What does the future hold for the dentist and for YOU – the patient!

The Business of Dentistry is what drives the formation of dental practices that serve your needs – but this business has become more challenging to the dentist over the years!

Huge student loans, payments to dentists controlled by insurance companies, competition for patients, and the choices involving corporate dentistry can put the dentist into a tight spot.

When dentists make poor choices and/or have trouble making ends meet, it is a sad truth that your needs may not be met in the optimal way.

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Contents of this Chapter


Private Practice – Sole practitioner – “Mom and Pop”







Private Practice – Group Practice

Choice I – Multiple General Dentists

Office Personnel

Office Structure and Organization

Office Technology

Choice II – Mixed General Dentist and Specialty Office


Office Structure

Private Practice – Multioffice Practice

Basic Idea

Demographic Variations

Do not compete clauses and Contracts

Multioffice Specialty Practices

Corporate Dentistry and Dental Support Organizations, DSOs

The Basic Idea

Structural Choices and Contracts

Advantages of DSOs, to you and to the dentist

Disadvantages of DSOs, to you and to the dentist

Bottom line for The Business of Dentistry and YOU

Basic things that you should know – what choices the dentist makes for YOUR benefit and their survival:

When a dentist is graduated from dental school, provided he/she is feeling confident in their clinical skills, they may choose to associate in an office, where they work with an experienced dentist, or even run the practice when the owner is elsewhere.

While it is generally true these days that new graduates don’t feel this confident, after another one or two years in a residency program, they will probably take an associate position.

After associating for a year or two, they may seek to start their own practice – and this practice may grow in a number of different ways – depending on the business acumen of the dentist/owner.

When you are a 26 year-old dental school graduate, business acumen is not something expected – and many people simply don’t have the motivation or gift in this area. Perhaps this will develop with more experience observing the organization and running of a dental practice, but it may not. Some dentists associate with a practice owner for their entire careers.

But – if practice ownership seems the desirable choice, a sole practice is the typical starting point. The individual practice may grow in scope and efficiency over the years and provide ample income to the dentist.

When a practice grows to the point where there is a waiting list for new patients to be accepted, the decision must be made about expanding – either to include other dentists in the practice, or to add another office. The second office will be managed by another dentist, but under the indirect supervision of the owner. Sometimes many offices are added in different areas to serve the needs of diverse communities.

For example, in some demographic areas there may be a high percentage of older patients, rich people, kids, teenagers, single parent families, history of drug abuse, etc.

The community served is the choice of the dentist.

The dentist/owner may even add other offices that are specifically for meeting the needs of orthodontic or endodontic or pediatric patients – specialty practices that fall under the purview of the dentist/owner.

On the other hand – if the dentist does NOT feel confident in their business acumen, they may elect to start a practice under the control of a corporate entity or Dental Support Organization, DSO.

They may even own an operating practice and decide to contract the management of that existing practice to a DSO. Or they may sell the practice and elect to work for the new dentist/owner who owns many practices.

Becoming involved with corporate ownership or management is another choice dentists make.

Certainly there is a need for management help for many dentists who are not interested in all of the business aspects of running a practice, and want to simply focus on the clinical work. But if they are young and inexperienced in the world they may find themselves signing a complex contract which they have no ability to understand adequately.

Not all corporations or DSO’s are created equal ….

We will discuss each of these options as potential business models in dental practice.

You NEED to be familiar with these business models, because YOU are the reason they exist. It is YOUR needs that drive the design of these practice models. It is YOUR money that supports these practices – or it may be your insurance company that supports these practices.

The exigencies of a successful business must be balanced with your needs and your treatment – and it may be up to you to determine that they are!


Private Practice – the Sole Practitioner

While the most common practice model in the U.S. at this time is the individual practice, this is changing fast.

It is important that you know something about why this is, because the practice that you have been going to and loved for many years may suddenly change for a variety of reasons.

Why a dental practice changes.

A friend of mine had been going to a particular private practice for over 20 years for regular cleanings and routine care. She found the owner to be caring and comprehensive without being overbearing. Then the owner’s son was graduated from dental school and he was brought into the practice. The son was far more aggressive about recommending work to be done, and far less compassionate about the needs and sensitivities of the patient. My friend has had to request that only the older dentist be involved in her treatment, as the level of trust is much higher.

In the scenario of the last paragraph, what would happen if the older dentist retires and the son inherits the practice – and then sells to a corporation or contracts for corporate management? Now the mandate of the practice may well shift even further away from patient-based to profit-based.

The driving forces for this change may be the $300,000 in educational debt that the son has from school, or from the fact that he just doesn’t have the experience to realize how important it is to work within the abilities of the patient, or what determines whether a procedure on a patient will be successful or is doomed to failure, or he just doesn’t have any interest in “running” the nuts and bolts of the office. Or, all four forces may be involved in this change – a change that impacts YOU!

A possible alignment with corporate ownership or management might mean that many more people get care they would not afford before, but the increased efficiency and change in mandate of the practice may be an unwelcome change to some.

Design of a Small Solo Private Practice – 6 Key Elements

The First Element of solo practice design that must be considered is the LOCATION – that is to say DEMOGRAPHICS.

WHO has the dentist decided he wants to treat? Of course, since this chapter is about YOU, the patient, you need to know what practices are within a convenient distance from your home – but you ALSO need to know WHY they are there.

Perhaps there are many people in your area that have full dentures. A dentist that likes making dentures may want to locate there so he can bring his expertise to bear more frequently than in another area.

Perhaps there are many people in the area that are very concerned about their appearance, and have the money to afford high-end cosmetic dentistry. A dentist might want to locate his practice there simply because the money is good – he can make a great living helping people look better. Hopefully he brings to it the skills and insights needed to responsibly do that kind of aggressive dentistry without over stepping the bounds of good sense.

Perhaps there are many families in the area where lots of kids need dentistry – even just simple fillings or space maintainers to get them through the phase where primary teeth determine the future dentition. A dentist that has a great rapport with kids, maybe not even a certified pediatric dentist, may love to have his practice in that area.

