There’s often conversation about what’s best for dentistry.

The traditional private practice model. The local dentist serving their community. Seeing generations of families. Preventative care. Drilling and filling. Relationship driven.

And then there’s the DSO model. Consolidation at scale. Access to capital. The ability to invest in technology that a single practice simply can’t. Despite the narrative that consolidation has slowed, deal flow is still happening. I know a few significant deals that are very much in motion right now.

Both models have strengths and both have trade-offs. Most people on either side of the aisle would probably agree on that.

This article isn’t another private practice versus DSO debate.

What I want to talk about instead is how organizational structure shapes technology decisions and how those decisions show themselves once groups start operating at scale.

Once groups move beyond just a handful of locations, technology decisions start to get more difficult.

At a certain scale, call it 40, 50, 60 plus practices, technology is no longer just about tools. It becomes about control, consistency, security, and how much autonomy exists at the practice level versus support at the organization level.

There are a lot of structural variations inside DSOs alone. TopCo only models. TopCo and OpCo structures. Joint ventures. Equity here. No equity there.

But the more I go down this structure path the faster this turns into a newsletter you skim before moving on to something else in your inbox.

So instead of debating structures in theory, I want to focus on two broad operating realities that exist.

The traditional DSO model, where technology decisions are largely centralized and standardized.

The partner-led or DPO-style model, where doctors retain ownership and influence at the practice level.

Both approaches work while both can also break down.

And the differences show up very clearly once tech stacks grow.

In a traditional DSO structure, technology decisions tend to be centralized. Not always but usually.

There’s a core tech stack. Approved vendors. A strong attempt at standardized systems. Networks, security, email, telecom, backup, compliance. A lot of this is dictated top down, and for good reason.

When you’re operating at scale, consistency and security matter. Vendor sprawl gets expensive. Forgotten contracts, overlapping tools, and fragmented data, all of this quietly eat away at EBITDA.

Standardization in this model is not just a governance exercise. It’s a clean and fastest way to create financial leverage in a growing group.

From an IT and operations standpoint, this structure can work really well.
Fewer surprises. Clear ownership. Easier support. Cleaner reporting.

Where it can get tricky is at the practice level.

If technology decisions feel imposed without enough context or flexibility, adoption slows and culture takes a beating. Doctors feel removed from decisions that impact their daily workflow. Teams comply, but they don’t always buy in.

The tension lives in how much control sits centrally versus how much autonomy remains local.

That balance becomes harder to maintain as the tech stack grows.

In a partner-led or DPO-style structure, technology decisions tend to live closer to the practice. Or in some cases committees are formed to support decision making. I have thoughts on those committees, but not for today.

Typically doctors retain ownership at the practice level, and with that comes real influence over day-to-day decisions. In theory, that autonomy is a good thing. When doctors are owners, the choices they make around workflows, staffing, and technology directly impact their own equity and outcomes.

That alignment can support better patient care and stronger financial performance when it’s working well.

But this model comes with its own challenges.

When every partner has full discretion over technology, stacks can drift quickly. One office chooses a premium platform because they love it. Another keeps an outdated system because switching feels painful. Telecom contracts pile up. Subscriptions don’t get cancelled. Redundancy creeps in.

Most of the time this isn’t malicious or careless. It’s just the reality of running a busy practice while also trying to be an operator, owner, and clinician.

I’ve yet to meet a doctor who hasn’t forgotten about a subscription at some point. I certainly have, even at my level.

At scale, these individual decisions pile up. What feels small at one location compounds across dozens. EBITDA takes a hit. IT teams struggle to support fragmented systems. Visibility disappears.

The upside of the partner-led model is autonomy which matters to doctors.
The risk is losing discipline where standardization actually protects the business.

That’s why the strongest versions of this model don’t leave everything open ended. They curate the infrastructure layer while preserving flexibility at the practice level.

When that balance is right, partner-led structures can be profitable and scale without losing control.

Once groups grow past a certain size technology decisions become extremely difficult.

At scale, technology choices shape behavior. They influence how teams work, how quickly issues get resolved, and how much trust exists between leadership and the practice level.

In centralized models, too much control without enough context can slow adoption and create resistance. The systems may be sound, but the people using them feel disconnected from the why.

In partner-led models, the risk swings the other way. Too much freedom without guardrails leads to extreme fragmentation and emotional decisions. Good intentions turn into complexity. Costs creep. Visibility fades. IT support becomes harder than it needs to be.

Neither of these problems shows up right away. They surface gradually as locations are added, vendors stack up, and decisions made in isolation begin to interact with one another.

This can cause technology conversations to get tense.

IT teams are trying to protect security, data, and cost structure. Doctors are trying to protect autonomy and workflows that make sense for their teams and patients. Leadership is trying to balance growth with discipline.

What works at ten practices rarely holds at fifty.
What feels flexible at one location can become fragile across dozens.

Scale doesn’t break technology on its own. It exposes where alignment exists and where it doesn’t.

What tends to work best sits in the middle of both structures.

Strong organizations don’t treat technology as either fully centralized or fully open-ended. They’re intentional about where standardization matters and where flexibility actually creates value.

Infrastructure layers tend to benefit from consistency. Security, networks, email, backups, telecom, data access, and core systems are hard to manage when everyone does their own thing. That’s where guardrails protect the business, reduce risk, and keep costs from quietly compounding.

At the same time, clinical workflows, patient experience tools, and certain marketing or growth initiatives often benefit from local input. Doctors and teams closest to the work usually know what helps or hurts their day. That autonomy matters.

