In years past, a trip to the dentist office often meant an appointment in a one-chair practice owned by a single dentist who employed a nurse technologist and perhaps a bookkeeper.
Now, many Americans take their dentist appointments at large practices employing several dentists or at corporate dental chains where doctors are employees.
A number of factors are remolding the dental profession, leading to the growth of corporate dentistry and challenging the traditional model of independent dentists practicing within their own offices.
Dr. Raymond Martin, a Mansfield dentist who heads the Massachusetts Dental Society, said young dental school graduates are increasingly choosing to work for large dental chains, such as Aspen Dental, rather than go it alone because of the burden of college loans and the immense cost of equipping and staffing their own offices.
"Today, the average Massachusetts dental school student is graduating with $250,000 in school loans," Martin said. "And some who are coming from private schools may have as much as $400,000. That's a big load."
The cost of a dental education is just the beginning. Opening and equipping a dental office can cost anywhere from $350,000 to $550,000, according to the website howtoopenadentaloffice.com, with the biggest pricetag in high-growth regions like the Northeast.
Further, regulations and the complexities of insurance coverage mean dentists need to hire additional staff to handle billing and assure compliance with laws like the Health Insurance Portability and Accountability Act (HIPPA).
The increasing costs and complexities have prompted more dental school graduates to seek employment at large-scale dental chains or purchase existing practices, rather than take on the burden of starting their own business.
But there are exceptions like Attleboro endodontist Dr. Lynsey Doan, who opened an independent practice last October on North Main Street after years of working for other dentists.
Doan, a Vietnamese immigrant who graduated dental school with the usual burden of student loans, said she took the leap so she could have more autonomy and practice at what she considered the highest level.
"I wasn't finding it satisfying," Doan said of working out of a variety of dental offices where the quality of furniture and equipment often varied.
She also said she walked away from one corporate chain where she says she was urged to perform root canals on teeth that were too far gone.
"I refused," she said.
Doan is not alone in her disenchantment with corporate dentistry.
In 2014, after legal action by former Massachusetts Attorney General Martha Coakley, Aspen Dental agreed to pay $990,000 to settle allegations of deceptive advertising and marketing practices and failing to give refunds to consumers for services not provided.
Aspen Dental declined to comment concerning its practices and referred a reporter to the Association of Dental Service Organizations, a trade group that represents dental chains.
Bill Head, vice president for government affairs, said corporate dentistry is a misnomer because all but four states require dental practices to be owned by dentists. Dental Service Organizations, like Aspen, provide marketing, billing and other aspects of the practice while dentists are the licensed owners at each office.
Head says there's no fundamental difference between dentists working at a DSO or "corporate" practice and a dentist-owned and run office.
"Dentists at DSOs and independent dentist offices all went to the same kinds of dental schools," he said. He also said dental service organizations also subscribe to a code of conduct that draws a "bright line" between patient care and non-clinicial issues.
Doan and others who prefer to remain independent say running their own practices gives them the freedom to pursue their profession in accordance with their own standards.
When Doan opened her own last year, she brought in advanced equipment so she could practice endoscopy through a microscope, affording her superior vision. She also brought in a dental CAT scan machine to give her a better view of each patient's dental anatomy.
While she saw only a few patients during her first weeks, Doan says her practice is gradually growing. She says she feels more freedom now, and is proud of the homey, oil painting-decorated office she designed herself.
"I have no regrets," she said.
Nor does Dr. Chris Peluso, an orthodonist who, along with his father Joseph, operates offices in Attleboro and North Attleboro.
"In my opinion, there is a huge difference between dentist-owned and corporate offices for patients. Corporate dentistry is just that, corporate. There are CEOs and stockholders, and revenue is the driving factor.
"In our practice, we believe that if you treat patients right and provide excellent care, then the revenue will come."
Over the past several years, dental experts like Martin and consultant Dr. Roger Levin say, the dentist's office has been subject to a cascade of economic and social changes that have put pressure on practitioners to cut costs and become more efficient.
It all started with the 2007-2009 recession, Levin wrote in an online article, as fewer patients sought treatment and rejected elective treatments. That, combined with the emergence of lower-paying reimbursement plans and competition from big chains, have put additional pressure on traditional dentist's offices to streamline their business practices.
Insurers are also applying pressure on dentists.
Delta Dental of Massachusetts, the largest dental insurer in Massachusetts, asked member dentists in December to agree to a new contract. Some dentists say the contract is unfair and would make it more difficult for them and allow less choice for their patients.
Mansfield's Martin said dentists were told last year they had to approve the contract within two weeks. He met with Delta's president and got the deadline extended to Jan. 31. The deadline has since been stretched to late February.
But requiring dentists to sign right away is not the only thing that got Martin and many other dentists' attention. The contract included changes that dentists say would be costly for them and potentially make access to a dentist harder.
"There are a number of things we think are onerous," said Martin, whose organization has gone to the Massachusetts Insurance Commission and the state Attorney General about the contract.
Dentists say Delta has created a new for-profit Preferred Provider Organization plan that would provide a lesser rate of reimbursement to dentists. Some dentists have said they would be operating at a loss on certain procedures billed at the new rates.
A spokeswoman for Delta Dental said provider fees under the new network would be the same as those offered under existing PPO and Premier networks. However, the demand for higher-cost indemnity plans that pay dentists the most are declining.
If demand for indemnity products like Premier continues to decline, she said, there could be a financial impact to dentists who only participate in the higher-paying Premier network.
Dentists fear Delta will eventually stop selling the Premier network, altogether, leaving patients with no alternative to the lower-paying PPO.
While patients wouldn't be forced to switch under the new contract, many expect that companies and organizations that provide dental coverage through Delta Dental will eventually migrate to the least costly plan.
In response to Delta Dental's moves, the Massachusetts Dental Society has filed legislation calling for a review of the planned changes.
"Patients rely on dentists to help them navigate the system and access care," said state Rep. Angelo Puppolo Jr., D-Springfield, the bill's sponsor. "There should be no barriers imposed by an insurance carrier to restrict access to appropriate care.
"The only way to ensure this protection is to regulate Delta as a for-profit insurance company with the same Division of Insurance oversight as when Delta was a non-profit."