The Best Growth Strategies for DSOs

Dave Salciccioli is the Co-founder and CEO of Relay, a deployment partner that closes the gap between technology purchased and technology that actually works. Learn more at relaywithus.com. 

I've spent a lot of hours in DSO board meetings, L10 meetings, quarterly business reviews, and annual planning sessions. For years, the growth discussion was mostly about growing through acquisitions and de novos. But in 2022, the economics changed and the conversation shifted. 

Labor, supplies and borrowing got expensive, while the fees insurers paid stayed flat. Margins compressed, valuations came down, and good practices got scarce. 

Brian Colao describes the last five years as an unnatural state: every expense up, reimbursement flat, and a wave of DSOs restructuring between 2022 and 2025 to cut overhead and find growth inside the practices they already owned. In TUSK Practice Sales' Q2 2026 market report, 69% of DSOs said their private equity sponsors expect acquisition activity to rise this year. The disciplined ones are turning down deals that miss their standards instead of deploying capital because it's there. 

The DSOs growing profitably haven't stopped acquiring. They've stopped relying on it. The same seven levers show up in every one of them. I'll take them one at a time, then come back to the order they go in. 

1. Same-store growth is the engine 

Adam Richichi, CEO of Archway Dental Partners, said it plainly at the Yankee Multi-Site Summit this year: organic growth tells you the truth about your business, because you can't hide operational issues when you grow from within. A group showing mid-to-high single-digit organic growth, Archway's target, has proven its operating model works. One that can't is buying revenue. 

Start with the spread between your locations. Pull any number in this section by location and you won't get one figure. You'll get a spread. A group reporting 45% case acceptance usually has an office well above that and an office well below it, on the same software and the same fee schedule. 

The top office rarely has a secret. It has an office manager who builds a way of doing things and holds people to it. The bottom office has people working just as hard without one.

Most same-store growth is closing that distance: find what your best location does, write it down, and make it the default everywhere else. 

That's what I mean by fool-proofing success, and it's no knock on the people. A strong system means an ordinary Tuesday produces a good result without anyone having to be a hero. The front-desk hire in her second week gets the same outcome as the fifteen-year veteran because the script, the checklist, and the number on the wall are the same. When results depend on who happens to be working, the growth leaves when that person takes a vacation or another job. We've all seen that movie. 

It's unglamorous work, and it compounds. Every location you bring up to your own best office is growth you already know how to produce. The spread shows up in four places. 

Case acceptance. This is the biggest of the four: the share of treatment a dentist recommends that the patient actually schedules and completes. Henry Schein One's 2026 Catalyst Index puts the industry average at 45% and the top tenth of multi-location groups at 75%. At the average group, more than half the care its own dentists recommend walks out the door. 

Consistency explains that gap better than size does. Top groups present treatment the same way at every chair, hand the dentist a verified out-of-pocket number before the conversation starts, and see declined plans in real time, by dentist and location, so someone follows up while the patient is still engaged. 

That out-of-pocket number needs a financing strategy behind it. A patient who can't see how to pay says "let me think about it," and that's often the last you hear. An aggregator like Endeavor takes one application and routes it across several lenders, so more patients get an answer in the same conversation, and the team isn't bouncing between lender portals. Done well, paying for care becomes part of an exceptional experience. 

Moving from 45% to 60% means a third more accepted treatment without signing a single LOI. 

Hygiene. Hygiene visits are where restorative work gets diagnosed. A patient who stops coming in for cleanings is a patient whose crown never gets found. Three numbers matter: reappointment (hygiene patients who book their next visit before they leave), recall (overdue patients the office brings back), and reactivation (patients unseen for a year or more who return at all). 

Groups that run these as campaigns, with a list, an owner, and a weekly number, beat groups that wait for the phone. Every group has the software. What separates them is whether anyone looks at the unscheduled list on Tuesday. 

Schedule utilization. An open hygiene hour or an unfilled hour in a dentist's day is inventory that expires at five o'clock. The fixes cost next to nothing: rules that reserve certain blocks of the schedule for high-value procedures, a consistent protocol for confirmations and cancellations, and a short-notice list of patients that somebody actually maintains. 

