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Avoid Dental Disaster: Insider Guide to Choosing an Ethical Dentist

Updated: 21 hours ago

In a world of corporate greed and cash-in-quick schemes, how do you pick a trustworthy and ethical Dentist? Dr. Sanders wants to help you spot "bad dental practices" so you can make an informed decision.

The aim is to help people avoid unnecessary dental expenses and traumatic procedures

In this article, Dr. Sanders provides you with a guide to empower you in selecting trustworthy and ethical dentists, she highlights the importance of making informed decisions beyond the lure of corporate greed and quick cash schemes in dental practices. 

Dr. Sanders (Owner Dentist)

Take Aways

  • Corporate Dental Chains: The article cautions against blindly trusting corporate dental chains and Dental Service Organizations (DSOs), which are often owned by investment firms. It suggests that while not inherently bad, these organizations might prioritize short-term profit over patient care, and advise patients to scrutinize treatment plans and seek second opinions.

  • Autonomy in Financial Decisions: It highlights the importance of a dentist's autonomy in offering discounts, waiving fees, and making independent financial decisions. The lack of financial autonomy in large chains might limit the benefits a dentist can offer to patients.

  • Signs of Overtreatment: Dr. Sanders alerts readers to the potential for overtreatment in dental practices, which can be motivated by greed, ignorance, or educational differences. Patients are encouraged to look out for unnecessary procedures and seek second opinions for expensive treatments.

  • Patient Volume and Care Quality: The piece warns against practices that overload their dentists with too many patients at once, compromising the quality of care and the dentist's ability to engage and educate patients properly.

  • In-House Referrals: It criticizes the practice of referring patients to in-house specialists to boost profits, suggesting that it might not always result in the best care. Patients are advised to question such referrals and consider alternatives.

  • Choice of Labs and Vendors: The autonomy of dentists to choose their labs and vendors is championed as crucial for ensuring quality care. The article argues that corporate practices limiting this choice can negatively impact treatment outcomes.

  • Commission-Based Incentives: Dr. Sanders is critical of commission-based incentives for non-clinical staff, which might encourage unnecessary treatments or poor-quality materials to meet financial targets.

  • Accountability and Legal Recourse: Lastly, the article touches on the complexity of seeking reimbursement or damages from larger practices, highlighting the potential challenges in holding them accountable for over-treatment or substandard care.

Dr. Sanders urges anyone looking for a new dentist to be vigilant, ask critical questions, and prioritize their health and well-being when choosing a dental practice.

1 - Be Aware of Corporate Dental Chains

"Ask yourself, is this a corporate dental chain or DSO? Do I think their goals or behaviors are to maximize short-term profits before my care? Scrutinize the treatment plans and get a second opinion"

Firstly, Corporate dental chains by themselves are not evil. There are plenty of young great doctors who start there or retired doctors who don't want to bother with all the legal, accounting, and marketing "pain" of running your own business. Even Dr. Sanders started in corporate dentistry and found positives and negatives about the experience. 

However, Dr. Sanders thinks it's important that patients become aware of what a Corporate Dental Chain is and who owns it. 

  • Dental Service Organizations (DSOs) started in the 1990's and emerged in the 2000s as an opportunity for Wall Street to "buy up" private dental practice from retiring dentists and profit from a market that was historically local and private.

  • Corporate Dental chains (DSOs) are owned by Wall Street investment firms and investment banks List of DSOs and the brands you see like "BrightNow!" or "Gentle Dental" are brand names that bigger companies own. 

  • The doctors who treat you at a DSO, do not "own the office", they are employees licensed to perform dental services. However, other people are managing all other aspects of the business. Setting business targets, cutting costs, managing marketing, managing IT, managing the purchase of materials, and managing vendors the business does business with.

  • In most states, dentists are legally required to own their practices. To circumvent laws regulating dental practice ownership, investors create separate entities –Dental Service Organizations (DSO)— to provide "related practice management and business services", such as marketing, bookkeeping, and financial services.

If you're worried that Wall Street may incentivize the wrong "short-term profits" behavior, then you're not alone. 

