Is dentistry consumed with consolidation and should we be concerned?

As dentistry continues to consolidate across licensure, insurance, and practice models, the risk is not just efficiency, it is control. When pathways narrow, so do choices. Dental students and newly graduated dentists face major decisions, such as doing startups, maintaining access to multiple board examination options, having a healthy choice of options for which insurance company to accept (if any), or taking on private practice versus joining corporate. The question begs, will they even have that decision to make in the future, or will it be made for them?

If you blinked, you might have missed it.

Another partnership. Another alignment. Another step toward what’s being framed as a more efficient, more standardized future for dental licensure.

But before we even get to licensure, it’s worth recognizing that this pattern isn’t isolated.

What do people think when they hear the word “consolidation”?

When most people hear the word “consolidation” in dentistry, they immediately think of large group practices. They think of the big DSO expanding their footprint, acquiring practices, and building scale. To be fair, that is consolidation, but probably just the most visible version of it. You can see similar patterns in other parts of dentistry. 

Take Delta Dental. It isn’t a monopoly on paper. It operates as a network of regional entities. But in many markets, its influence is so significant that participation becomes less of a strategic choice and more of a practical necessity. When access to patients is tied to a dominant payer, the idea of “choice” starts to feel more theoretical than real.

Likewise, we have the Henry Scheins and Patterson Dentals of the world who are not only our source of products and supplies but also have a hand in our practice management software. Some of these distributors hold large-scale CE events and have practice management resources. They go beyond a simple distribution warehouse.

At the practice level, organizations like—enter any big DSO company here—continue to scale, supporting hundreds and now thousands of practices, backed by private equity and enterprise-level resources. These are no longer small, localized operations. They are sophisticated systems with the ability to influence how dentistry is delivered at scale. Again, not a monopoly, but clearly part of a broader movement toward fewer, larger decision-makers.

Additional reading: Do we trust dental schools enough to eliminate clinical boards? With Matt Shafer and Sheli Cobler

Looking at the numbers

When you step back and look at the numbers, the scale becomes even more apparent. Delta Dental, across its network, generates billions in annual revenue and carries an estimated valuation in the tens of billions. Executive compensation reflects that scale, with leadership earning in the millions annually. Heartland Dental, backed by private equity, has been valued in the billions as well, with executive compensation structures that extend far beyond traditional practice-level income. Compare that to the average private practice owner, who may earn a strong and well-deserved income, but operates in an entirely different financial universe.

With scale comes leverage

That contrast is important, because consolidation isn’t just about structure. It’s about where influence accumulates, and with scale comes something else: leverage.

To be clear, none of these consolidations are likely happening with bad intent. Most of it is driven by efficiency, alignment, and the belief that a more streamlined system benefits everyone. But every industry eventually runs into the same reality. When organizations reach a certain size, they don’t just participate in the market. They begin to shape it.

In insurance, that leverage shows up in predictable ways. When a payer becomes large enough, it doesn’t need to compete by expanding benefits. Annual maximums can remain flat and reimbursement rates can stagnate. Unfortunately, that drives providers to adjust to the system because access to patients depends on it. The market doesn’t move around the payer; the payer becomes the market.

How to scale while controlling cost

Every large system also faces the same operational question; how to scale while controlling cost. In other industries, that has led to outsourcing, standardization, and the pursuit of efficiencies in materials and processes. Sometimes that works but sometimes it introduces new risks because there is always tension between efficiency and quality.

We have seen this in other industries. From Standard Oil to AT&T to modern tech giants, consolidation often starts with efficiency and ends with control over access, pricing, and participation.

That broader pattern is crucial because dentistry is not immune to it. Now, bring that lens back to licensure.

A look at licensure

Recently, the American Dental Association (ADA) and the American Board of Dental Examiners (ADEX) announced a formal agreement to integrate the DLOSCE into the ADEX examination pathway. On the surface, it seems to check all the right boxes. Simplified licensure. Increased portability. Fewer redundant steps for candidates trying to enter the profession. All of that may be real and have value. But this isn’t just a standalone announcement. It’s part of a much longer story, one that’s been unfolding quietly over time.

To understand where we are today, you have to go back to the North East Regional Board of Dental Examiners (NERB). At the time, dentistry operated with multiple regional testing agencies. The structure reflected geography and the exams catered to local dental boards. Different regions, different exams, different pathways. Then came the shift, which didn’t happen overnight. NERB changed its name to CDCA in 2015 as it began to move beyond its regional roots. What followed was a continued consolidation of testing agencies, with CDCA merging with WREB in 2021 and with CITA in 2022 to form a conglomerate, and finally in August 2025 a move to merge with ADEX, the test development company developed by the various regional and state dental boards. Step by step, what had once been a system of multiple independent pathways began to narrow into fewer options, and that evolution was more than a name change. It represented a move from having many choices, to sometimes a consolidated and singular option.

But outcomes matter just as much as intent.

In licensure, the dynamic is different, but the principle is the same. As pathways consolidate, the organizations shaping those pathways gain increasing influence over cost, structure, and standards. That doesn’t mean those standards are lowered. But it does mean fewer voices are involved in defining them. And when alternatives become limited, pricing and quality pressure decreases and flexibility narrows.

What happens if those same pressures ever touch clinical examinations for dentistry?

No one is suggesting exams are being watered down. But the concept itself is easy to understand. If materials change, if processes are standardized to meet scale, or if evaluation models shift to accommodate volume, even small changes over time can alter outcomes. And when it comes to licensure, those outcomes don’t just affect candidates; they affect patients. At its very core, licensure exists for one reason: public protection as mandated by state dental boards.

State boards are not tasked with maximizing efficiency. They are tasked with ensuring that every licensed provider meets a consistent, defensible standard of care. Which means any system, no matter how aligned or streamlined, has to answer a simple question. Does scale strengthen that standard, or does it introduce pressure on it?

A question of stewardship

At some point this stops being an abstract conversation about alignment or consolidation and becomes a question of stewardship. Because when systems begin to concentrate, the outcome is no longer shaped solely by the organizations involved; it’s shaped by the people who decide whether that concentration continues unchecked or is balanced with intention. That responsibility sits with clinicians, educators, state board members, and legislators, anyone who has a role in how dentistry is regulated and how the next generation enters the profession.

If we believe that dentistry benefits from choice, from multiple perspectives, and from a system that reflects a true free market, then those principles have to be protected in practice, not just in theory. They require decisions that keep pathways open and prevent any single framework from becoming the only way forward.

In the case of licensure, the path is not complicated. When there are multiple examining bodies capable of delivering valid, defensible examinations that protect the public, those pathways should remain available in all states and to all licensure candidates. At a time when the number of testing agencies has effectively narrowed to two, it becomes even more important that states ensure both are recognized. That is what preserves candidate choice. That is what maintains balance. And that is what keeps the system from tipping too far in one direction.

Once control over entry into the profession becomes too concentrated, it is incredibly difficult to reverse. The decisions being made today that are quiet, strategic, and maybe even with good intent will shape what options exist years from now in assessing competency in dentistry for the safety of the public. By then, the conversation may no longer be about improving access or maintaining standards. It may simply be about working within a system where those choices have already been made.