A Newsy/USA TODAY investigation of a fast-growing dental chain finds dentists pressed to hit revenue goals, leading to claims of unneeded treatment.

Johannah Lancaster took her 3-year-old son to Dental Express for his first checkup, expecting a routine cleaning.

She never imagined the treatment plan the Niles, Ohio, dentist would come up with after he peeked into Gregory’s mouth for what seemed like only two or three minutes.

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.

What Lancaster didn’t know then: Dental Express was part of North American Dental Group, a chain backed by private-equity investors. At least a year earlier, the company had told dentists like Griesmer to meet aggressive revenue targets or risk being kicked out of the chain. Those targets ratcheted up pressure to find problems that might not even exist.

“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.”

North American Dental Group 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, handling a 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.

Ashley Hughes, dental assistant (Jeff Swensen / USA TODAY)

“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 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 a July email 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 that 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.

Refresh Dental offices in Kent, Ohio (Jeff Swensen / USA TODAY)

Patients had no way of knowing that 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 only regulate dentists, not the companies. Even then USA TODAY/Newsy found that dental boards rarely act on complaints.

In 3-year-old Gregory’s case, the Ohio state board did review the case. It 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, she recalled, 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 like it might pop. Lancaster rushed him to an emergency room, where they drained pus. 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.

Last week, Griesmer told USA TODAY that he figured out that 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.

“I’ve been doing it for 30 years,” he said. “I pretty much know what needs to be done.”

Griesmer acknowledged the company pushed dentists to make money but said that never influenced his treatment choices, He acknowledged the crowns he put in were too big and expressed regret about Gregory’s complications.

“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.

Gregory still fears dentists and his mother feels bad about the pain he suffered.

“The way that Gregory cried,” Lancaster recalled, pausing. “It’s sad.”

How A Private Equity Firm Works Big private equity firms have become active in the medical field.

Company denies debt drives treatment decisions

North American Dental would not comment on Gregory’s case, or that of any other patients named in this story, beyond pointing out that some of the dentists involved are no longer with the company.

Generally, the company denies allegations of overtreatment, saying that 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 by 2017, 17,600 dentists nationwide worked at them, according to the American Dental Association. Investment firm William Blair & Company estimated in 2017 that dental chains made up 16% of the market and pegged their growth at 15% a year.

Another kind of debt is helping fuel the growth of private-equity-owned dental offices: student debt. According to the American Dental Association, the average dental student graduates owing $287,000. Young dentists who can’t afford to start their own practices, leave retiring dentists with fewer prospective buyers. 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 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.

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.”

Ken Cooper, North American Dental Group's co-founder and chief executive officer. (Jeff Swensen / USA TODAY)

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.”

The Department of Justice won multimillion-dollar settlements against two other dental chains, alleging they had defrauded Medicaid by performing unnecessary root canals on children. One went out of business.

Cooper said his company has learned from problems with other corporate dental chains.

“Some of our peers have had missteps a couple of times,” he said. “We’ve learned from that.”

North American Dental said ultimately, the responsibility for treatment rests with the dentist, not the company. It noted that conflicting opinions are common in dentistry, citing a 1997 Reader's Digest story for which a reporter visited 50 dentists and received a wide range of diagnoses.

When asked if the company was concerned about Yelp and Google reviews where patients complain about overtreatment, Cooper said an internal analysis indicates patients are happy.

“You can go to any company in America and find a social media negative review, literally every company,” he said. “Even Disney World.”

Employees say they saw dentists drill healthy teeth

Former employees of North American Dental contend that pressure to overtreat stems directly from the company’s revenue goals. Ashley Hughes, the Ohio dental assistant, still cannot believe what she witnessed.

Shortly before 8 a.m. daily, 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. Small bonuses were dangled for exceeding targets.

“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. Root canals are much more lucrative. According to insurance company 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 have 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.

Hughes said she noticed that kind of double-dipping a lot.

“The patient is coming back a month later because their faces are blown out because they were infected and the teeth needed to be extracted,” Hughes said, “but we needed that money.”

Ricci Endsley, dental assistant. (Jeff Swensen / USA TODAY)

Dental assistant Ricci Endsley worked alongside Hughes at Refresh Dental in Austintown, a hectic office along a commercial strip with one full-time and one part-time dentist. She said she routinely saw patients being diagnosed with problems they didn’t have or being billed for treatments they didn’t get.

For example, 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.

“I told the office manager, ‘I will not go back in there. I will not be any part of what's going on in that room,’” Endsley said.

Sometimes she would go home at night in tears.

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.

This is not unusual. The Ohio board has four investigators handling nearly 500 investigations a year. Only a handful of those result in suspension of a dentist’s license.

Frustrated, Hughes and Endsley both quit in 2016. They continue to work as dental assistants and say they’ve never seen anything like it at other dental offices.

Asked specifically about the morning huddle, Cooper had a different take.

“It's a big part of our culture,” he said. “They open up each morning with personal professional gratitude and really just a way to help lift the spirits in the office like, ‘Hey, what do we really care about? We're here to serve patients.’”