Just Google "DSO over treatment" or "DSO whistleblower" and you'll find results similar to those below. 

To be fair, small local practices can behave unethically too and there are plenty of reports of that happening. The best advice we can give is to be aware that these Wall Street companies exist, be aware that the doctor does not always have control over the business, and be aware that these companies may operate more like a "Fast Food Chain" than your small town family dentist.

Be aware that these companies may operate more like a "Fast Food Chain" than your small-town family dentist.

2 - Does the doctor have freedom to offer you discounts and waive your fees?

In large dental chains (DSOs) and even in dental partnerships with multiple locations, it's possible that the doctor treating you may not have autonomy over financial decisions. 

It's possible that the dentist treating you may not have autonomy over financial decisions

We're going to let you in on a secret, typically corporate dental chains pay their employee dentists around 30% to 35% of whatever revenue they bring in. If the dentists owned their practice, this would be the "profit" they make by running a successful business. However, the doctor does not have the freedom to take the profit and use it to do good deeds. 

Ask the doctor if they own the practice, ask if they have autonomy to make financial decisions and offer discounts, waive fees and adjust treatment plans 

Let's say, a dentist can pull in around $1,000 a day. At a DSO, that means they make about $300 paycheck. You might say, "Whoah" that's too much money but we also want to remind folks that the doctor went to school for about 9 years where they made $0 and came out of school owing about $250k-$500k in student loan debt. 

Let's do some fake napkin math just to show where the money is going... 

  • Revenue: $1000

  • Doctor Pay: $300 = Doctor take-home pay 

  • Leftover to Pay Bills/Staff: $700

  • Bills: $400 = Employees, Utilities, etc. 

  • Profit: $300 = Doctor reinvest in business

If the doctor owns the practice privately, the profit of $300 also goes back to the doctor to invest in the company, offer discounts, waive fees, and offer employee bonuses. 

If the doctor owns the practice privately, the profit of $300 also goes back to the doctor to invest in the company, offer discounts, waive fees, and offer employee bonuses. However, with corporate dental chains, the $300 profit goes back to Wall Street for their "smart investing" decisions. 

To put that in perspective it's estimated that the DSO industry is worth about $140,000,000,000 (that's a billion) so in our example that would be $42,000,000,000 (billion) of that would have historically gone to dentists but instead goes to Wall Street bankers. 

To put that in perspective, it's estimated that the DSO industry is worth about $140,000,000,000 (that's 140 billion) so in our example that would be $42,000,000,000 (billion) that would have gone to local dentists but instead moves to Wall Street. 

From the patient's perspective, this ultimately means that the doctor's hands may be tied in what discounts and fee reductions they can offer you because they do not own the practice. To make this more difficult for the patient, DSO will often split the doctor role from the billing business role, and often the doctor cannot decide on "billing" but only "treatment". If the doctor finds ways to "waive" treatment then this reflects poorly on the person doing "office management" and creates more conflict because the doctor is losing their employer money. 

From the patient's perspective, if the doctor does not have financial autonomy, then the doctor's hands may be tied as to what discounts and fee reductions they can offer the patient

3 - Are there Signs of Over treatment ?

"I left because I was being asked to 'play the game' of upselling treatment and taking the human components out of the dental equation." - DentistryIQ

Dr. Sanders wants you to know that sometimes dental practices may over-treat patients. This happens for a variety of reasons such as greed, ignorance, or even differences in training and educational standards between schools. Here are some common signs of over-treatment... 

Over-treatment happens for a variety of reasons such as greed, ignorance, and even differences in training and educational standards. 

  • Filling Healed Cavities - Sometimes white spots and stains are signs that a cavity existed but later healed itself. Some dentists will opt to fill that space anyway without discussing other options with the patient. These may even "look" like cavities on x-rays but are not cavities when a skilled doctor takes a look. 

  • Excessive Deep Cleanings - Some doctors may not "probe" correctly or get bad readings which may lead them to think your gums are "bad" and they may ask for expensive "deep cleanings" 

  • Two-Year XRAYS - Sometimes a patient only needs certain X-rays every few years, this frees up insurance money for other important stuff but the dental office will take X-rays every year anyway because "insurance will pay for it"  leaving the patient with less for important care, and exposing the patient to unnecessary radiation.