Perhaps there are many older people in the area and a dentist enjoys helping the elderly with their dental issues.

It is also possible that a dentist sights his practice where the community is dominantly blue-collar, “working-class” people, and this is how the dentist was raised, and he would like to offer a high quality of service, tailored to the income and financial restrictions of the population.

The dentist may feel the call to educate the community to the types of dentistry that fix their oral problems while not involving great expense and not requiring replacement in a few short years, when finances will still be a problem.

There are as many different practice patient compositions as there are towns, and as many different dentists to match.

Two coastal southern California cities, Laguna Beach and Newport Beach, have very different patient demands because Laguna Beach was founded as an artist colony and most people that live there are more interested in art and expression than personal appearance!


The Second Element of solo practice design has to do with the PEOPLE that run the practice.

Depending on the patient composition, the staff, not just the dentist him or herself, must be predisposed to HELP people with their needs.

A dental assistant, a hygienist, or a front desk scheduler that see themselves working with rich people will have difficulty adjusting to working with people in need. Again, this may well have to do with how they were raised, their faith and spirituality, or just their native ability to empathiize – but it is critical that everyone on the practice team see their mandate clearly and passionately.

We’ve discussed before the nature of office staff, and their training to come into a practice – but it is not their FORMAL training that may be the most important thing they bring with them.


The Third Element of solo practice design is control of OVERHEAD.

If the practice is to offer you high quality dental care, not just the dentistry but the OFFICE itself must fit YOUR budget. By this I mean that if the office is too fancy for the community – or looks too disreputable, perhaps some decisions about setting up the practice were made poorly.

When establishing a practice in a wealthy community, the dentist is well advised to build the office so that it will give the patients the feeling they are in their own home – that is to say, really nice. This means FURNISHINGS like they have at home, art they may well like, flooring characteristic of an expensive home, etc. And, the precise LOCATION is important. The dentist would be well advised to create a kind of spa atmosphere in the practice – and locate it near a high-end spa, or in an area where one might be found.

As far as overhead is concerned – we’ve already identified two things that will increase the overhead greatly: location and office design and furnishings.

Assuming that the dentist will borrow the money to build the practice, how much will they have to PAY each month on the loan, and how much to pay the rent?

For a high-end practice the monthly interest on the construction loan may be $3500, the interest on the equipment loan and equipment leases (dentist office are expensive) may be another $6000, while the rent could be expected to be $10,000. Add to this advertising for $2000 per month and employees at $15,000 per month including benefits – and we have a total of $36,500 per month! This MAY be the appropriate overhead for a practice in this area – and the dentist hasn’t gotten paid yet!

For a more modest practice the dentist may be doing more of the daily work himself – may not have a hygienist, may have a lesser trained dental assistant, will have far less rent, have bought good but used dental chairs and equipment, and get his furnishings from Staples. It is unlikely he will have a CAD/CAM machine in the office and that may save $3000 per month, and advertising will be a very small portion of the budget.

Clearly the practice expense per month can be FAR less for a modest practice than for one catering to the wealthy.

The dentistry that is performed in an office catering to the wealthy MUST be expensive dentistry. Implants, crown and bridge, cosmetic procedures are necessary to cover the overhead. But the dentistry in a more modest practice may well involve the full range of fillings and even procedures that can be done to save a tooth that are NOT crowns – so that unnecessary expense for the patient is avoided.

At the end of the month the gross receipts minus the overhead (including various insurance payments as well) shows how much the dentist can take home as their income. There may well be a more grand income for the dentist to the “stars”, but the modest practice can provide a substantial income as well – and may be more in keeping with the motivations of the dentist.


The Fourth Element of design of a solo practice is EFFICIENCY.

Hopefully there does NOT have to be a trade-off between efficiency and personal service.

Efficiency has to do with how things MOVE in the practice. Are the roles of each person involved in a procedure choreographed well and followed smoothly? And, how does the office FLOW adapt to what the patient needs? If the patient needs more time to adjust to the nature and impact of the procedure, is this time allowed? If the patient has had traumatic experiences in the past, and their body reacts to the dental procedure as a traumatic invasion, is allowance made for the needs of this patient? Is there someone who can spend some time with this patient and help calm them? Has the dentist explained the nature of the procedure well to the patient ahead of time – hopefully before the day of the procedure?

If the dentist and/or hygienist has been working with a particular patient for a long period, it has been well established what that patient needs for them to be comfortable for whatever procedure is necessary. This allows for the flow of the office to be optimized. But when a new patient enters the practice it will require more time to determine what treatment is necessary and more time to communicate these needs to the patient, AND more time to work with the patient to see that they are comfortable with how those needs are met.

When the dentist collects information from the patient (See the chapters in Section IV on Diagnosis) and after the Treatment Plan (see the chapter in Section VI on Treatment Planning) is completed, with suitable alternatives depending on the patient’s choices and finances, the dentist should have an initial sense of what it will be like to work with that patient, and how much time different procedures will take. The dentist will also have an idea how much attention the patient will require during the procedure – time to comfort, for example.

An efficient practice will be SCHEDULED so that several patients are being treated at the same time in different chairs. It is not just that the dentist works with one patient while the hygienist (if there is one) works with another. For each procedure that a patient will need, there are times where the dentist does not need to be there. If the assistant is making a temporary crown, for example, the dentist can be with another patient. As the anesthetic is taking effect on one patient, the dentist can be working with another – for examples.

A well run practice will have patients scheduled so that the dentist’s time is most efficiently used. AND – a well run practice will ADJUST as necessary when something unexpected comes along. Perhaps the injection didn’t anesthetize the patient well enough on the first attempt and must be redone. Perhaps the assistant discovers that the dentist did a crown preparation so that making the temporary crown is not possible. Perhaps the patient becomes anxious during the treatment and needs more time to be comforted and reassured. Perhaps the patient shows up late for their appointment so that the other patients that were scheduled to be there at the same time are now different and have needs that don’t mesh as well with this particular patient.

