EBITDA Is Changing: The New Reality for Dental DSOs
The DSO playbook was built on efficiency, scale, and repeatability. That worked when margins were wide and costs were predictable. Those days are over. What used to be standard practice no longer guarantees stability, let alone profitability. The next phase of dental growth will belong to the organizations that can understand why EBITDA moves, not just where it lands on a spreadsheet.
The New Challenge: EBITDA Without Clarity
Most organizations today can report production, operating costs, and call volume across locations. They can track marketing spend and staff utilization. They can monitor financial performance month to month. What they cannot do as easily is explain why EBITDA moved in either direction. In many cases, leadership teams are left reviewing numbers that reflect the past rather than insights that help forecast the future.
This challenge is not about a lack of data. It is about data that remains disconnected. Financial reporting is being asked to do work that requires operational intelligence. Profitability, which once seemed straightforward, now depends on visibility that is much deeper and more specific than what traditional dashboards provide. As a result, dental DSOs are spending more each year to protect their position in the market while finding it increasingly difficult to defend their profitability.
Why EBITDA in Dental DSOs Is Getting Harder to Maintain
Three forces are making EBITDA more difficult to protect in dental practices across the country:
Rising cost to operate. Talent is harder to recruit and more expensive to retain. Benefits have become standard expectations rather than competitive advantages. The cost of internal support teams and administrative staffing continues to rise across nearly every DSO. The resources required to sustain operations now look similar to the resources once needed to expand them.
Unclear ROI on investments. Technology, marketing, training, and compliance are all necessary investments for growth, but they are difficult to quantify when results do not clearly link to revenue or margin protection. This has become one of the most pressing concerns for DSO CFOs, who are expected to prove value on spend that has historically been assumed.
Increased financial scrutiny from lenders and investors. A growing number of DSOs are finding that healthy numbers alone do not satisfy capital expectations. Investors are asking for attribution. They want clarity around the levers that drive margin and insight into what risks may exist where EBITDA appears strongest. This has elevated the importance of operational transparency as a requirement for continued growth.
These pressures are not temporary. Combined, they mark a shift in how profitability will be evaluated and defended in modern dental DSOs.
What a Healthy EBITDA Looks Like in 2025
Industry analysts report that most successful dental DSOs today operate between 14 and 18 percent EBITDA, while high-performing groups may reach above 20 percent when operational processes are strong and patient retention remains consistent. This range still signals health, but it now comes with a different expectation. Strong numbers are no longer enough to secure capital or pursue aggressive expansion. Leadership must be able to explain what is driving EBITDA and prove that those trends are sustainable.
This raises an important question for the year ahead:
Is EBITDA a number you report, or a story you can explain?
Operational Visibility: The New Competitive Advantage
The DSOs pulling ahead are the ones who treat EBITDA not as the destination but as the outcome of operational clarity. They are shifting away from broad reporting and beginning to track the inputs that shape financial performance. They can see how staffing levels impact treatment acceptance, how wait times influence patient attrition, how technology adoption changes production per chair, and how engagement affects long-term patient value. These insights allow EBITDA to be viewed not as a static monthly summary but as a dynamic indicator of health at every level of the organization.
This transition from financial reporting to operational intelligence is redefining growth strategy. It reduces reliance on assumptions. It creates alignment between operational leaders and financial stakeholders. Most importantly, it makes EBITDA defensible when decisions need to be justified in a room full of people who want proof.
The Next Stage of Dental DSO Growth
Growth inside dental DSOs can no longer rely solely on expansion. Adding more locations is not the only or even the most effective path to profitability. Stability now matters as much as scale. Efficiency matters as much as production. In many ways, the new competitive landscape rewards organizations that understand what protects EBITDA long before those numbers are published at month end.
The DSOs that will maintain strength over the next several years are not just the ones who report EBITDA accurately but the ones who can explain it clearly. They will build systems that surface correlations, understand what creates drag, track value across every patient touchpoint, and measure whether each investment protects profitability or quietly erodes it.
Once that level of clarity becomes part of decision-making, EBITDA becomes more than a benchmark. It becomes a strategy.
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Stop guessing at your practice’s performance. To define the new standards for 2026, we didn't just look at a few offices—we went deep. By polling over 3,000 practices and analyzing BILLIONS of hours of call data, we’ve uncovered the hidden "Visibility Gap" that is quietly draining revenue from even the busiest offices.
For many dental practice leaders, 2025 was a year of "recalibration." The data tells a nuanced story: while consumer dental spending actually jumped by 13%, dentist confidence in the overall economy took a meaningful dip. The uncertainty wasn't just a feeling; it showed up in tighter decision-making and a heightened focus on protecting what was already working.
As we move into 2026, the theme has shifted from survival to intention. The performance gap in modern dentistry is no longer about how hard your team works or how much "effort" they put in; it is entirely driven by the operating systems you have in place. The practices that succeed this year will be those that move from assumptions to standards—transforming visibility gaps into measurable insights.