New-patient conversion. Marketing makes the phone ring. The front desk decides what happens next. Picture a group that spends six figures on lead generation, then learns from its call recordings that a third of calls went to voicemail over lunch. I've seen versions of that more than once. In a February 2026 Peerlogic analysis of 4,280 calls across 26 practices, 38 percent of inbound calls went unanswered and only a quarter of new-patient calls ended in an appointment. The numbers that matter are the share of calls answered, the share of inquiries booked, and how many days out the first available appointment is. 

2. De novos, if you have a factory 

PDS Health opened 77 practices in 2025 and set a target of more than a hundred for 2026. Smile Partners opened its first de novo this year after a decade of growing only by acquisition. 

The appeal is control. A de novo starts on your software, brand, clinical protocols, and culture from day one. No data to convert, no legacy fee schedule to untangle, no team with 20 years of habits to win over. 

The cost is time: 18 to 36 months to reach an established practice's production. And it only pays as a repeatable process, with site selection, build-out, the standard equipment and software package, recruiting, and opening marketing each written down and improved after every launch. Treated as a custom project, a de novo burns capital and patience. Treated as manufacturing, it opens locations faster than deals close. 

3. Acquire like you can afford to say no 

Acquisition still matters. What's changed is how the best groups approach it. 

They underwrite quality rather than volume. When good practices are scarce, the temptation is to accept weaker financials, a practice whose revenue depends on one dentist who might leave, or an operational mess, because the fund needs to deploy capital. The disciplined platforms are tightening their criteria instead. Bill Becknell, CEO of Mortenson Dental Partners, expects the opportunity to keep growing as private practices seek support. He's right, and the groups that benefit will be the ones with a clean balance sheet and an integration team that isn't still digesting last year's deals. 

They treat integration as the moment the return is earned. The purchase price is paid on day one. The value comes in the first 120 days after closing, from a written playbook covering finance, operations, clinical protocols, technology, and culture, each with an owner and a date, each measured against the financial model that justified the deal. Acquisitions that quietly underperform for three years are almost always acquisitions where the playbook was a slide. 

They sequence the software carefully, because every acquired practice arrives with its own systems. Migrations fail on timeline more often than on technology: a data conversion that needs sixty days gets squeezed into two weeks to hit an arbitrary date. Move billing and claims first, so cash keeps flowing, patient records once billing is stable, and imaging last, with the most training. 

And they keep the people. Whether an acquired practice holds its production through the first year depends more than anything on whether the dentists and staff stay. Tell them early what will change and what won't, and mean it. 

4. Stop referring out 

General dentists routinely refer patients elsewhere for clear-aligner orthodontics, implants, root canals, extractions, and gum surgery. Every referral is a patient and a fee leaving the building. 

The specialists themselves are consolidating. L.E.K. Consulting projected in 2023 that the share of oral surgeons affiliated with a DSO would roughly double, from about 10% in 2022 to 22% by 2027, with specialty-focused groups growing fastest. A general group that doesn't build its own specialty capacity will increasingly be referring its patients to someone else's platform. 

A group can capture that production without adding a chair. Specialists can travel between  offices or be recruited into hub locations, and its general dentists can be trained to do more of the work themselves. 

5. Decide your payor mix on purpose 

Payor mix is a growth decision, because different plans pay very different amounts for the same crown. At the end of 2025, 35% of dentists told the ADA's Health Policy Institute they intended to drop at least one insurance network in 2026. By the end of the first quarter, 22% had. 

For a DSO, the questions are which networks to participate in market by market, how to use the group's size to negotiate better fee schedules, and how to shed the lowest-paying plans without losing the patients on them. 

In-house membership plans are the common answer. Uninsured patients pay a monthly or annual fee for cleanings and a discount on other work. The group gets predictable recurring revenue, less insurance paperwork, and a reason for those patients to stay. Blueprint Smiles, a seven-location group, compared 790 membership patients with its other uninsured patients. Members came in 7.3 times a year against 3.1 and generated about $3,000 a year each against roughly $1,060, according to a case study published by its membership-plan vendor. 

