Verena McClain went to her trusted family dentist in Germany one last time before starting graduate studies at Purdue University. So she expected a routine checkup six months later when she went to Dental Care of Indiana in Lafayette.
Instead, dentist Daniel Krueger told her she needed to replace a crown she had just gotten. Eventually, the treatment plan added up to $5,900 for four new crowns. With insurance, her out-of-pocket share would come to $3,300.
Puzzled, McClain decided finally to ask another dentist, who had a very different take: no cavities at all. No need for any crowns. McClain was so surprised she asked the dentist if she would check the X-rays again.
“She looked at them again more closely and said, ‘No, there’s nothing wrong with your teeth,’” McClain said.
“It’s one thing if you go to your car mechanic and they recommend something that you don’t really need,” McClain said. “But losing your perfectly healthy teeth, that’s a part of your body that they’re violating. How dare you try to do you that to me?”
What McClain didn’t know then: Dental Care of Indiana was part of North American Dental Group, which follows a new trend of dental offices bought by private-equity investors and turned into revenue-generating machines.
The chain started in Ohio and soon became among the fastest-expanding. It now has more than 200 offices in 13 states east of the Rockies, including 10 in Indiana, handling 1 million patient visits a year. Late last year it was bought by a Swiss firm that also owns hundreds of dental offices in Europe.
While any dentist might be tempted to find ways to increase profit, private-equity firms often saddle their companies with heavy debt at junk-bond-caliber interest rates. That may leave patients vulnerable, critics warn.
North American Dental Group has become a lightning rod for complaints in recent years, especially from former dentists and employees who say revenue pressures went far beyond what is typical in the industry.
USA TODAY and the investigative unit at Newsy, owned by The E. W. Scripps Company, spent more than a year examining the dental chain. Reporters interviewed dozens of its former dentists, employees and patients and reviewed thousands of pages of documents from courts, dental boards, patient records, social media reviews and other sources.
The investigation found that the intense pressure on North American Dental’s offices to meet daily revenue targets led to allegations of overtreatment. Patients complained they were diagnosed with a mouthful of cavities only to later discover nothing was wrong with their teeth. Employees said they felt uncomfortable with what they witnessed.
“I have watched them drilling perfectly healthy teeth multiple times a day every day,” dental assistant Ashley Hughes said in an interview. She worked for two years at a North American Dental office in Austintown, Ohio, not far from where Gregory was treated.
The financial squeeze was part of a daily companywide ritual known as the “morning huddle.” Staff said they met before the doors opened to discuss how to fill gaps between that day’s targets and scheduled treatments.
North American Dental pits office against office and dentist against dentist by sending out monthly tables ranking dentists and hygienists by who’s making the most money per appointment. Offices failing to hit their goals are colored in red — and told to step it up.
“Congrats to teams Alpine, Deerfoot and Life Smiles for starting the month out on a high note, exceeding their budget,” one regional manager wrote in an email in July to 11 Indiana offices. “Everyone else has a deficit to overcome.”
USA TODAY and Newsy interviewed 20 patients who sought second opinions after being told at a North American Dental office that they needed extensive dental work. In each case they said the second dentist prescribed little to no dental work.
A dentist at Refresh Dental in Kent, Ohio, told first-grade teacher Jennica Watson that she had seven cavities. Watson says she brushes twice a day and has checkups every six months. She went to another dentist, who said she had no cavities at all.
Twenty-seven-year-old Alex Miller, who installs countertops, switched to a new dentist at Corner Dental in Maumee, Ohio, who told him he had nine cavities. Suspicious, Miller went back to his family dentist, who told him he had none.
Nicky Demecs went to Corner Dental in Oregon, Ohio, and was told she had five cavities on one side of her mouth and three on the other. She had half the work done, then decided to get a second opinion: no cavities.
Patients had no way of knowing their dental office was managed by a company beholden to Wall Street investors or that their dentists and hygienists were expected to meet revenue goals. As North American Dental snapped up offices, it often retained their original names.
Private dental chains receive virtually no oversight. These companies don’t have to file financial statements with the Securities and Exchange Commission. And state dental boards tend to regulate only dentists, not the companies. Even then, USA TODAY/Newsy found dental boards rarely act on complaints.
The Ohio state board did review a case involving Johannah Lancaster, who took her 3-year-old son Gregory to Dental Express in the city of Niles for his first checkup, expecting a routine cleaning.