The front office employee, who answers the phone in a small office, also schedules the appointments and knows the patient’s needs. This person is of pivotal importance in determining how smoothly the practice runs on a given day. This person may also be responsible for collecting payments and filing insurance company claims – so it is a very important job to the success of the business. Efficiency in billing and collections is also a key point.


The Fifth Element of design of a solo practice is REFERRALS.

In a small practice, where there is only ONE dentist, it is often the case that this dentist does not feel competent in every dental procedure.

The Dentist’s Comfort Zone:

Many dentists do not feel comfortable with complex extractions, where the bone must be removed around a tooth before it can be extracted. Many dentists do not feel comfortable with complicated root canals procedures, where the canal system is complex and really curved. Many dentists will not feel comfortable doing complex tooth movement, orthodontic, procedures. Many dentists will not feel comfortable placing dental implants or restoring them with the appropriate prosthesis. Many dentists will not feel comfortable doing surgical periodontal procedures. Many dentists will not feel comfortable providing sedation or general anesthesia to patients for more complex procedures. Many dentists SHOULD not feel comfortable doing restoration of the patient’s entire dentition with crowns, even though there is a lot of money involved. Many dentists will not feel comfortable working with a patient who has very compromised medical issues without thorough consultation with a medical professional. Many dentists SHOULD not feel comfortable with complex cosmetic procedures that require a considerable knowledge of material choices and artistic vision.

Now – bear in mind that there is a natural temptation of all dentists to reach a little bit beyond their “comfort zone” to do things so that the patient does not have to be treated by a relative stranger to them, or to secure the payment for the procedure which they would lose by referral. The latter point is an important point, because YOU are the patient, and YOU would not like the dentist to be working at ALL beyond their comfort level!

Referring Out or Bringing Expertise IN?

Whenever a dentist is not comfortable he/she will seek to bring another person into the team that is assembled to treat a particular patient. That additional person may do that part of the treatment for the patient in their own specialty practice office, or they may do the treatment in the primary dentist’s office. Often implants are placed by dentists traveling to other dentist’s offices and working in their chairs – but most other specialty procedures are done in specialty offices as more specialized equipment is required.

An endodontist will often do procedures using a sophisticated microscope and specialized X-ray techniques. An orthodontist will need to work with the patient over a long period and schedule them in for adjustments periodically, all of which requires that they work from their own offices.

Patients – YOU – don’t generally like to be referred to another practice because they are familiar with the dentist and staff where they usually come. But there are times where this is necessary.

Sometimes compromises are needed when it has taken a long time for a patient to become comfortable with ANY dental procedure, and only tolerates them in a familiar setting. These compromises can be in the form of a dentist doing something that they usually refer out, or that they invite another professional into the office to treat that patient within their “comfort zone”.

As a patient, YOU must be part of the decision-making process as to what your needs are and what is needed to meet those needs. If you are not particularly comfortable with any dental procedure, but you have a good rapport with your general dentist, take some of his/her time to discuss how referrals are done and to whom they are made, so that you will feel safe.


The Sixth Element of design of a solo practice is use of TECHNOLOGY.

These days the use of digital X-rays is becoming commonplace. This is a rather expensive addition to a private practice, but eliminates the need to wet develop films, freeing up space and saving time for the staff. It also greatly increases the efficiency of the office.

Fully digital offices are far more efficient – with each chair having a monitor so the patient can see their films clearly.

Intraoral camera systems are also quite valuable – and the pictures that the dentist takes in the mouth can also be displayed on the chairside monitor. In this way you can see exactly what the dentist is talking about – fractures or decay or recession, for example – so you are more inclined to grasp the importance of what the dentists recommends.

Lasers can be quite useful in certain dental therapies – and dentists are constantly bombarded by companies what want to sell their laser for doing some procedure or another. While I am not an advocate of using lasers instead of burs and handpieces to remove decay and shape a tooth for a particular restoration, lasers for soft tissue management may be more generally helpful for the average dentist.

The BIG issue for a small private solo practice is whether they will consider leasing a CAD/CAM machine! The expense of leasing this machine every month must be paid from the monies saved by HAVING the machine. The value of the machine to the dentist is that no external laboratory fees need be paid for crowns made using this machine, so every dentist will want to do EVERY crown using this machine.

If EVERY crown for every patient is appropriately done the SAME way, then having the CAD/CAM machine may make sense – but I, personally, am a firm advocate of doing different types of crowns to meet the individual needs for various situations for particular patients.

Also – it is the rare solo practice that generates enough crowns every month so that the savings will actually cover the cost of the CAD/CAM machine.

BUT – perhaps the dentist has decided that offering ONE APPOINTMENT CROWNS will attract patients to the office that would not otherwise come, and the dentist wants to attract more patients as he is not fully scheduled. So even if the number of crowns done using the CAD/CAM system do not cover the lease cost, it may be worth while to have it simply for marketing purposes.

The value of a CAD/CAM system to a practice is determined by YOU!

Do you need to get the work done in one appointment? Do you want to avoid another visit to the dentist? Is your time so valuable that saving a couple hours of your time is worth a lot of money? Then look for an office with a CAD/CAM system. Otherwise, be aware that if a small solo office DOES have such a system they will tend to do ALL crowns using it. Maybe the best treatment for your particular situation is a partial coverage gold crown or a gold onlay. These CANNOT be done using a CAD/CAM system.


Private Practice – The Group Private Practice

When a practice reaches the enviable stage where there are more patients than the dentist can handle, then some decisions must be made.

Perhaps the dentist is content with a practice that provides nicely for them and their family and takes care of a patient base of over 2000 patients. But after some years of this day-to-day business, he/she might start to look for changes that might relieve them of some of the work, or might want to make changes that will allow more patients to be treated and increase the monthly income.

This could mean just adding a hygienist to the staff to handle all of the routine periodontal needs. But that would still be a solo practice.

It could mean adding other dentists to the payroll. And this can be done in several ways.

