By Scott Fugit
“Why put chemicals in your body if you don’t need them?”
I sat in the dental chair stunned. I had never heard a medical professional say such words. That would be heresy in the USA. It took me several long seconds to come up with a response, “I’m an American, drugs are a way of life for us. We usually get a topical pain killer to kill the pain from the shot of another pain killer.”
She laughed quietly. “Yes I know, I have heard that many times.”
I had made the leap. After careful consideration, discussions with expat friends and some internet research, there I sat, horizontal, mouth open and committed. It was an important expat rite of passage in progress. A psychological trial most of us will one day have to make. I had consciously, and by choice, put myself in the hands of a dentist in Cuenca, Ecuador.
In modern America, all dental decisions are financial ones too. For those of us whose teeth are in a senior age demographic, money is the new protective enamel. Without it, your dental health will suffer. As I approached retirement, I faced the common fear of the boomer generation: loss of medical insurance. Business consultants who specialize in dental practices call that a secondary motivator. A primary one is pain. These help form my purchasing pattern, a familiar term to every successful American dentist. I was pushed to get things done before it became unaffordable. Heard that before?
As I chatted with my American dentist, Dr. X, his cheerfulness seemed forced. Studies also show that personality is a major factor when patients choose a dentist — more strategic marketing. Then I let it slip. I would soon be traveling to Ecuador. This immediately generated a “better get it done” chorus among Dr. X and his staff. I was grey haired fruit, ripe and ready for the picking.
I’ve got to admit that for a dentist’s office, there was an impressive selection of movies. There were several high definition flat screens on the ceiling, with amazing headphone audio provided for my entertainment. Nice gear. It was matched only by several very cute twenty-somethings on staff in Dr. X’s beautiful, modern office. My dental inventory took only 20 minutes with each tooth photographed, charted and graded. It was all entered into my oral software database file. I silently wondered where else this information would eventually live. I didn’t let them do x-rays. “You’re the first,” was the young tech’s reaction to that. Many dentists will admit, x-rays are done mostly for liability protection.
My $100 cleaning included the standard brush and floss oral hygiene advice, which I find slightly annoying coming from someone who’s younger than every one of my three fillings. “I’ve gotten good at bathing too,” I joked. But it was time to close the sale. There was no discussion of the problem crown Dr. X had previously mounted, even though it fit like a bad suit. There’s no money in warranty work. My jaw popping TMJ symptom was also unmentioned; it’s not his field and outside referrals often mean a loss of revenue. However, my one discolored molar drew special attention. On the mind-blowing Sony – BRAVIA – 72″ HDTV, it looked like a bombed out sports stadium in a Tom Cruise sci-fi movie. I would definitely not be getting my tooth shaped “No Cavity Club sticker”. With the gorgeous co-host on one side of the screen, and Dr. X on the other, we all stared at the uncomfortable image. I was reminded of Jeopardy with Vanna White. In his defense, Dr. X never said the word “crown”. That was my mistake. He just nodded in agreement. I’m glad I didn’t mention brain surgery. By the time I had walked to the front desk with my bag of complimentary tooth brushes, paste and floss, waiting for me was a printed estimate for a new $1,400 crown and several appointment options. It didn’t take a marketing major to recognize I was being upsold.
I was ready for a second opinion — a foreign one.
As in everything expat, personal research and contacts are important. For me, it was the tried, true and oldest form of Cuenca network data search, advice from trusted expat friends. Within several days and three emails, I had an appointment with a recommended Cuenca dentist. I was booked and ready. It was my first midterm test in Expat 101.
I have a buddy back home who is permanently crippled with a caustic wit. He showed all the stereotypes and myths about foreign dental care when he told me, “If they’re shocked ‘cuz you have two small mouths and no teeth, tell ‘em that’s your nose.” Even less funny are the current dental care options available to many Americans.
After 50 years of debate, cost shifting to states, political maneuvering by profit seeking providers and straight-up budget cuts, Medicare dental coverage remains at zip. Low income folks and the elderly suffer the most. The boomer generation, along with their teeth, are aging. Many haven’t seen a dentist in years. In parts of the U.S., the situation is exceedingly grim. Incredibly, it is now possible to die in America from dental infections simply due to the lack of access to essential care. Don’t look for the subject to be covered on the corporate news, nor is there any real congressional debate. For Americans who lack jobs with dental insurance (70% to 90% of us), spiraling costs have left the U.S. dental system irrelevant at best, and at its worst, seemingly weaponized. This is particularly true for retired seniors on fixed incomes. Yes, other options have appeared, like dental coverage plans offered by individual providers or groups of care givers. Most of the time, these furnish cleanings and exams only. Major restorations or repairs are seldom included. The entire sad structure of U.S. dental care shows in both the worsening condition of America’s teeth, and expats negative attitudes. The latter appears in the form of comments plastered all over familiar Cuenca websites. Many times, people are also recounting excellent and cheap dentistry received in Ecuador. For those expats lucky (and smart) enough to see the dental health big picture, Cuenca is now option numero uno.
I didn’t sleep very well the night before my first appointment. The cab driver only had to glance at the card when my wife and I showed him the dental office address. I strode briskly into the building like a man confident in his purpose. Actually, I really needed the baños, which was locked. Also locked was my dentist’s office door, which seemed very odd. Doubt entered my mind. Then in a perfectly timed and classic moment of Cuencano kindness, a smiling passerby explained in broken English that we were at the back door of the office; the front was around the corner. Step one was soon accomplished, I had found the right place. Taking a deep breath, I opened the door and walked in.
As expected, the first words I heard were difficult to understand. We had stepped into the tiny waiting room and were immediately greeted by another patient, a Southern expat. Her Alabama twang was thick. Luckily, my wife speaks “y’all”, and they were quickly into a conversation. First insight? Ask at the receptionist’s desk for the bathroom key. It wasn’t long before I was ready. My name was called, and I settled into the foreign dental chair. It looked just like the American ones, but with a much better view.
My dental event was a planned one. Many expats have their first non-American dentist experience due to an emergency. Susan was new to Cuenca. During breakfast on just her second day, one of her crowns, made in Florida, did a spontaneous dismount stuck to a raisin. She quickly reviewed expat websites for recommendations. Another expat, David, broke a molar at the gum line. In serious pain, he headed for the dental office listed on a business card provided by a friend, forgetting his wallet. Both references had led to my chosen dentist and the same results: a fast response, immediate appointments and relief. Even without his wallet, David actually had enough pocket money to cover the cost of the appointment. Both expats mention personal service provided in a caring manner — even at 8 a.m. Early morning sincerity is hard to fake.
My sharp tongued friend back home had another stereotypical warning about foreign dentists: “If they put on a mask, start shaking spears and dancing in a circle, get up and run.”
Of course, it’s actually American dental patients who are running. For those who have gone elsewhere, it’s an open question: did they jump, or were they pushed? It is now called “dental tourism”, and it’s the fastest growing subset of medical tourism. A decade ago, most patients were heading to Mexico and Eastern Europe. Now, Asia and South America are popular options. The idea is that a patient’s savings on cheaper dental care will partially, or completely, offset the cost of a vacation. A web search quickly produces many related websites, businesses and facilitators. Some organize everything, including travel. Even within Ecuador, dental costs vary with Cuenca generally considered cheaper than Quito or Guayaquil. But most importantly, a typical estimate puts Cuenca’s average dental costs to be about 40-50% of that for similar work in the USA. Maybe even less. I ended up spending about $450. My work would have been at least three times that back home.
Considering the cost of air fare to Ecuador, add in estimates for food and accommodations, and decision lines start to form. One reasonable and current estimate: if you have planned dental costs in America approaching $3000 or higher, you’re close to financing a trip to Cuenca with the savings available there.
I was there, and in the chair, for the first time. Nervous, edgy and suspicious, I was soaking up every detail around me in a continuous flow of judgment influencing stimuli. There were many expat patients with ongoing conversations in English, the receptionist’s smile, her phone etiquette, the scheduling software she used, the staff’s lack of perfume and cologne, their demeanor and interaction vibe, plus the all-important dental equipment. There was the cleaning of instruments, books on the shelves, on and off of rubber gloves, the use of sink and soap, and every minutia my uneasy brain could register. It all piled up on my mental good/bad balance scale. So far, it was tipping towards stay here and see what happens.
As I shook my new dentist’s hand, I noticed something very different from all my previous dentists — it was the lack of a certain maleness. She was a woman. Do they even have female dentists in supposedly gender equal America? I’ve known none. Yet here in Cuenca, as I sat in the chair, it was she who stood and looked me straight in the eye, diminutive, soft spoken, smiling and confident. No problem here. I’ve liked women all my life. Still, it’s easy to understand how it all could strain an expat’s preconceptions, prejudices and biases, which are some of the most long lasting things we still make in America. My Spanish is a work in progress, her English is excellent. She has tiny hands, I have a big mouth. So far, a perfect fit. Our conversation was going well. I could feel myself calming. She began her exam, pausing often to talk. We agreed that I’m fortunate. My mouth is in good shape with only one existing crown and the one unsightly molar. On that, she surprised me with, “This dark is just surface decay, a shallow filling should make it fine.”
“Really? I was told I needed a crown on that tooth.” I explained.
She had moved on. Like poking a pitchfork under a pickup truck, she easily hooked her dental probe on the flat bottom edge of my existing Dr. X crown. From behind her mask and glasses she asked softly, “Do you feel this edge? I am concerned this fits very poor. You are lucky no decay has happened.”
I asked: “Are crowns supposed to store a sample of each meal?” “I need toothpicks more than a fork.” I had found one more reason to like her. She laughed at my jokes. When I asked about the bad fit, she got pen, paper and the model of a tooth which she had me hold. Pointing to the replica, she carefully diagrammed and explained how my tooth had been ground incorrectly, with no shoulders at the base, so the crown’s bottom sat on nothing.
I began to disparage Dr. X in blunt terms. She just smiled and took a very balanced tone, much more so than mine. “It is faster to grind the tooth like this. There are good and bad dentists everywhere but I see this often in my American patients. Sometimes up there, it’s mainly about business.” Truer words were never spoken. Honesty creates trust.
We also discussed my grinding, morning headaches, plus a jaw popping racket that could stop conversations in an entire restaurant. In just one conversation, I learned more about my symptoms of TMJ (Temporomandibular Joint Dysfunction) than in all previous lifetime appointments. I can even spell it now. I had been destroying cheap, soft mouth guards at the rate of one a month. Who knew they were worse than nothing? Certainly not Dr. X back home, who had advised me to use them. My new Cuenca dentist now explained that they lack proper spacing, and the spongy plastic provides just enough resistance to encourage nocturnal jaw clenching. She suggested a custom fitted, hard and inert polymer mouth guard. Over several visits, impressions were taken and the mold used for perfect sizing. During one appointment, a technician actually showed up, took my new mouth guard to their nearby lab and quickly made some adjustments, while I waited.
Nowhere does the deeply ingrained and lifetime indoctrination, which comes with being an American, show itself more blatantly than in attitudes about foreign medical and dental care. We’ve been trained, taught, lectured, browbeat and propagandized into never straying from the norm. We are taught that when it comes to all things medical, America is number one. As I sat in this alien dental chair, my experience growing, I began to detect more than calm, competent and professional voices. Now creeping into my consciousness was an unmistakable sound. It was the crashing downfall of another western disinformation façade.
Living in America are millions of potential dental tourists. Most of them completely oblivious that other opportunities exist, but awareness is growing. Of course, there are also no lack of stories about badly botched overseas dental treatments, a common narrative with U.S. dentists. Mexico is mentioned often during such discussions.
Am I one of those conspiracy theorists we hear so much about? Absolutely not. I am, however, an avid coincidence theorist. My belief is that a future American congress will form plans to somehow limit U.S .citizens from seeking dental care overseas — “for reasons of safety.”
Coincidentally, this effort will come as U.S. providers notice the increasing amount of money spent on international care. Pushing the issue will be some well publicized dental tragedies, as yet to be determined. There’s a small hole in the fence, and a few of the cattle are starting to escape the herd.
But now came the ultimate test: no chemicals. One expat friend told me he didn’t want to be numb either, he needed to be completely unconscious, a typical American attitude. