More Starts Won’t Save You by Mike Alan Gusching

The most expensive question in orthodontics is the one nobody asks

by Mike Alan Gusching

Years ago, I listened to a financial advisor whose clients were almost entirely dental specialists, the largest portion of them orthodontists.

He hadn’t planned it that way, but he knew their secrets: what orthodontists earned, what they were ashamed of, and what they were afraid of. He joked that “orthodontists tell their advisors things they don’t say to their significant others.” There was truth to that.

But what stayed with me was his timeline about age.

“Give me any age,” he said, “and I’ll tell you what orthodontists are dreaming of.”

Late 20s into the early 30s: Their thoughts revolve around getting away from a per diem and paying down a student loan balance of more than $500,000. They’re scrolling practice listings at midnight. At this stage, the orthodontist is trying to stop being an employee and aiming to become an owner. Happiness looks like starts of their own.

Mid-30s into the early 40s: The debt load changes. Student loans make way for practice loans. There’s staffing. There’s a husband or wife who wants the home kitchen remodeled. Oh, and there are children in the mix, plus a new car lease. Plenty lose control of their personal spending during this stretch. Pressure mounts. Happiness looks like more starts.

Then the advisor got to orthodontists in their mid-40s and 50s, and his tone changed: “Almost every orthodontist,” the advisor said, “hits a moment somewhere in this decade when the question stops being how many more starts do I need, and becomes something considerably harder to answer: What am I aiming for in the first place?”

I’d like you to ask that question now because I’ve found that many are losing the ability to answer it.

They can’t hear themselves over everyone else’s opinion. And the general opinion is to keep growing for growth’s sake.

More is better. More is what you’re supposed to want. More starts. More locations. More EBITDA. More organic revenue.

We’ve gotten to the point where the first question about a practice, before anything else, is how many starts they produce per year, as if that number were a complete report on a practice’s success.

And worse, that number keeps climbing. The “cottage-industry” practice benchmark of doing a couple hundred starts a year has given way to a new median that has crept steadily upward. And every year, the orthodontist who was perfectly fine last year wakes up feeling behind this year because of the latest benchmark report.

I’ve been inside thousands of practices. I’ve seen the schedules, the P&Ls, and the faces of the doctors who run them. Let me say this plainly: After a certain point, more starts won’t save you.

Here’s what else I’ve discovered: A $2 million practice and a $5 million practice can put the same money in the doctor’s pocket. Not always, but often enough that it’s worth pausing before you chase “more.”

Starts are what everyone boasts about. But what they don’t see is what those extra starts cost to produce: the debt service on the acquisition, the second and third locations that each need their own rent. The start number doesn’t include the associate whose comp comes off the top and also wants more in equity. And then there’s the expense nobody puts on a balance sheet: the orthodontist’s time.

Growth doesn’t automatically produce profit. It automatically produces complexity.

You know the podcast success archetype: An orthodontist takes over another practice, hires rock stars, builds to $10 million in a few years, and explains that anyone can do this. It makes for a great episode. What it doesn’t mention is how rare that outcome actually is. We don’t hear about the doctor who ran that same play, took on the same debt, worked the same 80-hour weeks, and ended up years later with the same take-home pay.

So what was that all for?

This is an industry with profit margins most businesses would die for. There is plenty of cushion in a well-run orthodontic practice to build an excellent life. You do not need to be the biggest practice. What you do need is to be clear about what you’re building and why.

I argue that you should question your practice mission before you set a start goal. Then ask yourself: Is your city or community asking you for more capacity, or are you responding to something else? Is this even still your goal?

The goal you’re chasing may have been set by a 20-year-old version of you who had a different life, a different outlook, and a different definition of success. A wise thing to know about yourself is that you won’t get it right; you’ll change in ways you can’t predict. So revisit these questions often.

Dr. Chris Bonebreak Jackson offered a definition of professional success that comes down to a single question we don’t ask often enough: “Are you happy?” If you are, you’ve succeeded. That means more than starts, more than revenue, more than a location count. It means you’ve built a life that supports you, your family, your team, and your community.

Chris Bentson, another person I hold in high esteem, has spent a career examining the reality behind practices that look impressive from the outside. When I interviewed him, he gave me one of the most useful pieces of advice for any provider: “Spend half a day by yourself and think about nothing else but what you want your business to look like in the next year. I don’t think we get alone and do this exercise enough. Sit by yourself and write this out; go back and then express it to your team. Best advice I can give.”

Let’s change the timeline. I’d love for the financial advisor I met to say this moving forward: “Give me any age ... and I’ll tell you that most orthodontists are thinking of their practice’s mission first, not their starts.”

The orthodontist who finally asks these questions doesn’t need to wait until their 60s. It’s the same question now as it will be then, and it’s a lot easier to answer today. 

Mike Alan Gusching is an orthodontic sales professional, speaker, and author of The Peak Orthodontic Practice: 20 Lessons and Interviews from Over 1,000 Practice Visits. As the son of an orthodontist, he brings a unique perspective to the industry. His latest book became a category No. 1 best-seller in early 2026.