Volume 1, Issue NO. 2
The Cascade Report
The average case acceptance rate in orthodontics right now is 68.3%, per the Planet DDS 2026 Outlook. It means nearly one in three patients who walk in for a consult don't start treatment. That's not a marketing problem. It's an execution problem.
ALGN - Align Technology
$179.40
▼ 6.2% YTD
Stock price YTD ▼6.2% | Q1 '26 revenue: $1.04B (+6.7% YoY) · 685.7K Invisalign shipments · $200M buyback announced May 1.
Market Pulse
Ortho Valuations Climb
The FOCUS Bankers 2026 report is out, and the numbers tell a clear story. Platform practices (5+ locations) are now trading at 9–11x EBITDA, while solo practices hold at 4–6x. Ortho deal activity is up 9% year-to-date, and orthodontic platforms now represent roughly one-third of all dental M&A. The premium drivers haven't changed: digital workflows, private-pay mix above 75%, and retained clinical leadership. But one new factor is emerging, team infrastructure. Buyers are increasingly discounting practices where everything runs through the doctor. According to Sofer Advisors' 2026 valuation guide, practices where the owner performs 90%+ of production see a 10–20% reduction in valuation, doctor-dependency is no longer just an operational risk, it's a measurable discount.
PE Confidence Holds
Despite macro uncertainty, PE money continues flowing into orthodontics. PE affiliation among dentists has nearly doubled in six years. Nine of the ten most active acquirers last year were PE- backed DSOs. The shift this quarter: DSOs are prioritizing regional density over national expansion. 69% plan more acquisitions, but they're getting pickier, clustering locations, requiring longer post-close employment terms, and investing in operational infrastructure before adding doors. Several states are now introducing legislation to limit corporate dental ownership. Per Becker's Dental Review, Kentucky, Illinois, California, and Pennsylvania have all introduced or advanced bills targeting PE ownership structures and non-
dentist management of clinical decisions, a regulatory dimension worth watching closely.
Orthodontics ≈ One-Third of All Dental M&A
Ortho remains a top PE target due to favorable margin profiles and cross-referral synergies. 78% of DSOs now expect recapitalization within 12–36 months. The practices that will command top-tier multiples are the ones investing in team and systems now, not just clinical volume.
Industry Moves
People, Platforms & Partnerships
Strategic SHift
Density Over Expansion
The DSO playbook is changing. After years of coastto-coast expansion, the smartest platforms are now clustering, adding locations within existing markets rather than planting flags in new ones. The logic: shared marketing spend, cross-referral networks, and unified operations teams. For independent practices, this has implications. If a PE-backed group is filling in your market, competitive pressure is going to intensify at the local level. The upside? Practices with strong brands, loyal teams, and operational discipline are exactly what these groups want to acquire, and they're willing to pay premium multiples for them.
What Drives DSO Buyers Today
Cain Watters' latest analysis breaks down which dental specialties are seeing the most acquisition interest. Orthodontics remains at the top, but buyers are getting more sophisticated in their criteria. The new must-haves beyond revenue: digital integration maturity, team retention rates, and notably, the degree to which the practice can operate without the founder in the chair every day. Doctor-dependency is no longer just an operational risk. Per Sofer Advisors, it's a 10–20% valuation discount for practices where the owner performs 90%+ of production.
TECHNOLOGY
Align's 2026 Innovation Pipeline & AI Integration
Planet DDS' Dental Economist Show tackles how practices are actually using AI and cloud-based tools in their operations. The verdict: the winners aren't the practices buying the newest tools, they're the ones operationalizing the tools they already have. Jill Allen's piece in Orthotown reinforces this: optimizing scheduling and patient flow alone can reduce wait times by up to 40%. The tech exists. The bottleneck is implementation and team training. Meanwhile, Align Technology debuted three major innovations at AAO 2026 (May 1–3): the Invisalign Specifix Attachment System for precision bonding, Integrated Buttons that eliminate separate elastic attachment steps, and a new Palatal Expander extending clear aligner treatment to younger patients. The focus is an integrated digital ecosystem scanning, planning, and monitoring in one workflow. For practices still running fragmented systems, the gap is widening.
CONVERSATION TO WATCH
The Residency-to-Reality Gap
Two threads converging this month: Dr. David Sarver on Ortho Takes raising important questions about whether orthodontic residencies are adequately preparing graduates for practice reality, and the AAO's push on student loan debt reform. New orthodontists are entering a market that looks fundamentally different from what they trained for, higher competition more corporate presence and patients who shop before they start.
"The global orthodontics market is projected to reach $38.21 billion by 2030. The practices that invest in team infrastructure today will be the ones positioned to capture that growth."