Choice I Group Private Practice – Multiple General Dentists

1. Office Personnel


If the dentist/owner decides to add dentists to the payroll, one or more general dentists may be chosen. A general dentist is one that has finished dental school and not gone on to complete additional training in a specialty, like endodontics, pedodontics, orthodontics, prosthodontics, periodontics, or oral surgery. Implantology is not a recognized specialty at this point, but there are dentists who elect to place implants and do nothing else.

Every general dentist has the training and mandate to perform procedures in each of the specialty areas, but they may well elect to limit the complexity of these procedures to the more basic level procedures.

For example, I would perform simple extractions but not extractions that required bone removal or where significant risks to nerves or the sinus was involved. I would work with kids down to 5 years old, but no younger. I would not do periodontal therapy that required cutting the gum tissue to get access to the calculus but I would do bone recontouring after gutting the gum tissue to enable better crown perparations,. I would do most root canals, but not when the canals system is too curvy. I would not do routine orthodontic “straightening” at all, and not do clear aligner procedures at all. I would do large and complex procedures involving tooth replacement and implants, but not place the implants. This is a fairly typical general dentist menu of options, although many will also refer to a specialist for any restoration on implants, and rightly so.

Now, some general dentists are more comfortable extending their repertoire in one or more different directions, depending on experience, skill and interest.

BUT – the dentist/owner may hire one or more additional general dentists that have mutually supporting interests – while none have specialized training beyond dental school.

Let’s consider that a given practice consists of 5 general dentists – with varying abilities in specific areas. There may even be one that has experience working before in a larger practice, and knows the intricacies of management and financial control that suggest they have assigned duties in this area as well as practice responsibilities. Maybe he/she will have one administrative day during the week and do patient procedures the rest of the time. Maybe there is one that really enjoys doing partial dentures and full dentures and has particular skills in that area – this simplifies the life of the other dentists if he/she takes all of the denture cases.

In any event – when YOU walk into a such a practice – you would be well advised to ask some questions about the dentists that are there and what their interests and experiences are.

Also – when you go in for your appointment to have a procedure done, WHICH dentist will you be seeing? Is that set, or do you see whichever dentist is available on that day? Obviously, it is easier to schedule the practice chairs when there is more flexibility about the dentist you will be seeing. But – of course – the patients will generally prefer to see a given dentist for every visit.

What if you have seen a particular dentist and don’t like him/her? How easy is it to switch to another dentist if the practice tends to keep you with the same one? The practice SHOULD make it VERY easy. They should ALWAYS ask which dentist you would like to see. You may simply indicate that you would like to try another dentist and see if they are more suitable for your personality or sensitivities, or they may ASK you.

What if one dentist gives injections for anesthesia by plunging the needle into your gums suddenly – the “bandaid” technique? But you’ve had another dentist in the past that took their time and was much less traumatizing with injections. You may want to jump to another dentist for the next visit. Do they ENCOURAGE you to do that, or do they try to argue you out of it? It might be a good idea to find out what their policies are up front before joining their practice.

Is there an online form that you are asked to fill out after your appointment so that you might indicate how you found the experience with one particular dentist? Do they encourage you to indicate unpleasant experiences?

The general health of a practice may be determined by how open about your experience you are encouraged to be!


Ancillary Employees:

Additional hires for a group dental practice will likely include one person that just does sterilization, one or more that just does billing, one that just answers the phone and schedules appointments, and the front desk person has responsibilities that are more restricted to the people in the waiting room.

Some practices seek to save money by hiring their own laboratory technician for a good portion of the work that is done. Their lab fees on the average could drop by 50% – but the cost of setting up the lab must be considered too. This may require additional financing that carries an interest for some years offsetting the savings. But, a dedicated technician can produce a superior quality of cosmetic restorations most easily for difficult cases.

And – obviously, there need to be enough assistants to work with all of the dentists. It would not be amiss if each dentist had two assistants assigned to them – that’s a total of TEN assistants. Maybe some are roving and will work with multiple dentists – especially those that have advanced training – particularly extended function, where they are legally allowed to take impressions for crowns. One assistant could be assigned to be responsible for every dentist getting the supplies and equipment they need for each procedure on the schedule.

The scheduler may be responsible for: 1. Making sure that the patients are scheduled with the right dentists; 2. Making sure that patients are scheduled so that the dentist can work efficiently with those that are there at the same time; and 3. Making sure an assistant is appointed to insure that any specialized equipment or supplies are available and at chairside when the dentist starts to work.

In a large dental office there may also be an IT guy. He/she is responsible for the computer facilities, hardware, software – including the CAD/CAM system. Since the office also has a website, this person will also be responsible for the website – to make sure it is running well and that the site is being found.

While a large office may have a person that is responsible for marketing and advertising, they may also contract out for that work. The IT guy is somewhat responsible for marketing, at least through the internet site – but there are more specialized procedures including greeting cards, and print media advertising that may be involved. Even putting together ads which will be placed in upscale magazines that have a large impact on the area of the practice may be part of that job.

The Office Manager

AND – above all – a larger practice will no doubt have an OFFICE MANAGER. They are responsible for everything about how the office is run. All departments report to them. They TRACK everything. They make sure that everyone is doing their job – and that the practice is healthy financially and personally. They are generally responsible for hiring and firing personnel so that the dentist/owner does not need to concern him/herself about those issues. The office manager RUNS the business, while the dentists DO the business. The difference is paramount to the success of the practice.


During the Covid pandemic, there should also be a person that is assigned to make sure that the office has minimized the risk of viral transmission as much as possible.

The viral transmission specialist is also responsible for making sure that all office protocols are supported for both staff and patients – including but not limited to mask wearing, and that the masks are the most effective.

But the dental office is one place where people’s masks are removed, and aerosols are generated directly from their mouths as air-driven handpieces are used. Hence the need to take adequate precautions!

At the present moment it is not clear how long Covid-19 will be a threat – but this Winter will teach us more no doubt, especially for those not vaccinated. Unfortunately the assumption on many people’s parts that vaccination will end the pandemic may well be naive. As the Delta and more variants to come are tested against the vaccines, we might find break-through infections and transmission occurring with greater ease.