  • Excessive Perio Treatment - Some patients get asked to treat periodontal disease when it's not there or they are billed for options that could have been done in a more affordable way with the same medical result 

  • Excessive Charges - Did you know that you may be billed for a doctor holding a wet cotton swab to your tooth? Each tooth can be billed separately? Adding up to hundreds of dollars that could have gone to more important patient care.  

To be clear, there is nothing wrong with doctors or local business owners making a profit. Dr. Sanders worked long and hard to become an engineer and doctor of dental surgery and she took enormous risks to start her business. 

But we do think there is a breaking point where patient care suffers when you add more "cooks to the kitchen" driven by short-term money incentives and a lack of understanding for the local community. Always, "Trust but Verify" and get a second opinion when the treatment involves major surgery or a lot of money.

Always, "Trust but Verify" and get a second opinion when the treatment involves major surgery  

5 - Too Many Patients or "Third Column"

Both private practice and corporate dental practice need to make money. It's a business. But there is a breaking point between "profits" and finding enough time to educate the patient and create a connection with the patient.

Have you ever noticed the dentist jump in and out of the room or move between rooms to see other patients. This is a common practice to make the "best use of time" and also allows the doctor to make a profit. In some cases, this makes sense, let's say standard "cleanings" where the hygienist is helping and the doctor pokes in to do a yearly check-up. That's normal behavior.

Bad practices will often push dentists into seeing three to four patients at a time to drive up profits at the expense of having enough time for the doctor to educate the patient

However, doctors can be pushed too far, and often this means working a "third column". A column is how many patients you see at a time, so two patients are two columns and three patients are 3 columns.

Bad practices will often push dentists into seeing three or four patients at a time to drive up profits at the expense of having enough time for the doctor to educate the patient and also unwind for an upcoming procedure. Ultimately, this pressure results in worse patient care because the doctor can't educate the patient, form a connection with the patient and de-stress for the next procedure.

Ask or simply observe how many patients the doctor is seeing, do you feel like you're getting enough time and the doctor is getting enough time to provide quality care?

6 - Does the company encourage and "refer" to in-house specialists to boost their profits?

The problem is that "in-house" is not always better which means the patient care may suffer. Also, the in-house may rotate and not be back for a month resulting in patient care being postponed and infection getting worse.

One of Dr. Sander's biggest issues is that some practices highly encourage only "refer in-house". There are normally laws against forcing a doctor to refer to only one place, but there is an unofficial pressure that happens.

For example, a corporate DSO may have other specialists, such as periodontists or orthodontists who rotate through the office. The more patients these doctors see the more money the DSO makes. So it is in their best interest to encourage the "in-house" practice for convenience and to make their employer more money

The problem is that "in-house" may not always be the best quality which means the patient could have gotten better care. Also, the in-house may rotate and may not be back to the office for a month, resulting in patient care being postponed and infection getting worse.

Ask the doctor if they had to refer a family member, where would they go? Ask the doctor how long will you wait to see the in-house specialist or how far you need to travel.

7 - Does the Dentist have autonomy to make decisions regarding the lab, the vendors and materials?

Dr. Sanders also has concerns about removing autonomy from the dentists to choose their vendors and labs. Bigger companies will strike a deal with a lab and all orders must go through only one provider. You can imagine that if the lab quality is poor or if they use bad materials then the doctor is stuck with the lab and cannot do much to help the patient get better quality.

Compare this with a doctor who has autonomy and owns a business, they can fire a lab and hire a new lab until they find one that meets higher standards and quality.

Compare this with a doctor who has autonomy and owns a business, they can fire a lab and hire a new lab until they find one that meets higher standards and quality. For Dr. Sanders, she is trained in both engineering and dentistry. She understands the strength of materials, the load they can bear until they break, and also the cosmetic properties that make them good materials for your smile.

However, when she worked at a DSO, she wasn't able to use this knowledge to get the patient better results because some other "business people" decided who the vendors and labs were without her input.

