The ‘Great 8’ by Dr. Christos Papadopoulos

The ‘Great 8’ 

What orthodontists need to consider before deciding to join a DSO, from a doctor who worked at one before opening his own practice

by Dr. Christos Papadopoulos

I vividly remember when my interest in orthodontics began. I was 14 and in orthodontic treatment when I asked my orthodontist, “So how do I become an orthodontist?” He smiled and said, “Well, it’s a long journey, but it’s a worthy one.”

Growing up in a town of less than 14,000 people in New Brunswick, Canada, I wasn’t sure what this “long journey” could entail, but I was fascinated with orthodontics. Watching my orthodontist not only create beautiful smiles but also improve patients’ lives by increasing their self-confidence was fun to watch. It was also a very positive environment; I could see that both the staff and patients truly enjoyed being there.

My orthodontist was happy to share his advice and invited me to shadow at his practice anytime. I realized how fortunate I was, so I visited the clinic after school and would shadow for the last hour of the day. It was a small, clean and professional practice that had a similar feeling to any type of doctor’s office I had ever been in. “Someday, you’ll be sitting in my chair,” he once said after he realized how motivated I was to become an orthodontist. It was there that my interest in orthodontics grew, and although I had always kept an open mind to other careers, being an orthodontist was at the top of my list.

The practice field pivots and shifts

After earning my undergraduate degree at the University of New Brunswick, I completed dental school at Dalhousie University in Halifax, Nova Scotia, and then did a one-year pediatric residency at British Columbia Children’s Hospital in Vancouver. I completed my orthodontic residency at Western University in London, Ontario, and I found myself trying to determine what path I would take next.

As I progressed through my final year of residency, I realized how different the orthodontic field was becoming. I was learning about direct-to-consumer treatments, clear aligner therapy, dental service organizations (DSOs) and the substantial increase in marketing thanks to the internet and social media—none of which I was exposed to when I was in braces 15 years prior. My, how the orthodontic landscape was changing!

During residency, I received a call from an orthodontic practice in New Brunswick about 80 miles from my hometown, asking me if I would be interested in returning. At the time I had been looking at a variety of available positions, but this was the only one close to home. I had been away from New Brunswick for approximately eight years, and after speaking with the owner of the practice, I was offered a full-time position as an orthodontic associate in his largest practice of five at the time. (His “DSO” phase was in its infancy.)

The prospect of working closer to home, being able to focus on my clinical skills, not having to deal with the “business” of orthodontics and being able to aggressively pay down student loans was a great scenario for me. I had experienced how long the journey was to become an orthodontist, but I was also aware of the journey ahead to pay down the skyrocketing tuition costs that orthodontic residents like me were experiencing.

As a diligent planner, I did my best to ask the right questions when speaking with the practice owner to ensure that I knew exactly what I was getting into. However, as much as we all try to do this, we just won’t really know some things until we enter the practice.

Learning what works—and asking questions

After working with the doctor for about two weeks, I began working alone and sharpening my skills, and for the next six months I grew more assimilated into the practice flow. It was around this time that the DSO began expanding as more practices were being purchased and brought under its umbrella.

As the DSO got larger, I began to understand the emphasis on utilizing practice metrics, office systems, doctor time for scheduling, defining staff roles, the increased demand for administrative support, branding and technological changes such as integrating better patient communication services. As a new associate, I had the unique perspective of being part of a fast-paced, ever-expanding DSO while working as the principal doctor in its largest practice as it grew from five practices to more than 50.

As the daily flow of the practice became routine, I began to ask myself questions regarding the growth of the practice and the overall DSO structure, and my entrepreneurial wheels began turning. Although there is no “perfect practice” anywhere, the practice I worked at did many things well with a staff that always took care of its patients. However, anytime a structural change took place, I was keen to ask questions like, “If this was my practice, would I do it that way?” As an associate, I understood that I was not a decision-maker, so I did my best to work within the systems, with the team, and make selective suggestions when I felt it was important. There are both pros and cons to not being a practice owner.

Answering the siren call of a solo practice

Fast-forward three years, and I realized that I couldn’t shake my entrepreneurial spirit and desire to have my own practice. I wanted to be hands-on with everyday decisions (both big and small) for the practice, its employees and its patients. As kindly as my colleagues and the DSO treated me, I simply felt there was something missing for me.

Each and every one of us is different and we all have our own ideal situations as practicing orthodontists. Some may feel that practicing orthodontics is fulfilling enough, but I desired to affect change in every aspect of the practice and be ingrained in the very fabric of its culture. Thus, after considerable thought, I made the decision to leave a great team and a comfortable salary while making no business/practice decisions, and start my own practice from scratch—with no team, no salary and now having to make every decision! Although it seemed like I had placed a huge weight on my shoulders, I felt energized for the climb ahead and was excited to build a practice from the ground up back in my hometown.

I learned many things from my experience working at the DSO, and if I can help at least one orthodontic resident or young orthodontist reading this, then this article has served its purpose. Here are my “Great Eight” pieces of advice for those considering joining a DSO as an orthodontic associate.