2. Office Structure and Organization

If the practice has 5 dentists and two hygienists, for example, and each dentist is used to working with two chairs, then there need to be 12 dental chairs – operatories – built into the practice. And there will need to be sterilization facilities capable of handling a much larger work-load than a solo practice.

How are these chairs organized – into groups of two, where each dentist has his own area, or more spread around? If the practice was built from the “ground up” – there is great flexibility as to how the chairs are laid out. Perhaps each dentist will have three chairs, and either use the third one themselves, or the third can be used by a hygienist when working on one of the dentist’s assigned patients.

How large does the sterilization facility need to be? How large does the laboratory need to be, especially if there is a technician hired? Should there be a special room for storing all of the supplies used for the practice? These rooms should be far from the patient treatment area. Should there be a computer-based inventory tracking system and reordering system?

Are the patient chairs isolated from each other well enough – so that patients don’t have an awareness that a lot of other people are there getting treatment at the same time?

Again – dentistry is a very intimate undertaking – and patients’ response to the treatment will vary from one individual to another. All patients will do better if they feel more isolated from others, and that their dentist is near-at-hand always. The best practices are designed to ensure this.

How large is the waiting room? Are there always lots of patients waiting? A well-run practice will minimize the number of patients that are waiting by holding to a tight but realistic schedule. But – a waiting room that is divided up into different areas, with trees and aquaria separating people from each other, is always a more pleasant experience for the patients.

How the front desk communicates with the dentists in the clinical area is important too. In a solo practice the front desk person would walk back and let the dentist know the next patient has arrived. But, for a larger practice there may be lights for each operatory or dentist area that indicate arrival of patients. These days there can be a small computer screen built into the wall where the front office can post messages of importance for the individual dentists.

THESE DAYS – with the Coronavirus – it is important to isolate parts of the practice from each other.

It seems likely that at the day of this writing, March 2021, there will be a couple years ahead of us where contagion with this series of viruses will be a concern. The clinical area of a practice is certainly the most likely to produce infectious aerosols.

If a dental practice were designed, or redesigned, these days to take into account the airborne possibility of viral spread, the clinical area would be well isolated from the rest of the office. Certainly, the front office personnel would never be asked to enter the clinical area, and the back office personnel – sterilization, lab and supplies – would be isolated as well – with pass-throughs from these areas into the clinical area that the assistants will use.

That would be the ideal organization of a large group practice in these times of the pandemic.

Also it would be best if the areas for each dentist can be disinfected, including the air being scrubbed of potentially infectious agents, independently – so that one area can be treated while others continue to work as normal. Clearly this will require more space in the floor plan!

AND – whoever is responsible for VIRAL TRANSMISSION in the office should have their own office from which to work. For example, it would be a good idea that this person have control of the air purification units – both those that are constantly in use near every chair, which include filtration and UV sterilization of the air that passes through, AND fogging machines for blowing droplets of hypochorus acid (an otherwise harmless agent, but one that breaks down virus particles in the air).

Even if the Covid-19 pandemic subsides soon – one thing we HAVE learned over the last 15 months is that what happens once CAN happen again – the dental offices that are designed to weather the current viral storm will weather best the next!


3. Office Technology

One of the greatest advantages of the larger private practice is the possibility that a CAD/CAM machine can be purchased or leased for the office, and it WILL NOT HAVE TO BE USED FOR EVERY PATIENT!

There will be enough crowns done in the practice in a given month to cover the expense of the machine without ALL crowns having to be done using it. That means that every dentist can elect to do that kind of crown that most directly benefits the patient in whatever situation it is needed.

From the chapters on Gold Crowns and Onlays, on Ceramic/porcelain Crowns, and on Ceramometal Crowns, involving both metal and ceramic – we saw that there are advantages to each form of crown. There is NO type of crown that is appropriate for everyone!

One of the dentists in a group practice may choose to do “state-of-the-art” gold restorations as his hallmark of quality – and many patients may see the wisdom of that. He/she can set up their own specialized practice within the larger whole. But, every general dentist will be empowered to use the CAD/CAM technology or not as the case dictates.

Using the CAD/CAM technology becomes far easier in a larger group practice as well, however. Each dentist that takes an impression with the optical/digital camera, can send that impression to their in-house lab technician, where he/she can make a ceramic crown on the spot and send it out for cementation by the dentist in 40 minutes. The dentist can treat another patient in another chair while the crown is being made.

On the other hand – dentists can sometimes use the optical/digital scanner for taking impressions for non-ceramic crowns, even if doing gold crowns and ceramometal crowns. They will send the impression to the lab technician with an indication as to the nature of the crown chosen, and the technician can make a die from the optical scan and make a gold crown, for example, using normal techniques. There are limitations to this use of the optical scanner, however – but the possibility suggests a great savings in time.


Choice II Group Private Practice- Mixed General Dentist and Specialty Office


With a larger practice, where many specialized procedures are done every day – there is the possibility of hiring specialists – those trained in and with certification in the dental specialties.

This gives the general dentists in the office more chance to refer simpler specialty procedures that they might be able to do themselves, to others that can do them more efficiently. The specialist will be doing more procedures that are beneath their skill level, however, and this might be less interesting to them.

But, keeping all specialty procedures in the office has a large benefit to the patient, in that they can stay in the office they are used to, and feel that what they are having done is under the supervision of the general dentist they trust.

Now, the problem is that specialists generally charge more for what they do than would a general dentist doing the same procedure. Everyone charges per hour rates depending on their level of training. If a dentist estimates charges based on $250 per hour, the specialist may feel that $350 per hour is more reasonable.

So – does it save the patient money to have specialists in-house? Maybe not. Does it make more money for the practice? Likely. Does it make more money for the specialist? Not likely – but they will not have to incur the expenses of setting up their own practice, with all the complications that involves. They will use equipment that is supplied and owned by the dentist/owner, so THEIR overhead will be far less.

But, if the patient is more happy because they can stay in the same office for every procedure, and the business makes more profit, this satisfies the major driving forces.