Michael Griesmer said the preschooler needed root canals — seven of them. Stunned, Lancaster asked why he had not even taken X-rays. Griesmer told her they weren’t necessary.
“I figured he is a professional, so I trusted him,” she recalls. “If I knew then what I know now, I would have never gone through with any of it.”
Two weeks later, in May 2013, the dentist put Gregory under and drilled his teeth. The Medicaid bill came to $1,273 – compared to the $61 that Medicaid would have paid for a checkup and cleaning.
In this case, the Ohio state board suspended Griesmer’s license more than a year later, board records show, only after Griesmer continued to treat other children without providing X-rays or adequate records to the board while under its supervision.
Gregory continued to have problems after the root canals, according to his mother and records from a malpractice lawsuit. While he was recovering from general anesthesia, one of his seven crowns fell off. Lancaster said she told the assistant, who came back with a message from Griesmer: He had used off-the-shelf crowns that “were the smallest ones made and they were still too big for Gregory and that it’s fine.”
But it wasn’t fine. More crowns came off over time, and eventually Gregory’s right cheek swelled so much it looked as if it might pop. Lancaster rushed him to an emergency room, where the pus was drained.
Later, a dental clinic pulled four of the teeth Griesmer had treated.
Gregory faced more surgeries to fix the damage, according to the family’s malpractice lawsuit. Those medical bills came to $23,000.
“The 3-year-old boy was subjected to massive overtreatment,” said Nicholas Dello Russo, a dentist and instructor at Harvard University’s dental school who reviewed Gregory’s records. “This is child abuse.”
Last week, Griesmer told USA TODAY he figured out Gregory needed root canals — called pulpotomies when done on baby teeth — “just by sight.” He said he never took X-rays on 3-year-olds because they won’t sit still for them.
Griesmer acknowledged the company pushed dentists to make money but said that never influenced his treatment choices.
“In hindsight I would have taken some of those teeth out,” he said. “I wish I had it to do all over again.”
In March 2015, the dental board suspended Griesmer’s license for a year. The lawsuit was settled out of court for $20,000. Griesmer retired from dentistry and left North American Dental.
North American Dental would not comment on Gregory’s case, or that of any other patients named in this story.
Generally, the company denies allegations of overtreatment and says its mission is “to deliver best-in-class patient care” and give its dentists complete autonomy in making diagnoses.
An affiliated company owned by its dentists reviews dental work for any quality issues, the company said.
These so-called dental service organizations were virtually nonexistent 20 years ago, but investment firm William Blair & Company estimated in 2017 that dental chains made up 16% of the market.
Another kind of debt is helping fuel the growth of private-equity-owned dental offices: student debt.
Young dentists saddled with school debt can’t afford to buy practices from retiring dentists. That creates a buyer’s market for private-equity investors.
Some of the issues North American Dental faces are common among companies weighed down by debt from leveraged buyouts, said Eileen Appelbaum, an expert on private equity and an economist at the Center for Economic Policy Research.
“The big private equity firms have gotten very active in the medical field, which is a little bit concerning,” she said. “We’re not really sure that Wall Street is the best place to make medical decisions for us.”
Like many other dental chains, North American Dental Group teamed up with private-equity investors early on. Because these investors typically buy businesses by putting little money down and borrowing the rest, dental chains are forced to pay the debt.
Company data reviewed by USA TODAY/Newsy shows North American Dental’s debt nearly doubled in 2018 to $229 million and it lost $25 million in net income that year.
North American Dental, however, denies debt is a problem.
“We understand that it’s an easy — and perhaps attractive — hypothesis to imagine that dentists are motivated or pressured to drive up revenue to satisfy debt loads by talking patients into unnecessary care or cutting corners,” the company said in a statement. But the company is “set up, top to bottom, to prevent that from happening.”
The company also downplayed the role of revenue goals. In an interview, North American Dental’s co-founder and chief executive officer Ken Cooper described revenue targets as just “meeting the budget.”
North American Dental said ultimately, the responsibility for treatment rests with the dentist, not the company, and differences in dental opinions is common.
When asked if the company was concerned about Yelp and Google reviews in which patients complain about overtreatment, Cooper said, “You can go to any company in America and find a social media negative review, literally every company. Even Disney World.”
