At 65, my mother faced the same impossible choice confronting thousands of healthcare practitioners. She had built an amazing dental practice over 30 years, cultivated loyal patients who trusted her, and desperately wanted to pass her practice to a younger dentist who would care for her patients the way she had.
But there was no one to pass it to.
This is the story playing out across American healthcare. Dental practice ownership has collapsed from 85% in 2005 to 73% in 2021.^1 The traditional succession model (mentor passes practice to protege) is broken, and it's forcing devoted practitioners into DSO sales they never wanted.
The paradox: banks are more willing than ever to finance practice acquisitions, offering 100% financing plus working capital.^2 But young dentists still can't realistically buy. Average dental school debt sits at $296,500 upon graduation. Some residents carry $500,000-700,000 in total debt.^3 Practice acquisition costs $500,000+ including working capital.^4 That's nearly $1 million in debt for a new graduate. And the financial barrier is only part of it. Young dentists see established practitioners drowning in administrative work. DSO employment offers predictable salary, benefits, no management headaches. Even when financing exists, they're choosing employment over ownership. As the ADA noted, "these trends are not reversible."^1
Talk to any 65-year-old practice owner and you'll hear the same thing: "I just want to practice dentistry, not run a business." The mounting compliance burden includes HIPAA Privacy, Security, and Breach Notification rules, OSHA health and safety standards, Corporate Transparency Act ownership reporting^5, PCI DSS standards for payment processing, Anti-Kickback and Stark Law compliance. On top of that: insurance credentialing, staff management, EMR maintenance, supply chain logistics, accounting, tax compliance, cash flow management. This isn't what they signed up for when they went to dental school.
For practitioners like my mom, the DSO sale isn't a strategic financial decision. It's surrender. After 30 years of building patient relationships, establishing clinical excellence, and creating a practice culture focused on care quality, the choice becomes: sell to a DSO or watch the practice collapse under administrative burden.
The patient care concerns are what keep practitioners awake at night. Industry watchdogs and government officials warn that the DSO model "may incentivize profit over patients and ultimately put patients at risk."^6 Payment structures that "create perverse incentives that lead to overtreatment." Corporate standardization replacing individualized care. Efficiency metrics rushing patient interactions. Staff turnover disrupting long-term relationships. Pressure on clinicians to "do those things that ultimately boost profits at the cost of patient care."^6
After the sale, the practitioner becomes an employee in their former practice. Clinical decisions must work within DSO treatment protocols. Corporate efficiency metrics influence appointment times. New corporate hierarchy replaces personal management. Dentists must "adapt to new roles and routines, typically working within new management guidelines with commitments to continue practicing as an employee for around five years post-sale."^7
Why do they choose this despite the concerns? Financial necessity. No qualified individual buyers. Unmanageable administrative burden. Compliance costs eating into profitability. On the retirement side: 60-80% cash at closing provides security. Guaranteed employment during transition. Risk transfer to the DSO. Clean exit for estate planning.
The 10-year outlook is grim for independent practice. 40% of physicians are over 55.^1 DSO market expansion is expected to hit 75-80% of practices by 2034.^2 The baby boomer retirement wave will accelerate consolidation massively. Early sellers receive premium valuations (practices sell at 4-7x EBITDA individually, DSO platforms trade at 11-15x during recaps). Quality practices in dense geographies with high-margin specialties are most attractive to acquirers.
For practitioners facing this decision: start financial optimization 24-36 months before transition. Clean up books, maximize EBITDA, standardize processes, engage advisors. 12-24 months out, optimize corporate structure, organize documentation, begin buyer discussions. Assemble the right team: healthcare business broker, tax attorney, financial planner, accountant, healthcare attorney.
As ADA chief economist Marko Vujicic stated: "These trends are not reversible. Dentistry is heading exactly down the path of every other healthcare occupation that's gone through this transition of business owner/solo practice to working in groups."^1
The saddest part? Most practitioners never wanted this change. They were forced into it by systems that prioritized compliance over care, efficiency over relationships, and corporate profit over professional judgment. Behind every consolidation statistic is a practitioner like my mother, who just wanted to pass her life's work to someone who would care for her patients the way she did. That dream is dying, one reluctant sale at a time.
Sources:
- American Dental Association Health Policy Institute - Practice Ownership Analysis (2024)
- Bank of America Practice Solutions Dental Lending Survey (2024)
- American Dental Education Association Graduate Debt Survey (2024)
- American Dental Association Practice Management Resources (2024)
- Healthcare Compliance and Administrative Burden Studies (2024)
- Healthcare-Brew DSO Patient Safety Investigation (2023)
- Dental Practice Transition Studies - Multiple Industry Sources (2024)