Below is a summary of the forces shaping the industry this year. To see the full benchmarks and learn how to close your own visibility gap, you can access the full 2026 State of Dental Best Practices Guide here.
1. Stability is the New Growth
In previous years, the "best" practices were the ones growing the fastest. Today, the most confident practices are those optimizing for predictability and control. Stability has become a "moat"—a competitive advantage that prevents staff burnout and ensures no patient falls through the cracks.
2. The Technology Adoption Curve
We’ve moved past adopting technology just because it’s trendy. In 2026, practices are sequencing their tech investments based on where they feel the most risk.
- Predictive Dentistry: Tools that surface clinical risks early are building patient trust.
- Front Office Automation: Unified call and text workflows are being adopted to protect revenue
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3. AI: Let it Finish the Job
AI is no longer a futuristic concept; 35% of dentists are now using AI tools. However, the data reveals a surprising trend: AI performs best when humans stay out of the way of routine tasks.
When AI agents are given "ownership" of the first mile of communication—answering a question and booking the appointment—resolution rates can exceed 75%. When teams intervene too early in these automated loops, performance actually drops by 30%.
4. Closing the "Visibility Gap"
There is a massive difference between feeling informed and being informed. While most practices report high confidence in their front office, only 36% actually review performance data weekly. To win in 2026, you must replace assumptions with validation.
5. The "e-Patient" and Demand-Based Hours
The modern patient expects your office to operate like a high-end consumer business. Call volume doesn't follow a neat 9-to-5 schedule; peaks typically hit around 3:00 PM, right when your team is at their highest operational load. The most successful practices are shifting their "coverage" to follow this demand using AI and digital channels.
Success in 2026 belongs to the practices that move from visibility gaps to measurable insights. As Ryan Miller, CEO of Peerlogic, puts it: "If 2025 was a year of recalibration, 2026 is a year of intention."
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For dental service organizations, 38% of revenue comes from the phone. New patient acquisition, case acceptance, hygiene utilization, and reactivation all begin with a conversation.
Yet for many DSOs, call performance is still evaluated at a surface level or not evaluated at all. Leaders may see total call volume by location, but lack clarity into which conversations actually convert into booked appointments and revenue.
Comparing call performance across multiple dental locations is essential for understanding where revenue is generated, where it is lost, and where operational improvements will have the greatest impact.
Why Call Performance Matters at the Enterprise Level
For multi-location dental organizations, small inefficiencies scale quickly.
A missed call or poorly handled inquiry at one location may feel insignificant. Across ten, fifty, or one hundred locations, those same issues can represent millions in unrealized revenue annually.
Call performance directly influences:
- New patient acquisition
- Chair utilization
- Hygiene reappointment rates
- Marketing ROI
- Front office staffing efficiency
Without a consistent way to evaluate call performance across locations, leadership teams are forced to rely on incomplete indicators such as production totals, marketing spend, or subjective call sentiment.
The Challenge: Inconsistent Data Across Locations
One of the biggest barriers to comparing call performance is inconsistency.
Different locations may:
- Handle calls differently
- Use different scripts or workflows
- Track outcomes manually or not at all
- Rely on anecdotal feedback rather than data
As a result, leaders struggle to answer critical questions, including:
- Which locations convert the highest percentage of inbound calls?
- Where are missed calls impacting revenue the most?
- How does call handling affect marketing conversion by region?
- Which operational changes actually improve booking rates?
- How are my marketing efforts performing?
Without standardized data, performance comparisons are unreliable.
Key Metrics DSOs Should Use to Compare Call Performance
To evaluate call performance across multiple dental locations, DSOs need to focus on metrics that tie conversations directly to revenue outcomes.
Key metrics include:
- Inbound Call Volume by Location
- This establishes demand and highlights variability across regions or campaigns.
- Answered vs. Missed Calls
- Missed calls represent high-intent patients who were unable to connect. This metric is critical for identifying revenue leakage.
- Call-to-Appointment Conversion Rate
- This measures how effectively locations turn conversations into booked appointments.
- After-Hours Call Capture
- Calls outside business hours often go untracked, despite strong booking intent.
- Marketing Source Attribution
- Understanding which campaigns drive calls that convert allows DSOs to invest more confidently in growth channels.
When these metrics are viewed consistently across locations, performance gaps become clear.
What High-Performing Groups Do Differently
High-revenue groups do not treat call data as a front-office issue. They treat it as a lever for enterprise growth.
High-performing organizations:
- Standardize call performance reporting across all locations
- Identify top-performing offices and replicate best practices
- Detect underperforming locations early
- Align marketing spend with positive conversion metrics
- Support front office teams with Agentic AI that can scale and be configured to each office and doctors preference (no missed calls, consistent AI call handling, and more)
This approach shifts call performance from reactive troubleshooting to proactive revenue optimization.
Turning Insights Into Action
Comparing call performance is only valuable if it leads to operational change.
