learning, and specifically residency training.

In my time as an older and seasoned resident, that question that was posed to me in my interview was clearly answered. I gained an extremely deep understanding of research both classic and contemporary. I was exposed to different practice philosophies based on that literature and the vast experience of the faculty. I had the luxury of caring for patients with ample appointment time, direct guidance, and the advantage of experts from other fields just a short walk down the hall.

As a team, my coresidents and I tackled uncommon cases and rare pathologies. My preexisting standards of care elevated higher than even the staunchest faculty member in my predoctoral training. I engaged in research projects that gave me immense insight into how we advance science in our profession. Most impressive was the learning from the referred failures and complications from providers in the surrounding area.


Balancing cost and career
Fairness to the topic would dictate that there is obvious mention of the cost of specializing. Given that the average educational cost to complete dental school is approximately $312,000, in the absence of a program in which there is a paid stipend instead of tuition, residents can often increase their debt by another $300,000 or more.8 Although we as providers have little control over the larger forces that affect the cost of education, we must balance this cost against our ethical duty to always strive for the best possible patient outcomes.

Every journey through pre- and post-doctoral training will be different and should be individualized to each dentist’s unique circumstances. If we are honest that financial pressures do affect clinical decision-making—even if it is in the form of what treatment modalities to add to one’s armamentarium—a counterbalancing decision should also be made to invest in one’s training so as to be one’s best possible self as a provider. 

References
1. E Istrate et al. Dentists of Tomorrow 2024: An Analysis of the Results of the 2024 ADEA Survey of U.S. Dental School Seniors Summary Report. ADEA Education Research Series, Issue 7, December 2024.
2. Shaikh, Muneed & Inglehart, Marita. (2018). Dental and Dental Hygiene Students’ Career Choice Motivations in 2009-17: A Mixed Methods Approach. Journal of Dental Education. 82. 848-856. 10.21815/JDE.018.079.
3. Sadid-Zadeh R, Sahraoui H, Lawson B, Cox R. Assessment of Tooth Preparations Submitted to Dental Laboratories for Fabrication of Monolithic Zirconia Crowns. Dent J (Basel). 2021 Sep 27;9(10):112.
4. Alley BS, Kitchens GG, Alley LW, Eleazer PD (2004). A comparison of survival of teeth following endodontic treatment performed by general dentists or by specialists. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 98:115-118.
5. Morris HF, Ochi S. Influence of research center on overall survival outcomes at each phase of treatment. Ann Periodontol. 2000 Dec;5(1):129-36.
6. Abei Y, Nelson S, Amberman BD, Hans MG. Comparing orthodontic treatment outcome between orthodontists and general dentists with the ABO index. Am J Orthod Dentofacial Orthop. 2004 Nov;126(5):544-8.
7. ConsumerAffairs. “Invisible braces and Invisalign statistics 2025 [2024]” ConsumerAffairs.com. May. 29, 2024.
8. Istrate EC, Ph.D., M.A.I.S., Asmita Samanta, M.S.; Carolyn L. Booker, PhD.; Karen P. West, D.M.D., M.P.H. Dentists of Tomorrow 2024: An Analysis of the Results from the ADEA 2024 Survey of U.S. Dental School Seniors. American Dental Education Association (ADEA) Education Research Series. Issue 7, December 2024.

Author Bio
LeRoy Horton Dr. LeRoy Horton, MS, DICOI, is director of the Periodontal and Implant curriculum at Pacific Northwest University. Originally from Athens, Greece, he moved to the United States as a teenager and later graduated from the University of Washington School of Dentistry in 2007. After 14 years in private practice, he pursued specialty training in periodontics at Oregon Health & Science University, earning a master’s degree in periodontal science. Board-certified in periodontics and dental implant surgery, Horton lectures nationwide and serves as president of the Seattle King County Dental Society.
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