— Grand View Research, 2026
Feature
The 68% Problem
Your Biggest Growth Lever Isn't More Marketing
CascadEffects practices see 75–90% case acceptance rates. The gap between average and great is worth $500K+ annually.
I was at a workshop last year with over 40 practice owners. Midway through, I asked the room a simple question: "How many of you are happy with your marketing?" Not a single hand went up. Then I asked: "How many of you know your case acceptance rate within 2 points?" Three hands. Out of forty.
That moment crystallized something I'd been seeing for years. Practices are pouring money into the top of the funnel, more leads, more SEO, more ad spend, while the real leak is sitting right in the middle of their own building.
The average orthodontic case acceptance rate in 2025 reached 68.3%, according to the Planet DDS 2026 Outlook analyzing 2,800+ practices. That's up from 64.4% the year before, progress, but it still means nearly one in three consults don't convert.
Let that sink in.
For a practice doing 30 consults a month, that's roughly 10 lost starts. At an average case fee of $6,000, that's $60,000 per month walking out the door. Not because the clinical outcome wasn't there. Not because the patient didn't want treatment. But because something in the experience, the intake, the call handling, the financial presentation, the follow-up, didn't land.
This isn't a clinical problem. It's a team execution problem.
Where Cases Are Actually Lost
Most practices assume case acceptance gaps live in the treatment coordinator room. But that's rarely the full picture.
By the time a patient sits down to discuss treatment, the trust decision is already mostly made. It was formed during the first phone call. During the wait in the lobby. During the handoff between the front desk and the clinical team.
We see this pattern in every practice we work with: case acceptance isn't a single-point failure. It's a system-wide one. And the fix isn't better closing techniques, it's better team alignment from first touch to contract.
That's the opportunity hiding in plain sight. Not more patients. More starts from the patients you already have.
What CascadEffects Does Differently
When we engage with a practice, case acceptance is one of the first things we audit, not just the number, but the full journey. We map every touchpoint from first inquiry to signed contract and identify exactly where patients are falling off.
Then we build the fix into the team, not around it. Role-specific training. Call scripts that are practiced, not just posted. Handoff protocols that create a seamless patient experience. Financial presentation frameworks that are comfortable for the TC and compelling for the patient.
And critically, we build the measurement system so the practice can track case acceptance weekly, by provider, by referral source, and by TC. Because what gets measured gets managed.
Mint Orthodontics is a perfect example. Within six months, they saw a 17% increase in production and 13% growth in new starts. Not from more marketing. From better execution on the patients already walking through the door.
For Vendors and Partners
If you're a rep, a vendor, or a technology partner reading this, here's why this matters for your business too.
The practices with strong case acceptance are the ones most likely to invest in your products, because they have the revenue to do it and the clarity to know what they need. They're also the ones most likely to implement well, see results, and become long-term customers.
Practices stuck at 60% case acceptance are stuck everywhere. They're tight on cash, resistant to change, and chronically reactive. They buy on impulse and churn on frustration.
The 80%+ practices? They buy with intention. They implement with discipline. And they grow with you.
The Bottom Line
The biggest growth lever in orthodontics right now isn't more marketing, better technology, or a bigger ad budget.
It's converting the patients you already have.
It's training the team to own every touchpoint. It's building systems that don't depend on the doctor being in every conversation. And it's measuring what matters, weekly, not quarterly.
The 68% problem is solvable. And the practices that solve it will be the ones that win in 2026 and beyond.
Casey Bull
FOUNDER & CONSULTANT, CASCADEFFECTS
Casey Bull is the founder of CascadEffects, a business transformation firm for orthodontic and dental practices. She holds an MBA from Pepperdine University and has spent over a decade in healthcare leadership roles including COO and Global Director positions. She is also the publisher of The Cascade Report.
Practice Observations
What We're Seeing
Staffing Pressure Is Reshaping Compensation
The 2025 Orthodontic Products/Levin Group Annual Practice Survey confirms what we're seeing on the ground: 74% of orthodontists report a shortage of staff available for hire, unchanged from last year, and 57% are actively trying to fill at least one open position right now. Staff compensation is up 6.3% year over year, and not a single practice reported lowering pay. The response? Practices are increasing base compensation (56%), adding technology for productivity (46%), and offering more bonuses (29%). As Levin Group put it: this is "a crisis that will last at least 10 years."
Production Growth Is Outpacing New Patient Growth
Here's an interesting signal from Cain Watters (Ep. 281): average ortho production has increased by over 8%, outpacing the rise in new patient flow. That means practices are getting more out of the patients they already see. Higher case acceptance, better case mix, and more comprehensive treatment plans. This validates the core thesis of this issue: the biggest opportunity isn't more patients. It's more from the patients you already have. The practices that understand this are quietly pulling ahead.