Endsley shook her head.

“I don't know what kind of morning huddle he's ever sat in on,” she said, “but for 14 months, everyone I've sat in on was not at all encouraging.”

A patient dies in the parking lot

Unnecessary fillings and crowns can lead to a lifetime of expensive dental work as they wear out and need to be replaced. But in rare circumstances a trip to the dental office can also be deadly.

April Walters was in fragile health when she went to a Detroit-area dentist to have 19 teeth pulled. In fact, the first time she went in March 2016, the dentist at Dental Care of Michigan postponed the procedure after checking her heart rate.

The dentist, Rana Rabban, had been out of dental school less than two years.

But the second time Walters went, Rabban pushed forward. Walters’s doctors had approved her for the treatment despite her high blood pressure.

She wore an oxygen tank during the procedure because of serious lung diseases. Her blood pressure was high and her heart, the records show, was racing at 135 beats per minute.

Surgery under those conditions calls for an experienced anesthesiologist, who could monitor the patient carefully, said Heddy Dale-Matthias, an anesthesiologist who reviewed Walters’ records for USA TODAY/Newsy. That would have meant sending April to an oral surgeon, she said.

Details of what happened are contained in dental records and alleged in a malpractice lawsuit the family brought against the dentist and the office last year. Walters’ sister, Crystal Cutright, testified that she sat in the dental chair with Walters, stroking her hair during the treatment.

Concerned, Rabban stopped the procedure early. Walters collapsed in the parking lot. CPR didn’t save her. The family’s malpractice lawsuit is still pending. In response to it, both Rabban and the company denied they did anything wrong.

How To Select A Dentist If you are trying to find out if your dentist is managed by a private equity firm, you might just ask them.

Non-dentists question dentists' treatment decisions

While North American Dental says dentists are in total control of patient care, interviews with former employees and emails 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 a July email to 11 Indiana dental offices, 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. Neither Watson nor the company responded to questions about the email.

Cooper, the company’s chief executive officer said the problem in the industry now is that insurance won’t cover some treatments, so dentists often let patients walk out the door with disease in their mouths.

“Doctors have been trained to treat to insurance, so there is undertreatment out there, not overtreatment,” Cooper said.

To prevent this, North American Dental tracks how often dentists diagnose advanced gum disease. If an office is diagnosing the disease less often than disease prevalence statistics from American Dental Association, Cooper says the dentist will be told about it and may get training about the disease.

Yet an executive for the American Dental Association cautioned that its disease statistics shouldn’t be used to guide diagnoses.

“There is never a time where a population statistic will override the individual needs of a patient,” said David Preble, senior vice president of the ADA’s Practice Institute.

The treatment for advanced gum disease is typically expensive deep cleanings. Several former employees said patients without the disease frequently were sold deep cleanings.

Cheryl Knab, a benefits administrator, says this is what happened to her a little over two years ago at a North American Dental office in Westlake, Ohio. In Westlake, the cost of a regular cleaning is $91 to $104, according to Delta Dental, while a deep cleaning costs more than $1,200 for a full mouth.

Knab returned to her previous dentist, who told her she did not need a deep cleaning. When Dello Russo, a periodontist who specializes in gum disease, reviewed her X-rays, he agreed.

Dental chains skirt laws requiring dentist owners

In most states, you have to be a dentist to own a dental practice. The impetus for those laws is the common belief that dentists will look after the patient’s best interest.

Dental chains, including North American Dental, have devised corporate structures that allow them to skirt those laws. North American Dental rents the office, owns the equipment, employs the staff, handles the billing and, according to insiders, sets the revenue targets. The dentists are employed by a second affiliated company that owns the practices.

North American Dental Group was started by someone who never went to dental school. After less than a year at Ohio’s Youngstown State University, Cooper became the lead singer in a guitar-driven rock band that released a single album with Atlantic Records.

During that time, he faced lawsuits and tax liens for unpaid debt. He also in 2002 pleaded no contest to a felony drug charge and was sentenced to 180 days in jail suspended and 12 months of probation. (Recently he went back to court and had his criminal record expunged.)

A few years later, he landed a job in a dental office in Canfield, Ohio.

“I was actually wearing scrubs, working the front desk, checking in patients,” Cooper recalls. “I didn't have a background in dentistry.”

But he came up with the idea of putting together a group of dental offices. He opened his first Dental Express office in Canfield, Ohio, in October 2008. Soon, however, Cooper faced problems.

One dentist, who sold his practice, accused Cooper of withholding $300,000 for treatments the dentist had performed. He sued Cooper and the case settled out of court. Two of Cooper’s early dentists, including Griesmer, had their licenses suspended. One dentist convicted of writing narcotic prescriptions for nonpatients got his license back later.

Despite those bumps, Cooper’s dental group drew the interest of a Boston private equity firm, Abry Partners. In 2012, Abry invested in Cooper’s company in a deal worth an estimated $40 million, according to Pitchbook, a private-equity research firm. That allowed the company to buy more offices.

