DSO affiliation among U.S. dentists has more than doubled since 2015 — from 7.2% to 16.1% — as practice ownership has dropped to a 20-year low of 73%, according to TUSK Practice Sales’ Q4 2026 Dental Market Report.
Eight notes from the report:
- DSO expansion continued during the third quarter, with several large platforms combining and adding regional groups, and entering new states.
- Financing conditions tightened significantly after the Federal Reserve raised its target rate to 3.75%-4% on Sept. 16 and new underwriting rules from the Small Business Association took effect Oct. 1. Lenders now require a 1.25x debt service coverage ratio, a 36-month seller note standby period and an independent quality-of-earnings review on deals above $3 million.
- Practice ownership has dropped from 85% of dentists in 2005 to 73% in 2024, while DSO affiliation has more than doubled from 7.2% in 2015 to 16.1% in 2024. Among dentists up to 10 years out of school, 26.5% are DSO-affiliated versus 9.1% of those 25 or more years out.
- The average dentist retirement age has risen from 64.7 in 2001 to 68.7, with 33.8% of dentists now 55 or older.
- State regulatory activity is increasingly affecting deal structure. North Carolina’s Session Law 2026-41, effective July 7, no longer requires dental management arrangements to be submitted to the State Board of Dental Examiners for prior review. Other state ownership, notice and Medicaid changes in California, Washington, Kentucky and Illinois are also shaping how transactions are structured.
- Park Dental Partners remains the only publicly traded U.S. DSO after its December 2025 IPO. TUSK expects that DSOs preparing for recapitalization or an IPO will actively seek to partner with high-performing practices to strengthen their EBITDA before going to market, creating near-term acquisition opportunities for well-run practices.
- More than 20 PE-backed dental platforms are seven or more years into their hold periods — setting up a wave of DSO recapitalizations, secondary sales and potential IPOs that is expected to reshape the acquisition landscape over the next 12 months.
- Reimbursement rates and practice revenue are lagging behind inflation and expenses. Reimbursement rates have increased 19% since 2021, while inflation has risen by 27%. Practice expenses have risen by 4.9% over the last five years, while practice revenue has only risen 1.4%.