Consider the possibility that there is an in-house orthodontist. Since the younger patients are often in for adjustments, it is more likely that a parent can schedule their check-up appointment at the same time since they will be driving in anyway – and this benefits the practice as well as the patients. This is equally true of pedodontists on the clinical staff, although often with the younger kids a parent will want to be watching as the work is done.

There are multiple advantages to mixed specialty offices, especially for the specialists that really don’t want to go to the trouble of setting up their own practice, or don’t have the business acumen to do so wisely. These are advantages to the business of the practice and to the specialists, but this can represent advantages to YOU, the patient, as well.

It is more likely that the Billing Specialist will have to have more experience in a wider selection of procedure codes than for a typical solo practice or group general dentist practice. For a general practice there may be a couple hundred different procedures that have standardized insurance codes, but many hundreds total when you add in all of the specialist procedures.


Office Organization

It is more likely with a practice involving specialists, that each specialist will want and benefit from a structure where they feel they have their own “mini-practice” within the clinical area. There may even be separate clinics for different procedures.

In the days of the pandemic – it would be greatly to be preferred that orthodontic and pediatric procedures be done in separate clinics, since these are mostly procedures done on younger people and cross-exposure to a variety of adults may not be the wisest choice.

But equally important is the fact that younger people will feel safer in a clinical area where there are not particularly noisy and extensive procedures being done on an adult nearby.


Private Practice – Multioffice Practices

Basic Choices for Multiple Office Practices

When I first started practicing after dental school I worked 9 months for a guy that had just bought the practice. That was the first practice he bought. I have no idea where he got the money, but when I saw him at a convention about 8 years later he owned ten practices and was living in a 10 million dollar house. He appeared to be a shockingly unethical dentist to me as I worked for him – but that did not deter him from financial success apparently!

The problem is that if you own multiple offices, how do you know that the dentists working in the offices are working as you would like? You have to keep track of the production and the cases in each office on a regular basis.

The guy I worked for could have started me running his second practice, but I had quit by then. On the other hand, there were times working in his first office where I refused to do certain procedures planned for patients, because they were extreme overtreatment – crowns on teeth that needed no more than a simple filling, for example.

If you are an unethical dentist, you must find other dentists to run your other dentists who see ethics the same way you do – as something flexible and able to be distorted for your best interests. If you are an ethical dentist, you need to find dentists that will treatment plan only what is necessary and valuable for the patient, not for the dentist.

I had a friend who owned three offices at one time – and he was always struggling to see that the managing dentists in the other offices treatment planned consistent with his vision, and did work consistent with the quality that he espoused. He had a series of dentists in to the other offices over the years before he finally gave up and sold them off.

You would think that all dentists do things about the same, but you would be quite wrong. I thought that when I was graduated from dental school, and got my mind changed immediately.

But – the issue becomes way more complex when you have multiple office practices. The standards that the owner wants to maintain must be clarified in NO uncertain terms, in writing, and reviewed frequently by every managing dentist, and they will take these protocols and standards to any associated dentists working in that office. The owner will spend most of his time managing, rather than doing dentistry. Maybe that is what the owner prefers?

Another friend was managing 15 offices for a large corporation in California – one of the early and largest “chain” dental offices in the U.S. ALL he did was evaluate how things were going at each office, looking at cases, spot-checking treatment plans, and making sure planned work was consistent with corporate policy – while still having to manage the financial operations of each office. Hard work!

One way to potentially make multiple offices work more easily is for the owning dentist to be involved in each treatment plan over a set total cost – say $5000. The owner will visit the office and have the cases presented for evaluation and make the final decision about what needs to be done. At least in this way there is consistency for the large cases across all of the offices.


Demographic Variations Across Offices

It may be that a dentist who owns multiple offices will want to locate some in more high-end areas, and other offices in less well-to-do regions. So, the dentistry in each area will be different, in terms of the typical types of procedures done. If the owner hires a dentist that knows a lot about partial dentures and full dentures, he could set that dentist up in an office in area where a lot of removable appliances are needed. If the owner hires a former military dentist that knows how to do large amalgam restorations rather than crowns, he might get set up in a town where most people cannot afford crowns but need to have the teeth restored nevertheless.

The picture I am painting here is that the owner finds really high quality dentists who have certain skills and preferences, and helps them establish a practice in an area where they are more likely to utilize their specialized skills. Of course the problem comes when that dentist decides to go out on his own and build his own practice somewhere and leaves the owner to find another qualified person to run that particular office. Not necessarily easy to do.

So – if a particular office in a multioffice practice is more unique, and its range of procedures and disciplines is well managed by a particular person, who creates the office “in their own image” – replacing them might be difficult. AND, what if they decide to set up their own practice nearby? Hopefully the subject of non-competition was dealt with in the work contract.


Do Not Compete Clauses and Contracts

When a dentist owns multiple offices and has many dentists working for him/her in these offices, and some particularly fine managing dentists – there needs to be a contract to cover every situation that arises, and with many dentists there will be MANY situations!

Of course pay scales and work responsibilities will all be spelled out in detail, but the most important may be the non-compete clause.

Here it is assumed that the managing dentist for some office decides to quit and start his own office nearby. If he/she is popular with the patients, they might all decide to leave the group office and go with the dentist who quit. Obviously that is a big problem, and that is why non-compete clauses exist – to prevent the dentist from opening another office too CLOSE to the first. What is a distance where people will NOT drive, even if they like that dentist? That is the subject of much debate in the dental community, but also in legal circles.

If the contract states that when the dentist quits he cannot work or start a practice within 50 miles of the first practice – that is probably safe with regard to the movement of patients away, but is it legally enforceable?

All U.S. citizens who have been paying attention to the news now know that the number of attorneys that you have is more important than what the contract says. Some people in business break contracts all the time, refuse to pay someone for work rendered, for example, and know that the person will not want to get into a law suit. Some people LOVE to sue – and those would be the ones with the most money. For some people the law is irrelevant to them, because they have lawyers on retainer who protect them in the courts. They are never held accountable for bad actions.