The debt from private-equity-driven leveraged buyouts can put tremendous financial pressure on companies like North American Dental. In December 2017, North American Dental Group had total debt of $128 million, according to company financial data reviewed by USA Today/Newsy.

Daniel Krueger, dentist. (Carrie Cochran / Newsy)

Daniel Krueger, a dentist and until recently one of a small number of individual shareholders of North American Dental, said he was told in 2017 by someone at the company – he believes it was Cooper – that the company critically needed to refinance its debt. Krueger said the urgent message was that he had to sign papers agreeing to the refinancing.

“This was a do or die moment for the company,” he said. "‘We've got to get this financing.’"

The company declined to answer most questions about its financial condition, saying that it pays its debts. But the company data reviewed by USA TODAY/Newsy shows that debt nearly doubled in 2018 to $229 million at the end of the year, North American Dental lost $25 million in net income in 2018.

Late last year, North American Dental’s private-equity owners sold the company to Jacobs Holding, a Zurich-based firm that invests on behalf of a nonprofit foundation. So far, Jacobs has not replaced top management or made noticeable changes to practices uncovered by the USA TODAY/Newsy investigation.

Jacobs did not respond to email requests for an interview.

At the time of the purchase, the CEO of Jacobs Holding said in a news release: “With its high-quality standards in dental and patient care, North American Dental is a perfect fit with our vision and values.”

Social media reviews expose high-production offices

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 Krueger that had been targeted on social media. Among the critics was a Purdue University graduate student, Nick LeBonte, who was told by Krueger that he had 16 cavities. When LeBonte sought a second opinion, another dentist said he had no cavities at all.

Verena McClain, a student from Germany, joined the fray after she was treated by Krueger two years after he joined North American Dental.

Krueger told her she needed to replace a crown she had just gotten in Germany. Over the course of two more visits, he said she needed four crowns, at a cost of $5,900. With insurance and a discount, her out-of-pocket share would come to $3,300.

She decided finally to ask another dentist, who said nothing was wrong. McClain asked her to double-check.

“She looked at them again more closely and said, ‘No, there's nothing wrong with your teeth,’” McClain said.

Dello Russo reviewed X-rays for both McClain and LeBonte, and confirmed neither needed the work done.

“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 that to me?”

Echoing the company’s perspective about second opinions, Krueger told USA TODAY/Newsy that 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.

“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 added, the onus is on the patient to be a savvy consumer.

Complete Dental Care, with seven offices in eastern Ohio and two in Pennsylvania, that dentist Robert Doyle sold to North American in 2018, also has been accused of unnecessary treatments on social media. A whistleblower lawsuit in federal court adds heft to those accusations, saying that those practices and North American Dental are defrauding Medicaid by diagnosing unnecessary root canals.

The whistleblower, John Kramer, runs the only competing dental office in Martins Ferry, Ohio. When he started seeing patients seeking second opinions, he was shocked.

The lawsuit says Kramer saw one patient last May who had just gotten two root canals and was told she needed more, but X-rays showed otherwise. Shortly after, Kramer saw another patient who was told he needed 18 root canals.

[RELATED: Dental boards rarely punish dentists]

Kramer alleges that while nine teeth needed to be pulled, the other teeth were fine. Kramer said in the lawsuit that not only did the patient not need root canals, but no patient would ever need 18 of them at once.

Lawyers for North American Dental and Doyle dismiss the federal lawsuit as a dispute between competing dentists and say Kramer has failed to prove his allegations.

In an interview, Doyle’s lawyer, Elizabeth Stepp, denied all allegations of fraud. She said It makes no sense that any dentist would risk losing their license to hit revenue targets or that any dentist could be told to perform procedures that they didn’t believe were medically necessary.

“It’s more about how hard are you working not how many unnecessary procedures are you doing," she said.

If Kramer prevails, he stands to get 30% of the judgment with the rest going to Medicaid for fraudulent payments. But he insists money is not his motivation. Instead, he said, he believed a lawsuit “was the quickest way to stop (the) behavior.”

His lawsuit alleges that unnecessary treatments are systematic at North American Dental.

It cites an unnamed company insider who says that starting in March 2019, North American Dental created a team including Doyle to teach offices in Cleveland and Pittsburgh how to increase their revenues.

Since then, the lawsuit alleges, the office in Shaker Heights – a Cleveland suburb – has grown daily revenues from $5,000 to as much as $12,000. The goal is $15,000.

The secret to success? The company insider alleges that Doyle’s team taught hygienists to add root canals to patients’ treatment plans, even if the dentist said no root canal was medically necessary.

Carrie Cochran, Ciara Bri'd Frisbie and Lauren Knapp contributed to this story.

David Heath is an investigative reporter on the USA TODAY national investigations team. Contact him at dheath@usatoday.com or @davidhth, or on Signal at (240) 630-1962. Mark Greenblatt is a senior investigative reporter with Newsy. Contact him at Mark.Greenblatt@scripps.com or @greenblattmark.