Do Your Due Diligence Before Joining a DSO, Part 2: Solutions

Michael W. Davis, DDS


Many dentists who work for dental service organizations (DSOs) face significant problems (see Part 1). Throughout the DSO industry, company operations and focuses are very diverse and rarely uniform. Each company, and even clinics within the same DSO, operate off disparate business models. 

Also, the lack of regulatory enforcement of this industry outside of North Carolina has resulted in business paradigms that circumvent the rule of law. In many states, and with a good number of DSOs, it’s an established and entrenched “wild west” relating to the concerns of employees and patients. 


Potential dentist employees in the DSO industry should preform a background check on the companies they’re applying to before accepting a job. With all of the marketing hype and spin designed to attract prospective dentist employees, what can be believed?

Simultaneously, the dental educational-industrial complex unceasingly is building new dental schools and increasing graduation class sizes, creating a very tight labor market for dentists. All too often, the primary employment available to doctors within a given demographic is with certain DSOs that operate outside the rule of law. 

Regional and national meetings sponsored by the DSO industry often conduct seminars on attracting and retaining doctors to “partner” with their operations. Doctor turnover, as well as overall staff turnover, has become a significant problem for some DSOs, especially those with disturbing operational models that place production profits above positive patient outcomes.

These DSOs couldn’t be more pleased that there exists an ever-increasing number of recent dental grads to hire. They also relish the prospect of dental therapists replacing pesky ethical doctors, and for much lower labor costs. These firms generally are forceful advocates of expanding “access to care” to advance their self-serving agendas.

“For dentists, it’s important to research and gather information about any potential employer, regardless if the employer is a dental service organization or a solo practitioner,” said Dr. Dave Preble, DDS, JD, senior vice president of the ADA’s Practice Institute, which advises dentists to:

  • Engage in meaningful conversation with potential employers and ask questions throughout the process
  • Review potential employers’ websites
  • Engage in internet searches about these employers
  • Check the comments and ratings that have been posted about the practice (while keeping these ratings and comments in appropriate perspective, since comments on many ratings sites are often of questionable veracity)
  • Check with their state dental association and state dental board concerning the good standing and track record of these practices and their principals

“Dental schools teach dentists the art and science of patient care, but not contract law. Simply put, any expectation a dentist employee has for compensation and benefits needs to be spelled out explicitly in the contract,” said Preble.

“If it is not specifically stated that a benefit is provided, the employee should not assume that it is. If there is a benefit that the employee believes should be provided (or that they believe they have been promised), it is best to raise it at the contract stage and to get it in writing,” Preble said.

The ADA urges dentists to have employment contracts reviewed by a lawyer in their jurisdiction who is aware of the specific circumstances of their situation. There also are several resources available for dentists at the ADA Center for Professional Success.

The ADA has taken positive steps to assist in dental practice transitions. This not only helps senior doctors or those with an illness or disability transfer their practice, but it also helps younger colleagues obtain a dental practice. 

“In April 2019, the ADA Business Innovation Group launched ADA Practice Transitions, an online service designed to match dentists who are looking to join a practice with owners who are seeking a partner, associate, or someone to purchase their practice. During the current pilot phase, the service is available to dentists and practice owners in Maine and Wisconsin,” the ADA said in a statement.

“The service includes an online platform with tips, tools, and training relevant to each dentist’s situation. In addition, an ADA Advisor is assigned to the partnership to help facilitate the process and foster a positive relationship for both parties beyond the transaction. The ADA believes ADA Practice Transitions will make the process of joining, expanding, or leaving a practice easier and more predictable,” the ADA continued.

More information about ADA Practice Transitions is available at the ADA’s New Dentist Now blog.

“Due diligence in any employment opportunity is critical, but perhaps even more so with a DSO. Although they all claim to have the best working environment and pay, I have dealt with more than a few disgruntled dentists working in a DSO,” said Frank R. Recker, DDS, JD, a former member of the Ohio State Dental Board and attorney who now practices with a focus on dental law.

“The issues include a lack of staffing, little attention to sterilization issues, and high staff turnover, especially with dental assistants with very little experience or training. In addition, some dentists are ‘discouraged’ from sending a patient out for ‘specialty’ care or using the lab of their choice,” said Recker.

“Ask for the names of several former dentist employees and the names and contact information for existing employees or dentists. Find out how much turnover the DSO has experienced. Go to the Secretary of State’s website and find out the incorporators, ownership, et cetera,” said Recker.

Recker also advises dentists to inquire about the professional aspects of the business. As a corporation, its documents will include the names of its dentist shareholders in order to avoid regulatory issues involving dentists employed by entitites other than another dentist or dental professional corporation. Plus, he urges dentists to visit the website of the clerk of the county where the office is located to find out if any suits have been filed against it.

“A verbal arrangement, which is often the most attractive lure to a new dentist prospective employee, is not enforceable. The actual contract will state that,” Recker continued. 

“And, find a lawyer who is familiar with such transactions so you can protect yourself to the extent possible. Leaving a DSO without notice or failing to comply with a mandatory notice provision can lead to expensive litigation most dentists cannot afford. Lastly, make sure the contract contains an arbitration clause for any disputes and that each party bears their own costs of the arbitration, including legal fees,” he said. 

Obviously, a great deal of due diligence is advised prior to signing an employment contract with a DSO or with any employer. Far too many organizations are not to be trusted. Far too many have a historical track record of abuses to the public and employees. Because of contract nondisclosure and non-disparagement agreements, “bad actors” aren’t readily apparent and lurk under the radar. Unfortunately, several of the more troubling DSOs are very high-profile companies with very appealing marketing, public image campaigns, and charity events.  

An initial outlay of $3,000 to $5,000 in legal expenses for performing due diligence in investigating a DSO for a recent graduate or for a doctor exiting the military seems like a great deal of money. It is. However, that sum is peanuts compared the many tens of thousands of dollars spent in attorney fees to exit a one-sided contract with an unethical employer.

Too many doctors have no idea if the employment contract they sign is with an ethical DSO that desires to offer solid remuneration for ethical care of patients or, by contrast, views employee doctors more like indentured servants to be run into the ground until their next hire. Employee dentists need to know the reality upfront. Due diligence on their potential DSO employer or any employer is essential.

Dr. Davis practices general dentistry in Santa Fe, NM. He assists as an expert witness in dental fraud and malpractice legal cases. He currently chairs the Santa Fe District Dental Society Peer-Review Committee and serves as a state dental association member to its house of delegates. He extensively writes and lectures on related matters. He may be reached at or

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