Does DSO Ownership Affect Clinical Quality? What the Evidence Actually Shows
By Dr. Hendrik Lai, Managing Partner, Viturtal Consulting
Ask a room of private practice dentists about DSOs and someone will say the care is worse. Ask a room of DSO executives and someone will say that is a myth spread by people who don't like the competition. Both positions are stated with more confidence than the evidence allows.
I come at this as a practising dentist who has also run multi-site operations. I have seen excellent clinical care inside DSO-supported offices, and I have seen production targets push treatment decisions in directions I would not defend. The ownership model did not decide which one happened. The governance did.
This article sets out what the research actually shows, where it is silent, and what separates a DSO that delivers consistent, high-quality care from one that doesn't. It is written for DSO leaders, the sponsors who back them, and dentists deciding whether to affiliate.
Key takeaways
- There is no robust evidence that DSO-supported offices produce worse clinical outcomes than private practices, and no robust evidence that they produce better ones. The direct comparison has not been studied well.
- The best recent research looks at what is billed, not outcomes. A 2025 study by the ADA Health Policy Institute team found that practices acquired by private equity shifted toward higher-cost, non-preventive procedures after acquisition. That is a warning sign worth taking seriously, not proof of worse care.
- The cases that shaped public opinion are real. Federal settlements involving pediatric Medicaid dental chains centred on allegations of unnecessary treatment driven by production incentives.
- DSOs also expand access. Private equity-affiliated practices are more likely to accept Medicaid, and large group practices have been at the forefront of standardized, prevention-focused care.
- Quality is driven by clinical governance, not ownership: dentist autonomy, how incentives are designed, peer review, and whether quality is measured at all. Good DSOs can prove their quality with data, and the best ones already do.
What the Research Actually Shows
The honest summary is that the evidence is thin, mostly indirect, and points in more than one direction.
| Evidence | What it found | What it doesn't show |
|---|---|---|
| Nasseh, LoSasso and Vujicic, Health Affairs, 2024 | Dentists affiliated with private equity rose from 6.6% in 2015 to 12.8% in 2021. PE-affiliated practices were more likely to participate in Medicaid. | Any measure of quality. The authors call for research on quality and affordability. |
| Nasseh, LoSasso, Vujicic and Downey, Health Services Research, 2025 | After PE acquisition, practices shifted toward non-preventive, non-diagnostic and higher-cost procedures. Implants per visit rose 14% from baseline, reaching 46% four years later. List prices rose 3–5%; negotiated insurance payments did not. | Whether the extra treatment was unnecessary, or whether patient outcomes changed. |
| Benevis / Kool Smiles settlement, U.S. Department of Justice, 2018 | In the DOJ's words, "Benevis and the Kool Smiles clinics will pay the United States and participating states a total of $23.9 million" to resolve allegations that the clinics billed Medicaid for medically unnecessary pediatric pulpotomies, extractions and stainless steel crowns between January 2009 and December 2011. The government alleged that "Kool Smiles clinics routinely pressured and incentivized dentists to meet production goals." | Liability. In the DOJ's words: "The claims resolved by this settlement are allegations only, and there has been no determination of liability." It also says nothing about DSOs generally. |
| ADA Health Policy Institute research on DSO dentists | DSO dentists are much more likely to participate in Medicaid or CHIP than non-DSO dentists, across age groups. | Quality of the care delivered. |
| Willamette Dental Group (large multi-specialty group practice) | A standardized, evidence-based, prevention-focused care system with diagnostic codes in the EHR, clinical decision support and quality metrics, used to track oral health over time. | It is an integrated group practice, not a PE-backed DSO, so it shows what scale makes possible, not what DSOs typically do. |
How to read this
The treatment-mix finding is the one to take seriously. A shift toward higher-cost procedures after acquisition can mean two different things. It can mean the practice now offers services, such as implants and in-house specialists, that patients previously had to be referred out for. The same study found practices became more multi-specialty after acquisition, which fits that explanation. Or it can mean production pressure is changing treatment thresholds. Claims data cannot tell those apart. Only clinical review can.
The settlements explain the reputation. The cases that drew congressional and media attention involved pediatric Medicaid chains and alleged incentive structures that tied dentist pay to production. They are a documented failure mode, and any honest discussion has to acknowledge them. They are not evidence that the DSO model produces worse care in general.
Access is part of quality. A patient on Medicaid who cannot find a dentist willing to see them gets no care at all. DSO and PE-affiliated practices accept public insurance at higher rates than the rest of the profession, which matters in a country with thousands of dental shortage areas.