Casey's Take
Your Practice Doesn't Have a Marketing Problem
Most practices that feel stuck are spending more money on marketing when their real problem is conversion and follow-through at the team level.
You don't need more leads. You need a team that knows what to do with the ones you already have. - Casey Bull, CascadEffects
New patients are coming in. They're just not starting. And the assumption is always the same: we need more leads. We need better SEO. We need a bigger ad budget.
No. You need a front desk that knows how to convert a phone call. You need a TC who presents treatment as an investment, not an expense. You need a followup system that doesn't let a warm lead go cold because everyone was busy.
This is a team execution problem, and it's solvable. But it requires something most practice owners aren't comfortable with: letting the team own more of the process.
Here's what I'd recommend if you're reading this and its resonating:
Audit your last 30 consults. How many started? How many had a follow-up call? How many just…disappeared?
Mystery-shop your own practice. Call your front desk as a new patient. Time how long it takes to get a callback from a web form. Experience what your patients experience.
Set a 100% close rate expectation. For every consult the TC closes them on either of the following: SDS, Start Date in the future, and Follow-up call date/time
Our practices are currently seeing 75–90% conversion rates.
Here's how the rest of the industry stacks up.
Data Worth Knowing
685.7K
Record Invisalign clear aligner shipments in Q1 2026, up 6.7% year-over-year. Align reaffirmed full-year guidance of 3–4% revenue growth.
Planet DDS · analysis of 2,800+ practices
9–11x
EBITDA multiples for orthodontic platform practices (5+ locations). Solo practices trade at 4– 6x. The gap is widening, and team infrastructure is becoming a premium driver.
AAO Environmental & Technology Scan
68.3%
Average orthodontic case acceptance rate (2025). Up from 64.4% the prior year, but nearly 1 in 3 consults still don't convert. At $6K/case, a 30- consult practice loses ~$57K/month in unrealized starts.
Planet DDS · analysis of 2,800+ practices
78%
Of DSOs expect recapitalization within 12–36 months. Exits are accelerating, and operational readiness is the deciding factor in valuation premiums.
VMG Health / Group Dentistry Now
8%+
Average orthodontic production increase, outpacing the rise in new patient growth. Practices are getting more from existing patients through better case mix and acceptance.
Cain Watters · The Ortho Competitive Advantage · Ep. 281
74%
Of orthodontic practices report a staffing shortage. 52% are actively hiring right now, many just to maintain current operations, not to grow.
The 2025 Orthodontic Products/Levin Group Annual Practice Survey
Resource in Focus
FOCUS BANKERS · MONTHLY FEATURE
2026 Orthodontic Valuation Report
Market intelligence from the FOCUS Investment Banking team · focusbankers.com
9–11x
EBITDA multiples for orthodontic platform practices with 5+ locations. Premium drivers include digital workflow maturity, private-pay mix above 75%, and increasingly, retained leadership teams that can operate independently of the founding doctor.
4–6x
EBITDA multiples for solo orthodontic practices. The gap between solo and platform valuations continues to widen, creating a strong incentive for practices to invest in, operational infrastructure, not just revenue growth, before exploring a transaction.
~33%
Of all dental M&A activity is now orthodontic. Ortho platforms remain a top PE target due to favorable margin profiles, predictable revenue, and cross-referral synergies. Deal activity is up 9% year-to-date with no signs of slowing.
5 yrs
The new standard for post-close employment terms. DSOs are learning from early integration failures and now requiring longer commitments from founding doctors, a signal that operational transition planning has become central to deal structure.
What This Means for Your Practice
Whether you're planning an exit in 2 years or 20, the factors that drive premium valuations are the same factors that make a practice run well today: team depth, operational systems, financial clarity, and a brand that's bigger than one person. The best time to build those things isn't when you're ready to sell, it's right now. FOCUS Bankers releases updated valuation data quarterly. This is the kind of content that keeps you informed and a step ahead.
Read the full report
Events & Conferences
The Calendar
Where to Be & When
Constituent Meetings
Webinar/Virtual Meetings
May
13
AI IN ORTHODONTICS: How the Tools Your Colleagues Are Already Using Are Changing Everything
Event details here →Must See Events
Casey Bull, CascadEffects | RETAIN: How AI is Transforming Retainer Compliance and Recurring Revenue
How RETAIN uses AI to drive patient retention and recurring orders. The role of AI in patient communication, lifecycle tracking, and reactivation. What orthodontic practices can implement today to grow without adding headcount.
Event details here →BUILDING A HIGH-PERFORMING TEAM 3 WEEK LEADERSHIP RESET
A 3-week live program designed for orthodontic practices that want better alignment, accountability, and execution without micromanagement. Learn how to create clear priorities, establish a repeatable operating rhythm, and build systems that drive team ownership and consistency.
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