The mix works when:

• Core systems are curated and supported centrally
• Practice-level teams have a voice in tools that affect their daily lives and workflows
• Technology decisions come with context, not just mandates
• Flexibility exists inside a framework

When teams understand why something is standardized and where they still have room to influence decisions, adoption improves. Trust builds. The stack feels supportive instead of restrictive where the overlords control everything.

The goal isn’t perfect alignment. It’s more of a functional, secure alignment.

Enough structure to scale responsibly and enough flexibility to keep teams impactful and engaged.

This balance is what keeps technology from becoming the problem.

A recent visit to MB2 is what really crystallized this for me.

Spending time with their team reinforced how difficult it is to balance scale, autonomy, and discipline at the same time and how strategic you have to be to get it right. They operate with the benefits of a large group while preserving a partner-led mindset that keeps decisions grounded at the practice level.

Technology there isn’t treated as a control mechanism. The focus is on staying ahead of where technology is going without losing sight of how those decisions actually land with doctors and teams.

Conversations with Thomas, Rick, Juan, and others made it clear how much thought goes into that balance, shared infrastructure, flexibility, and constant dialogue between IT, ops, and leadership.

Similar thinking exists between Kyle Surratt at The Jetty Group and Chad Johnston at Sunset Technologies who joined me on the visit. Both spend time inside all types of DSO environments helping groups understand where standardization and security protects the business and where autonomy should remain intact.

Those conversations were a big part of what sparked this article.

They’re a reminder that structure alone doesn’t determine outcomes. How leaders operate inside that structure is what ultimately shapes whether technology becomes a solution or friction.

This isn’t about declaring a winner between DSO or DPO.

It’s about recognizing that structure shapes how tech stacks are set up and that set up impacts the business both from a workflow perspective and EBITDA impact.

Centralization without context creates resistance and autonomy without guardrails creates chaos.

The groups that navigate this well are intentional about both. They curate the infrastructure layer. They protect security and cost discipline. And they preserve autonomy where matters to doctors and teams

As organizations grow, the technology conversation has to evolve with them. What worked early rarely holds forever. The willingness to revisit assumptions, adjust guardrails, and stay aligned across IT, ops, and clinical leadership is what keeps the stack from becoming the problem.

That’s the difference between technology that scales to provide value and technology that scales ineffectively and costs the business money.

Have thoughts on this? Please book some time with me here.

In this Off Script episode, we talk about why tech pilots and rollouts in DSOs so often miss the mark. We dig into what actually makes pilots work (and fail), why field time matters, and how operators should think about consolidation vs point solutions without losing sight of the core value they originally bought.

Some other key topics discussed:

➡️ Why most DSO tech pilots struggle: lack of clear value definition, weak internal champions, and misaligned expectations between vendor and operator
➡️ Why leadership needs to spend time in the field to understand real operational constraints inside practices
➡️ Consolidation vs point solutions: innovation is good, but vendors and DSOs can’t lose sight of whether the original core product is still delivering measurable impact

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Inner Circle - San Antonio

CareStack Inner Circle had a very open, conversational vibe. It wasn’t overly scripted, which made the discussions around technology adoption feel grounded.

Partners exhibiting had solid traction, with a lot of genuine curiosity from operators looking to better understand where technology is actually heading in dental. The combination of CareStack, Overjet, and OS Dental makes a lot of sense. PMS end-to-end, imaging, and data/analytics working together instead of in silos.

Abhi, CEO at Carestack framed change in an interesting way, noting that change equals pain and that the opposite of uncertainty isn’t certainty, it’s courage. That landed well given where the industry is right now.

Emily Ryba, CEO at OS emphasized true collaboration with both clinicians and DSOs, which reinforces why the partnership feels aligned rather than forced.

The bigger takeaway for me was that point solutions are still important, but there is momentum in how they come together to form platforms. That shift feels like a meaningful next chapter for dental tech.

Dykema DSO Leadership - Dallas

This was the third iteration of Brian’s Dykema DSO Leadership event, and each one seems to level up. It’s an event I personally won’t miss. The collaboration among executives provides a real market signal and gives a clear view into current market conditions, emerging trends, headwinds, and tailwinds shaping DSOs right now.

One theme that stood out most was this: as we move into 2026, scale alone is no longer the differentiator. The strongest organizations are re-anchoring around discipline, selective M&A, operational consistency, and thoughtful use of technology to drive same-store growth and margin stability. Technology is no longer a nice-to-have or a back-office decision. It’s a strategic requirement.

One trend I’m watching closely is private equity becoming more involved in technology decision-making than in years past. My sense is that the most profitable, well-run DSOs feel less pressure here. But groups with thinner margins or less clarity are seeing more influence, particularly around AI adoption and technology spend.

The CEO panel pictured above discussed a unifying takeaway that long-term success depends less on chasing high multiples and more on people, operational discipline, transparent value to patients, and evolving care models, including medical–dental integration, to meet patients where they are.

If you want more insight on this event, feel free to shoot me a message or book some time with me, happy to compare notes.

Also, Brian and I are launching a podcast soon, so stay tuned.

“We’ve Done Pilots Before” Is the Wrong Confidence — In this edition I discuss how dental technology pilots don’t look like they used to. The tools, workflows, and expectations have changed, and old playbooks don’t always apply.

What I keep seeing is pilots rarely fail because the technology doesn’t work. They fail because the conditions around the technology weren’t set up correctly. Clarity, ownership, alignment, and realistic expectations on both the DSO and vendor side.

Truly appreciate you being here and making it to the end. Have ideas, questions, or tech you want me to explore? Just reply to this or book some time with me to discuss.

- Matt