The gap in the evidence is a measurement gap. Dentistry has historically lacked standardized diagnostic codes and outcome measures, so outcomes are rarely tracked consistently anywhere, in DSOs or in private practice. Claims that private practice care is better are not evidence-based either.
Why Ownership Isn't the Driver: Clinical Governance Is
A solo practice with a dentist under financial pressure can over-treat. A DSO with strong clinical leadership can deliver more consistent care than most independent offices. What matters is the system around the clinician. In my experience, five things separate DSOs with consistently strong care from the rest.
1. Dentists own clinical decisions, in writing and in practice
In most states, the corporate practice of dentistry doctrine already requires that clinical decisions stay with licensed dentists. Good DSOs go further than legal compliance. Clinical decisions are explicitly outside the operating team's authority, and regional operators are never measured on, or allowed to comment on, individual treatment plans.
2. Incentives that don't pay for more procedures alone
Production-based pay is standard across dentistry, private practice included, so the issue isn't its existence. It's whether production is the only thing measured. The allegations in the pediatric Medicaid cases centred on production bonuses and quotas. Strong DSOs balance production with quality and patient measures, and never set targets for individual procedures such as crowns or root canals.
3. A clinical leadership structure with real authority
A chief clinical officer, regional clinical directors who still practise, and a clinical committee that sets protocols. Their authority has to be real: if a clinical director cannot stop an operational initiative they consider unsafe, the structure is decorative.
4. Standardized protocols, with room for clinical judgment
Evidence-based protocols for caries risk assessment, periodontal diagnosis and treatment thresholds reduce variation between dentists. This is where scale is an advantage: a single practice rarely has the resources to write, train and audit protocols, and a group does. Protocols should set the standard of care and leave the individual decision to the dentist.
5. Peer review and chart audits that look for over- and under-treatment
Regular, structured review of radiographs and treatment plans by peers, with the purpose of calibration and teaching, not discipline. Audits should flag both overtreatment and missed diagnoses: under-treatment and missed preventive care are quality failures too.
These are the same levers that drive consistency between locations, which we cover in our DSO analytics and benchmarking framework.
How Good DSOs Prove Their Quality
The strongest answer to "DSO care is worse" is not an argument. It is data. A DSO has something most private practices lack: one data platform across many locations. That makes it possible to measure clinical quality consistently, which most of the profession cannot do.
Start with recognised measures
The ADA's Dental Quality Alliance (DQA) publishes standardized quality measures, mostly designed for Medicaid and dental plan assessment. Several are being developed for practice-level use, including:
- Sealants on first and second permanent molars
- Topical fluoride for children, and for adults at elevated caries risk
- Periodontal evaluation and ongoing maintenance for adults with periodontitis
- Care continuity and preventive services for children
- Oral evaluation following a problem-focused visit
The DQA notes that its practice-level measures are still in draft and should not yet be used for public reporting or performance comparison. Internally, though, they are a credible starting point because they are not invented by the DSO itself.
Add operational measures of clinical quality
| Measure | What it tells you |
|---|---|
| Re-treatment rate (restorations or crowns redone within 2–5 years) | Durability of the work |
| Procedure mix by provider vs. group norms | Outliers in either direction, for clinical review |
| Preventive-to-restorative ratio by location | Whether prevention or repair drives the practice |
| Diagnosed vs. accepted treatment by provider | Unusually high diagnosis rates, or unusually low acceptance |
| Hygiene reappointment and periodontal maintenance compliance | Continuity of preventive care |
| Patient complaints and board complaints per 1,000 patients | Patient-reported problems |
No single number proves quality. A procedure-mix outlier may be the best clinician in the group, treating a high-need population. The value is in flagging cases for clinical review, not in ranking dentists.
Report it
A DSO that tracks these measures should report them to its clinical leadership every quarter, to its board, and in summary to its dentists. Sponsors should ask for them. Over time, publishing aggregated preventive-care measures is the most credible way for the sector to answer its critics.
Clinical Quality Diligence: Questions for Sponsors and DSO Buyers
Clinical quality is a financial risk as well as an ethical one. Over-treatment shows up later as payer audits, recoupments, board complaints, litigation, dentist turnover and reputational damage at exit. Financial diligence rarely examines it. These questions should be part of every platform or add-on review:
- Who has final authority over clinical decisions, and is that written into the management services agreement and the operating model?
- How are dentists paid? Is any bonus tied to specific procedures, or to production alone with no quality or patient measures?
- Is there a chief clinical officer with authority to stop operational initiatives on clinical grounds? Ask for an example of when that happened.