1. Ask yourself, “Where do I see myself in 10 years?” and work backward.

Graduating from orthodontic residency is a significant accomplishment and should justly be celebrated with those who helped you along the way. However, shortly after the celebration, the real work will begin. Before simply jumping on any opportunity, do some introspection and ask yourself what the desired purpose of your career is and what purpose you want it to serve for you. Will your career only be a way to make a living, or did you become an orthodontist for other reasons, such as being a practice owner or affecting change at a greater scale? Would you be happy as an associate in the long term? How often do you want to work and how large of a practice do you desire? Where do you want to live, ideally?

Maybe you are unsure of the answers to these questions, and that’s OK! But it’s important to take your time, think quietly and try your best to envision your career and life 10 years from now. As you navigate your short-term goals, keep that long-term vision in your rear-view mirror at all times so you can glance up and not lose sight of it.

2. Identify your immediate priorities.

When I graduated from orthodontic residency, my priority was simple—associate at a practice I felt comfortable in, do good clinical work and aggressively pay down my student loans while learning the business of orthodontics. I did not want to deal with practice ownership at that time, no matter how enticing that may have been. What do you want for your career and life right now?

3. Take time for introspection: What kind of orthodontist do you want to be?

No orthodontic practice will be able to offer you the exact working parameters you desire. However, you can control the way you will practice by placing yourself into a practice that aligns with your ideals and goals as a clinician. Do you want to be in a practice that is high-volume and sees 100-plus patients per day? Do you want to be part of a large team with fast-paced days? Do you want to work independently, or with other orthodontists? What kind of orthodontist do you want to be? Ask yourself if you are a good fit for the practice, but also determine if the practice is a good fit for you. Determine that first, and it will make your decision-making process that much easier when comparing options.

4. Find out whether there are restricted covenants

This is an important issue you need to consider regardless of whether you plan on associating with a DSO or an independently owned practice. Is there a restricted covenant in place that will not allow you to live and work in the place you desire if the position doesn’t work out? A colleague of mine signed on with a practice in a town they wanted to live in, and within 10 months it unfortunately didn’t work out. Because of the restricted covenant, they cannot practice there for an extended period of time, which forced them to leave town.

5. Establish how you will be compensated—now and in the future.

Simply looking at a “daily rate” that is offered to you and taking it for face value is a big mistake; you need to determine how hard you will be working for that rate. Find out the average number of cases this practice has started in the past two to three years, how many patients per day the practice sees, and if you will be working alone or with other orthodontists in the practice. Additionally, determine how many days per year you will work, and if there is any other additional compensation mechanism for practice growth. A daily rate can be excellent or poor, depending on the situation you find yourself in.

6.Speak with colleagues you trust and seek their opinion (both within and outside of the practice or DSO).

When you were in orthodontic residency and had trouble treatment-planning a case, what did you do? You consulted your co-residents, your instructors and maybe even other orthodontic colleagues. The same collaboration applies with your decision on choosing where to practice.

In residency, it can be overwhelming with everything on your plate at once: patient cases, board exams, research and finding the right practice for work. However, you need to do your due diligence and ensure you get the opinions of colleagues who work(ed) at the practice, have worked for the DSO or know about the practice/DSO culture from other orthodontists. Speak with trusted colleagues, ask for their advice and don’t be afraid to seek further clarification from the practice owner when in doubt.

7. Determine if the DSO’s philosophy aligns with yours

This can be difficult to establish, but do your due diligence and determine if this practice is a match for you. Sometimes even within a DSO, some practices under the same umbrella operate very differently, so do your best to ensure that the individual practice is the right practice for you, regardless of your overall impression of the DSO.

8. Identify if there are growth opportunities for you within the DSO.

This could be an irrelevant question for those who do not wish to stay with a DSO long term, but for those who want to associate and have no desire to own their own practice, ask yourself if you want to be involved with the DSO in a larger capacity than just as a clinician. Some DSOs will offer opportunities for you to take on a leadership role; find out more about this and if this is something that you would be interested in.


Working with a DSO has been an overall positive experience for me. I am grateful for many things I would not have experienced or learned otherwise in such a short time. I worked with a great clinical team, advanced my clinical skills faster than if I had done a startup after residency, built lasting friendships and got to witness first-hand the growth of a DSO from five to more than 50 practices.

However, words cannot describe the excitement I’ve had in fulfilling my dream of returning to my hometown, betting on myself and growing PapadopSmiles Orthodontics from scratch. I am prepared for the ups and downs, and I look forward to sharing my start-up experience with readers in the near future.

Author Bio
Christos_Papadopoulos Dr. Christos Papadopoulos was born in Saint John, New Brunswick, Canada, and earned a bachelor’s degree with honors at the University of New Brunswick, a DDS at Dalhousie University and a master’s in clinical dentistry/orthodontics at Western University. He accepted and attended a pediatric residency at British Columbia Children’s Hospital in Vancouver before beginning an orthodontic residency. He will open his own practice, PapadopSmiles Orthodontics, this fall in his hometown. Online: Instagram: @papadopsmiles.

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