Drilling healthy teeth
Former employees of North American Dental contend pressure to overtreat stems directly from the company’s revenue goals. Ashley Hughes, the Ohio dental assistant, said she still cannot believe what she witnessed.
Shortly before 8 a.m. each day, staff would gather in the break room for a morning huddle at which the office manager laid out the revenue gap between the office’s target and scheduled treatments. They nearly always began the morning thousands of dollars short, Hughes recalled.
“Before we saw our first patient of the day, they would discuss money and figures and what we needed to do to get to where they wanted us,” she said.
Besides drilling healthy teeth, Hughes said, she saw dentists perform root canals on teeth that instead needed to be pulled.
According to insurer Delta Dental, pulling a tooth in Austintown costs up to $183, while a root canal can cost $1,142.
A deeply decayed tooth inevitably will need to be pulled later, exposing the patient to the possibility of serious infections, according to Dello Russo, the Boston dentist who reviewed case files for USA TODAY/Newsy. He characterized root canals on badly decayed teeth as a way to double-dip, allowing dentists to charge first for the root canal and later to pull the tooth.
Dental assistant Ricci Endsley worked alongside Hughes at Refresh Dental in Austintown. She said she routinely saw patients being diagnosed with problems they didn’t have or being billed for treatments they didn’t get.
She said one patient was charged for a tooth being surgically removed when the patient actually had had a simple extraction. One costs $305, the other $183. She saw root canals crowned with decay left inside, meaning the patient would be back later to have that same tooth pulled.
“There wasn’t one day that I worked there that I could say that that was a good day,” Endsley said. “Every day there was an issue with either something being billed that wasn’t done or it wasn’t billed properly or the standard of care was not there.”
At times, she said, she would peel her gloves off in the middle of a procedure and walk out.
Hughes and Endsley said they frequently took their complaints to the office manager, who would pass them to her regional director, but nothing ever happened.
“If I saw something or assistants questioned, ‘I don’t think this person needed a root canal, etc.,’ the only recourse I had was to take X-rays and send it up the chain,” said former office manager Dixie Weisgarber. “That would happen quite often.”
The assistants finally went to the Ohio dental board to report inadequate care, unhygienic practices and overbilling of patients. The board conducted a brief investigation but — according to board records — dismissed the complaint without taking any formal action.
Non-dentists making the decisions
While North American Dental says dentists are in total control of patient care, emails and interviews with former employees suggest a different reality.
The manager overseeing a cluster of offices in the region that includes Austintown emailed daily, Hughes said, going over patient records and billings and “wanting to know why we didn’t do certain procedures on patients.” That manager was not a dentist.
It didn’t just happen in Ohio. In an email to 11 Indiana dental offices in July, another regional manager, Sarah Watson, notes that only three were meeting their monthly revenue targets. Watson was a former regional manager for LensCrafters and Pier 1 imports, according to her LinkedIn profile.
Watson’s email, obtained by USA TODAY/Newsy, asks dentists not meeting their goals if they are following procedures to entice more patients to agree to fluoride treatments, bone grafts and oral cancer screenings. Dello Russo said those procedures tend not to be covered by insurance and can be used to drive up billings.
Watson also asks dentists whether they are getting patients to agree to treatments before telling them how much they will have to pay out of pocket.
Social media blows the whistle
As it grew, North American Dental bought high-revenue-generating dental offices, some of them already being criticized on social media for overtreating patients.
In 2015, the company bought 11 Indiana offices from dentist Daniel Krueger that had been targeted on social media. Among the critics was a Purdue University graduate student, Nick LaBonte, who was told by Krueger that he had 16 cavities. When LaBonte sought a second opinion, another dentist said he had no cavities.
Echoing the company’s perspective about second opinions, Krueger told USA TODAY/Newsy different dentists can see things differently. Some offer a lot of options and some will leave decay in a patient’s mouth and wait to see if it gets worse.
Asked about another dentist telling McClain, the woman who sought treatment from Dental Care of Indiana in Lafayette, her teeth were healthy, he said he did not recall her situation.
“I don’t remember that exact particular situation, But I’m glad that she went and found some other dentist that she felt comfortable with,” he said. “But my recommendations — 100% — I stand by them. What I recommended for the patient, I would do it for my family member.”
And, Krueger said, the onus is on the patient to be a savvy consumer.