When leadership teams have clear visibility into call handling and conversion trends, they can:
- 'Adjust staffing models based on real demand
- Improve scheduling workflows
- Refine marketing investments
- Set performance benchmarks across the organization
From Data to Action: Scaling with Evidence
The most successful DSOs have moved past the era of "assumptions." Inbound calls are your most controllable revenue driver, but you cannot manage what you do not measure. By establishing visibility first, leadership can finally compare performance across the enterprise and identify exactly where revenue is leaking.
The Strategic Foundation: Metrics First
Before you can automate, you must audit. Standardized metrics allow you to:
- Identify the Gaps: Pinpoint which locations are losing demand and why.
- Maximize Utilization: Turn every marketing dollar into a booked chair.
- Benchmark Performance: Set a group-wide standard for patient experience.
The Next Step: Bridging the Gap with Agentic AI
Visibility exposes the problem, but Agentic AI solves it. Once you have a clear view of your metrics, you can strategically augment your operations to:
- Capture Every Missed Opportunity: AI handles missed calls and after-hours demand instantly, ensuring no lead goes cold.
- Standardize Call Handling: Drive consistency across 10 or 100 locations without adding headcount.
- Proactive Growth: Use AI to bridge the gap between "identifying a leak" and "closing the sale."
The bottom line: Data provides the map; Agentic AI provides the engine. Together, they turn fragmented communication into a scalable, predictable revenue machine.
Scaling a dental practice is exciting. It is also where many practices start to lose control of the very systems that made them successful in the first place.
As practices expand beyond a single location, patient communication becomes harder to manage. Call volume increases. Messages spread across systems. Front office teams operate differently at each location. Leadership loses visibility into what is actually happening day to day.
For practice owners and executive teams, the challenge is not growth itself. The challenge is scaling without losing control of patient communication.
Why Patient Communication Is the First System to Break When Scaling
Most dental practices scale by adding locations, providers, and staff. What they often do not scale at the same pace is communication infrastructure.
As a result, leaders face issues like:
- Missed calls during peak hours
- Inconsistent patient experiences across locations
- No clear way to measure call handling or follow-up
- Limited insight into which locations are converting conversations into appointments
- Reactive problem solving instead of proactive management
These challenges compound quickly once a practice moves beyond one location. What felt manageable at one office becomes operational drag at two or three.
Patient communication is no longer a front desk issue. It becomes a leadership issue.
The Hidden Cost of Poor Communication at Scale
When patient communication is fragmented, revenue loss is rarely obvious at first.
It shows up quietly as:
- Empty chair time despite strong marketing demand
- Patients who never call back after being put on hold
- Inconsistent scheduling performance across locations
- Teams feeling overwhelmed rather than supported
Without visibility, leadership often assumes the issue is staffing or marketing. In reality, it is a lack of centralized communication insight.
Scaling without control leads to guesswork. Guesswork leads to missed opportunities.
What Control Actually Looks Like in a Scaling Dental Practice
Control does not mean micromanagement. It means visibility.
High-growth dental practices maintain control by ensuring leadership can see and understand patient communication across every location.
This includes:
- A unified view of calls, texts, and patient conversations
- Clear performance metrics tied to real outcomes
- Consistent communication standards across offices
- Insight into where breakdowns are happening before they impact revenue
When patient communication data lives in silos, this level of clarity is impossible.
Why Centralization Is Critical Before Opening the Next Location
Many practices wait until communication issues become painful before addressing them. By then, the problem is harder to unwind.
The most successful practices centralize patient communication before scaling further.
Centralization allows leaders to:
- Compare performance across locations using the same benchmarks
- Identify coaching opportunities based on real conversations
- Ensure coverage during high-volume periods
- Maintain a consistent patient experience as volume grows
This approach supports growth without adding unnecessary complexity.
Scaling Without Sacrificing the Patient Experience
One of the biggest fears when scaling is losing the personal touch that patients value.
Centralized communication does not remove personalization. It protects it.
When systems are aligned:
- Teams respond faster
- Patients feel heard and supported
- Offices are not overwhelmed by call volume
- Leadership can support teams instead of reacting to problems
The patient experience improves because communication becomes intentional, not reactive.
Building a Communication Strategy That Scales
Scaling a dental practice successfully requires treating patient communication as infrastructure, not an afterthought.
Before expanding to additional locations, leadership should be able to answer:
- How many patient calls are we missing today
- Which locations convert conversations into appointments most effectively
- Where do patients drop off in the communication process
- How do we support teams as volume increases
If those answers are unclear, growth will magnify the problem.
Scaling With Confidence
Growth should create opportunity, not chaos.
Dental practices that scale without losing control of patient communication do so by investing in visibility, consistency, and centralized insight. They replace assumptions with data and reaction with strategy.
Patient communication is where growth either compounds or breaks down.
Getting it right early makes scaling simpler, more predictable, and more profitable.
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