If a dentist leaves a practice and sets up his own practice 5 miles away when the non-compete specifies 50 miles, this may be a law suit waiting to happen. If the multipractice owner finds that many patients are leaving, and he has enough cash flow with his many offices to support the hiring of some really good attorneys, he may pursue the suit. If the judge decides that the original contract was valid, he wins – but if the judge decides that the original contract was usurious, even if the moving dentist signed it, it may be declared void. In the latter event, the leaving dentist gets to keep his practice, but he might have trouble paying all of the legal fees!


Multioffice Specialty Practices

When it comes to multioffice practices, the sky is the limit, and the variations in design are many.

The owner may have 20 offices, and may decide to make certain ones specifically for specialties. In this way commonly used equipment can be more efficiently used, for example. He/she might have one office that ONLY does root canals, and all of the other offices will refer to that one for endodontic treatment. He can guarantee enough business to keep the endo practice working just from the other offices in the network.

But, of course, if some offices are designated endodontic offices, or orthodontic offices, or periodontal offices, of oral surgery offices – with the appropriate specialists working there – the patients will have to travel for treatment. This works against the tendency of patients to want to stay at their “home” office – but may be in the best financial interests of the business. Will patients accept this? Maybe, if presented right and if the travel is not too much.

It may well be that the efficiency of each office is greater if each can be organized around a particular specialty.

And – it may be that enough laboratory business is generated from the network of general dentistry offices so that a laboratory can be built as a separate business – maybe with many technicians sharing sophisticated equipment. This could again be a financial benefit for the network – and the laboratory could easily be built large enough to accept outside work as well.


Bottom line for Multioffice Practices

There are as many ways to design a multioffice network of dental practices as there are creative business-oriented dentists out there. But – it’s a big business, which many people are not cut out for.

But – for YOU, the patient – the only reason this is discussed at all is for you to have some idea what is involved with the practice you are thinking to attend. Yes – dentistry is a business. Does that business exist to serve YOU or serve the business owners? Is that mutually exclusive? NO, it is not.

Can YOU determine when a dental practice is more patient care oriented or more business oriented? I am hoping that the descriptions in this chapter will give you some questions to ask!

Corporate Dentistry and Dental Support Organizations, DSO’s

The Basics

Now we enter another world of dentistry!

And this is a really big and controversial topic. But it one that MUST be covered, as more and more dental practices in the U.S. are joining DSOs. Right now it is approaching 10% and rising quickly.

There are some DSOs who have over 4000 dental practices in their network!

Serious “business-types” see that combining dental practices into really large organizations can produce huge profits. The companies that put these networks together may be funded by venture capitol on a large scale, or may be publicly traded, on the stock exchange.

The idea is that these large companies appeal to the dentists that work under their “umbrella” – and there are a variety of ways to do that. Maybe the starting salary right out of dental school is $175,000. That is pretty appealing to someone who has student debt of $300,000 which they need to start paying on soon.

Maybe the new graduate is not confident in their skills yet, but the corporate network can assure them of a mentor who will help them learn the “ropes” and improve their skills and confidence on patients in the practice.

Maybe the new graduate doesn’t feel that they will have to take a residency in general practice if they can learn on the job in the DSO office.

And, maybe there is an experienced dentist who has run his own practice for many years and gotten tired of the effort. He may contract with a DSO to manage the office in the future, so all the dentist has to do is dentistry. That may be tempting!

But, I am talking now to YOU – the patient – and what do YOU get out of corporate dentistry, particular from DSOs?

It MAY be that the only chance you have to get dentistry done at all is through a well-managed DSO network where the scale of the business is so large the costs have been reduced to the point where charges to the patients are very reasonable. It is well known that DSOs do provide much care to people that would otherwise not be able to afford it. Also, dentistry can be done that is paid by government programs supporting those with limited means.

But some state dental associations are concerned that in SOME DSO offices the likelihood is that more dentistry will be done for patients that is not necessary, and they are fighting the competition of DSOs within their state.

More on the pros and cons, for the dentists AND for YOU soon.


Structural Choices with DSOs and Contracts

There is one typical type of DSO contract – where the DSO contracts to MANAGE the dental offices. In some states non-dentists are allowed to OWN dental practices, and a DSO can be formed which OWNS many practices. This is more unusual.

Individual state laws determine much of what is possible with DSO organizations, but many are even powerful enough to get state laws changed! For example, in California dental practices can only be owned by licensed dentists, but at some point in the future this law could be changed and the DSO mandate radically shifts.

But, for now – the DSO will have MANY functioning offices under their purview – these offices are independently owned, but the management is done completely by the DSO. This includes virtually EVERYTHING other than actually practicing dentistry.

The contracts which the dentist/owners sign with the DSO, or the associate dentists that do not have an ownership share sign, are legally challenging contracts. That is to say, they are LONG and VERY carefully crafted to get the most advantage for the corporation.

I talked with an attorney the other day who represents many people that are involved with DSOs on a contractual basis. He said that the average DSO contract runs from 150 to 200 PAGES!

Can you imagine a 26 year-old dental school graduate that has ANY ability to fathom such a contract before signing?

Of course, you can well guess that the non-compete clause is very carefully drawn. It may be non-enforceable, but what 26 year old will fight it?

At what point can the dentist LEAVE the contract? That certainly depends on the organization. For the young dentist working to work in a DSO for a couple of years can be a great experience. But there are specific DSO contracts that may require their employment for 5 to 7 years. Obviously, if there is a big investment of the organization into the dentist, they would like to take advantage of their work for as long as possible. Quite justifiable.

Even though the owner of the practice contracts to have the DSO manage the practice, any new associates sign a contract with the DSO for their employment – and they become more valuable with every year they are working in the practice. The DSO will fight to keep them working in the practice – as it is to the benefit of the organization AND to YOU!

What does the contract with the dentist/owner say about HOW decisions are made in the practice? We’ve already seen that many managerial decisions impact the way the dentistry can be carried out. But, are there DSO policies that are handed down that restrict what the dentist decides to do? This is really a gray area.

The DSO is not legally allowed to make any decisions or encourage any protocols which restrict the way the dentistry is carried out. Only the dentist has the knowledge to make these decisions.

