The chart is already open when my patient walks in. Forty-two years old, no significant medical history, last seen 18 months ago, not by me, but by a practice three miles down the road. I scroll through the treatment plan they sent her home with. Seven procedures and four of them major. A timeline that would have her back in a chair every six weeks for the next year. She looks nervous, the way she always looks nervous, she tells me, because every time she left that other office, something new was wrong.

The X-rays don’t support what’s been recommended. A dentist with time to actually look would have watched three of these for another year before touching them. Someone was in a hurry or working toward a number. In my experience, those two things tend to go together.

I’ve been on the inside. I know what the quota looks like.

Nobody told me about the number during dental school. I learned how to read an X-ray and think through a treatment plan the way my professors trained me: slowly, conservatively, with the patient’s long-term health as the only variable that mattered. What I didn’t learn was that my first job would hand me a daily production target before I’d finished my coffee, printed on a sheet as casually as a restaurant manager posting an evening sales goal.

The number required me to be slightly less conservative than my training, twenty times a day, until that stopped feeling like a choice. The system doesn’t break you in one dramatic moment but works gradually, through the daily pressure of a number attached to your name in an office managed by people who have never looked inside a patient’s mouth.

I left after I recommended a treatment I wasn’t certain about and spent the drive home trying to convince myself the X-ray justified it. Not because I couldn’t function inside that system, but because I could see exactly what staying would make me. So I bought my own dental practice.

It’s a machine.

In 2024, the dental industry recorded 161 private equity deals, the highest number of any health care sector that year. As of mid-2025, approximately 130 private equity-backed dental service organizations operate across the country, more than in any other health care vertical, with many structured specifically to sidestep regulations that prohibit direct corporate ownership of dental practices.

Physicians reading this will recognize the arc. Private equity entered medicine with the same promise: relieve administrative burden, let doctors focus on patients. What it delivered instead was production quotas, shortened appointments, and a generation of clinicians burned out from practicing inside a system that measures their value in billing codes. Dentistry is following the same playbook, roughly a decade behind, and patients have no idea it’s happening.

What happens to patients inside that machine

Investigations by KFF Health News and CBS News found that dentists at certain corporate-owned chains were allegedly extracting healthy teeth and replacing them with expensive implants. The American Dental Association’s own ethics documents acknowledge that in corporate environments, front office staff can receive compensation tied to production metrics, meaning the person checking you in has a financial interest in the procedures that happen in the operatory.

The problem isn’t that corporate dentists are bad people. The problem is that a crown quota makes a dentist look at a shallow crack differently than a dentist with no quota would. It doesn’t take malice. It just takes a number, repeated daily, until clinical gray areas start resolving themselves in a particular direction.

Why I chose a different way

I now own a fee-for-service concierge practice in Huntersville, N.C. It is harder to build than an insurance-driven model, requires more patient education, and is not accessible to every patient in every zip code. What it gives me is the ability to recommend waiting without a quota in the back of my head, to use the best material available rather than the one an insurance fee schedule will partially reimburse, and to spend enough time with a patient to explain what I’m seeing.

When someone sits down in my chair after years at a corporate practice, with a chart that doesn’t add up, I can tell them the truth about what I’m looking at. That should be the baseline. For a growing number of Americans, it isn’t.

What you can do right now

Ask your dental practice whether it is independently owned or part of a larger organization. Ask your dentist whether they operate under production targets. Ask for the clinical reasoning behind any major treatment recommendation and consider a second opinion for anything involving crowns, extractions, or implants.

The patient in my chair didn’t know any of this. She just knew she was nervous every time she left the dentist and that something always seemed to be wrong. She deserved a dentist whose only job in that room was to think about her teeth. That should not be a luxury, but right now, for too many patients, it is.

Abbey Gonzales is a dentist.