- What clinical protocols exist, for caries risk, periodontal diagnosis and treatment thresholds, and how is adherence checked?
- How often are charts and radiographs peer reviewed, by whom, and what happens when review finds a problem?
- Which clinical quality measures are tracked by provider and location? Ask for two years of data. A DSO that cannot produce any is telling you something.
- Which providers sit far outside group norms for procedure mix, and what did clinical review conclude about them?
- What payer audits, recoupments, board complaints and malpractice claims have there been in the last five years, and how were they resolved?
- What does dentist turnover look like, and what do departing dentists say about clinical autonomy in exit interviews?
The answers often predict post-close performance better than the quality of earnings report does. See our operational due diligence checklist for DSO acquisitions and what private equity looks for in a dental platform for the rest of the diligence picture.
Frequently Asked Questions
Do DSO dental offices provide worse care than private practices?
There is no robust evidence either way. No large peer-reviewed study has compared clinical outcomes, such as restoration failure or tooth loss, between DSO-supported and independent practices. Quality depends more on clinical governance, how dentists are paid and whether quality is measured than on who owns the practice.
What does the research say about private equity in dentistry?
The share of U.S. dentists affiliated with private equity roughly doubled from 6.6% in 2015 to 12.8% in 2021 (Health Affairs, 2024). A 2025 study in Health Services Research found that after PE acquisition, practices shifted toward higher-cost, non-preventive procedures and raised list prices by about 3–5%, while negotiated insurance payments did not change. Neither study measured patient outcomes.
Why do DSOs have a reputation for over-treatment?
Largely because of high-profile federal cases involving pediatric Medicaid dental chains, which alleged medically unnecessary procedures driven by production-based incentives. In the 2018 Benevis / Kool Smiles case, the U.S. Department of Justice announced that "Benevis and the Kool Smiles clinics will pay the United States and participating states a total of $23.9 million." The DOJ also stated: "The claims resolved by this settlement are allegations only, and there has been no determination of liability."
Do DSOs improve access to dental care?
The evidence suggests they help. DSO dentists and private equity-affiliated practices participate in Medicaid and CHIP at higher rates than other dentists, according to ADA Health Policy Institute research and a 2024 Health Affairs study.
How can a DSO demonstrate clinical quality?
By tracking recognised measures, such as the ADA Dental Quality Alliance preventive-care measures, alongside re-treatment rates, provider procedure-mix outliers, periodontal maintenance compliance and patient complaints. These should be reported regularly to clinical leadership, the board and investors.
Should I join a DSO as a dentist if I'm worried about clinical autonomy?
Ask the same questions an investor would: who has final say over treatment decisions, how you will be paid, whether any bonus is tied to specific procedures, and how peer review works. Then speak to dentists who have left the group. Their answers will tell you more than the recruiting pitch.
The Bottom Line
The claim that DSO care is worse is not supported by good evidence, and neither is the claim that it is just as good. What the evidence does show is a real risk: incentive structures that reward volume alone can push treatment decisions the wrong way, inside a DSO or out. DSOs have the scale to measure clinical quality in ways most of dentistry cannot. The ones that do it, and share the results, will win the argument, and the dentists and investors worth having.
Viturtal Consulting helps DSOs build clinical governance and quality measurement that hold up to scrutiny, and helps sponsors assess clinical risk in diligence. Get in touch.
Sources
- Nasseh K, LoSasso AT, Vujicic M. Percentage of Dentists and Dental Practices Affiliated With Private Equity Nearly Doubled, 2015–21. Health Affairs. 2024;43(8):1082–1089.
- Nasseh K, LoSasso AT, Vujicic M, Downey T. Financial incisors: Cutting through the effects of private equity on dentistry market dynamics and care delivery. Health Services Research. 2025. Summarized in Dental Economics.
- U.S. Department of Justice. Dental Management Company Benevis and Its Affiliated Kool Smiles Dental Clinics to Pay $23.9 Million to Settle False Claims Act Allegations Relating to Medically Unnecessary Pediatric Dental Services. January 10, 2018.
- ADA Health Policy Institute research on DSO dentist Medicaid and CHIP participation, as summarized in Decisions in Dentistry, 2017.
- American Dental Association. Dental Quality Alliance: Dental Quality Measures.
- Drivers Advancing Oral Health in a Large Group Dental Practice Organization. Journal of Evidence-Based Dental Practice. 2016;16 Suppl:104–112.
- White et al. Tracking oral health in a standardized, evidence-based, prevention-focused dental care system. Journal of Public Health Dentistry. 2020.