But – the DSO may require that all crown cases be done by their corporate laboratory! Or they may require that all cases be sent to a lab in China with which the DSO has a contract. The dentist/owner may well have no choice about that. These are things that the practice owner will need to clarify before signing the contract – just to make sure that his patients receive the care that is consistent with his goals. Just to be clear, it is possible that the DSO laboratory contracts will result in a better result for the patient.

The contracts make it clear that production is “coin of the realm”. The associate dentists may even be paid a set salary with a percentage of the production added as a bonus. This is all controlled by the DSO management team. But this means that every dentist will be working to do MORE dentistry FASTER. Obviously, this COULD compromise the patient’s care – but not necessarily. A set daily salary plus a percentage of production has been a feature of group practices for many decades.

As a teacher, one of my goals is to establish series of courses that help dentists DO dentistry faster and more efficiently without compromising anything about the success. This CAN be done without compromise!

Now – don’t get me wrong – it is certainly possible to do good dentistry fast, and all dentists should strive for that. But if things are done that are not needed, and things are done faster while taking short-cuts that compromise the results, that is not good.

And clearly this is true for solo practices, group practices and DSO practices equally. It is always up to the judgment of the dentist. Dentists are licensed for individual practice assuming they will make good judgments.

That being said – every dentist should be keeping a firm grasp on their ethical standards, and their dental standards – but when one is burdened with debt it can be more than challenging to be under contractual obligations to a corporate entity.


The Advantages of DSO dentistry

Advantages to YOU:

You may well be able to get dentistry done that would be otherwise out of your financial reach. There is good reason to believe that the growing group of seniors – baby boomers (yep, I’m a card-carrying member of that generation) will be more likely to afford dentistry with the advent of DSOs. The economy of scale with a 1000 office network is hard to deny.

Advantages to the Dentist/owner and Associate Dentists:

Technological advances may be more likely utilized in a DSO because they can negotiate with vendors with much more power than a single office or small group of offices.

The DSO can assist in the complex problems with compliance monitoring by government organizations.

Career growth and peer collaboration is more likely in a large organization of practicing dentists working for the same corporate entity.

Insurance policies for the office and malpractice policies for individual dentists can be secured more reasonably by a larger entity.


The Disadvantages of DSO Dentistry

Disadvantages to YOU:

When an office is production-driven, the patient may pay the price of having dentistry done that is not necessary. Of course, this is a broad generalization, but it has happened.

I’ve had students who worked for large corporate dental entities who saw very clear statements by the corporation as to what should be done on patients, whether needed or not. State regulators eventually caught up with this one situation, and the corporation was monitored on-site for many years to make sure the infraction didn’t happen again – but it happened. The dentists were told to simply drill out the occlusal grooves on ALL posterior teeth that had not been restored before, and place amalgam restorations, whether or not there was any sign of decay. And – I once saw a patient who had been thus treated, and there were two small amalgam fillings that had been placed WITHIN composite fillings! To clarify, the patient already had composite fillings on two teeth, but the dentist did not notice them in his haste to place the amalgam fillings. So he drilled out a little of the composite and filled it with amalgam, but the amalgam NEVER EVEN TOUCHED THE TOOTH!

When there is a corporate dialectic which overrides the clinical decision making of the dentist, that is not a good thing. Each dentist is ultimately responsible for every patient they treat. You can expect that they will take this responsibility seriously, but it is not always that way when other forces are brought to bear.

Again – to be fair, I must not generalize. I don’t want you to think that you cannot get good dentistry done at a corporate owned or DSO office, certainly you can. Perhaps it is the only way you can get ANY dentistry – so that is great. But, be aware of the forces at large and look carefully around you.

Disadvantages to The Dentist/owner and Associate Dentists:

For the owner, if he/she want to sell their practice – the contract with the DSO will go along for the ride. This makes the practice harder to sell, and the equity in the practice for the owner is much lower, from what I have read. Again, I am sure this does not apply to ALL DSO organizations – there are some notably good ones!

I suspect that selling a DSO managed office in a great DSO network may actually INCREASE the value of the office for the selling dentist.

For the associate dentist they have little or no flexibility in their employment after signing the DSO contract. Before signing I hope they have met for a conversation with someone working under that contract, so they will hear what limitations are placed on them.


Not all DSOs are the same!

There was a notorious case involving a DSO called Comfort Dental in Colorado years ago. The practices of this DSO have been dramatically and pains-takingly researched and presented in a blog by Debbie Hagan. Her blog is called by the daunting name of Dentist the Menace. If you really want to hear about the problems that such an organization can cause individual people, find her blog. Can you imagine me recommending you to read a blog of that name when I am a dentist? Name notwithstanding, Debbie is doing work that needs to be done. She has close to 1000 new people signing into her blog every day! That says something ….

Just bear in mind that the character, good or bad, of a DSO is determined by who manages it. They may have the patient’s best interests at heart, or their affiliated dentist’s best interests at heart, or their own best interests at heart. Of course, if they are publicly traded, the share value at the end of each quarter must be of primary interest.

But – I know DSOs that really do have more public spirit and drive for providing good care than others.

If YOU are thinking to go to a practice that is managed or owned by a DSO, do your homework. If you have no choice as to what practice you go to – at least ask the right questions of your dentist. You know all of the right questions from THIS site!

Bottom Line for The Business of Dentistry and YOU

Since I am writing about dentistry for YOU, the patient – it seems strange that I’d spend so much time discussing the business of owning a dental practice. The reasoning, which I feel strongly about, is that the practice of dentistry is to provide a service to YOU. Not all dental practices DO that!

So – we, as responsible consumers, need to do our homework. I say “we” because I also go to the dentist. There is a chapter on this site called Selection of a Dentist. In it I talk about the dentist themselves – but the organization of which they are a part is critical as well.

Between that chapter and this one, you should be able to more confidently determine if a particular dental office will suit you. If all you need is an occasional cleaning, the decision is not of such importance. But if you need much more, the decision can be a life-changing one.