Ask the doctor if they have the autonomy to change labs and choose vendors. Ask if they have seen defects from the lab and if they use different labs for different procedures.

A good practice will give the doctor autonomy and a good doctor may use different labs for different things because they have different skills and materials.

8 - Are commissions involved? If so, are they used to encourage office managers to increase sales?

Everyone deserves to be paid. At the end of the day, even a dentist who owns their practice is "paying themselves" with whatever the profit is after paying all the bills and expenses. Dr. Sanders wants patients to be aware that there are pay structures that might and often do create the wrong type of behavior and it's good to keep an eye on it.

Bonus targets often result in the manager speaking to the dentist and trying to influence them to "add more" to the treatment plan. Dr. Sanders has also experienced doctors trying and take a more conservative approach and the office managers refer to "bonuses" and ask the doctor to simply put a crown on it to meet targets

For example, Dr. Sanders sees that "Office Managers" are often given an end-of-year bonus which aligns with the target of "revenue" even though the office management does not put together the treatment plan at all. This seems odd. Why would someone who does not create the treatment plan or perform the treatment be given a commission for revenue from a treatment plan they don't control?

Ask if office managers are given bonuses for revenue or something else. Try to figure out what the company is measuring because that will tell you where their heart lies.

This approach often results in the managers speaking to the dentist and trying to influence them to "add more" to the treatment. Dr. Sanders has also seen doctors try and take a more conservative approach and the office managers refer to "bonuses" and ask to simply put a crown on it. Other times, Dr. Sanders has seen office managers try to mandate X-rays even though they are not licensed to do so.

Instead, you should be looking for a bonus structure to align with other values. For example, how many patients return for follow-up care? What are the patient's reviews and are they positive or negative? Do employees stay with the company or do they leave because they don't like the office? Did the office manager help recover money from insurance companies "who did not want to pay"?

Bonus structure around these metrics creates an environment where the manager is improving the office not trying to influence treatment and nickel and dime patients.

9 - If something goes wrong, who are you fighting with?

Mistakes may happen and dental treatment always comes with some degree of risk. But what happens when you find out that you were over-treated and never needed a procedure? What happens when the doctor does not meet dental standards for care?

With a bigger practice, the doctors are often moved around between other locations making them hard to track down. You might try and speak to the office manager but she reports up to 2,3,4 or more people and none of them can make a decision. And if you need to go after them legally, you will often be locked into arbitration, outside of the courts fighting very large legal teams.

Ask yourself, is it easier to do business with the dentist who owns the practice locally or a corporate 1-800 number or chatbot?

About Dr. Sanders

Dr. Jacqueline Sanders, an award-winning dentist based near Tacoma, Fircrest, and Lakewood, has a journey to dentistry that reads like an inspiring storybook. Born into a hardworking family in Chicago, where her parents lacked high school diplomas and her father, a union ironworker, battled a severe back injury, the odds were stacked against her.

Despite her early artistic flair, guidance counselors nudged her towards art, failing to see her potential as a doctor or scientist. Her story unfolds from working minimum wage jobs to support her husband through college, to embarking on her own educational journey at Austin Texas Community College. Jacquie's determination saw her excel in subjects necessary for an engineering degree, a foundation that would later inform her dental career. Transitioning to the University of Texas at Austin, she discovered a passion for chemistry and neurobiology, leading her to dental assisting over the summer break and eventually to dental school, driven by a desire to serve and a strong work ethic.

Dental school wasn't just about education for Jacquie; it was an opportunity to give back, volunteering at homeless shelters, refugee clinics, and along the Mexican-American border. Despite the personal loss of her father and the challenges of Covid-19, her resolve only strengthened, shaping her into a compassionate Doctor.

The corporate dentistry world's profit-driven practices disillusioned Jacquie, propelling her to establish Floss & Fido, a practice embodying her vision of home-like, patient-first care. With a hands-on approach, leveraging her engineering acumen and artistic talent, she created a welcoming space for her patients, further reflecting her commitment to accessible, compassionate dentistry.

Dr. Sanders (Owner Dentist)



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