The other half of the payor mix is what you offer outside insurance. Implants, clear aligners, cosmetic work, and sleep appliances are paid largely out of pocket, at fees the group sets. Every one of those cases shifts the mix toward cash without dropping a network. 

6. Providers decide everything above 

Every lever on this list runs through clinicians, and the workforce numbers make provider strategy urgent. Among dentists actively recruiting a hygienist, 91% told the ADA's Health Policy Institute it was very or extremely challenging. About 31% of working hygienists expect to retire within five years. A group that hasn't rebuilt its culture, its pay, and its career paths for the workforce it actually has will find growth capped by capacity, whatever the demand. 

Simply Dental started showing its dentists and hygienists the true P&L for their own practice: how full their chairs were, what they produced per day, how their decisions showed up in the numbers. The clinical team got more engaged, not more anxious. 

Associates deserve their own line in the plan. They're the dentists a group adds as it grows, and raising what each one produces is same-store growth by another name. Start with production per hour. Monthly production mostly tells you how many days someone worked and how full the schedule was. Production per hour is the fair baseline. It lets you compare a three-day associate with a five-day one and shows who needs help with diagnosis, treatment presentation, or speed. 

Then invest against that number: mentorship from a senior dentist, continuing education that widens the procedures they can do, and an assistant and a schedule that let them work at their level. Invest in your associates. It comes back to every chair. 

7. Technology, if it is deployed correctly 

Technology is on every DSO's growth plan, and the potential is real. AI radiograph analysis, automated revenue cycle management, automated patient outreach, and cloud platforms are all producing measurable results at groups that deploy them well. 

The catch is in "deploy them well." I've walked into organizations paying for four or five of these tools and running each at a fraction of what it was built to do. The tools were fine. The vendors had done their part: installed the software, trained staff on where the buttons are, and handed over the keys. What was missing was anyone who owned changing how the work actually got done. 

That work doesn't fit a software vendor's model, and most groups aren't staffed for it either. It usually lands on a regional manager who already has a full-time job, so it falls into the gap between the two. 

Technology becomes a growth lever when it changes the workflow at every site, and the metrics prove it. That takes a named owner, a rollout plan, training built for each role, a leader who shows up, and usage measured by location after go-live. Activated isn't adopted. Without that work, it's a larger software bill and the same numbers. 

It's also the most fixable problem on this list, because the fix is ownership rather than another purchase. 

Order matters 

These levers reinforce each other, and they work best in sequence. Same-store discipline comes first, because it improves the math on everything else. Build the integration playbook before the next deal, not after. Open de novos where you already have density. Layer specialty and payor strategy onto an operating base that's already stable. Invest in providers the whole way through, because every other lever depends on them. And treat every technology purchase as an adoption program with a number attached. 

Where to start 

Think back to the group losing a third of its calls to a lunch-hour voicemail greeting. It didn't need a new market, a new deal, or a new platform. It needed someone to listen to the recordings. That takes an afternoon. Cover the phones by the following Monday, and every dollar of marketing already committed starts converting at a rate the group has never seen, because for the first time the call gets answered. 

Take the growth assessment 

The Seven-Lever Growth Assessment scores your group on each of the seven. Take it with your leadership team, then shoot me your two lowest scores. 

Take the Seven-Lever Growth Assessment 

Sources 

• Becker's Dental Review, "The big trends driving DSO growth in 2026" (March 2026) 

• Becker's Dental Review, "PDS Health plans to open 100+ de novos in 2026: Q&A" (February 2026) 

• Becker's Dental Review, "22% of dentists have dropped insurers so far in 2026" (April 2026), on the ADA Health Policy Institute's Q1 2026 report 

• Group Dentistry Now, "DSO Executive Leadership Discussion from the 2026 Yankee Multi-Site Summit" (February 2026) 

• Brian Colao, "Thoughts for the DSO Industry in 2026 and Beyond", Medhealth Outlook 

• Clerri, "30 DSO Growth Trends Reshaping the Dental Industry in 2026" and "30 DSO Industry Statistics Shaping Dental in 2026" (March 2026)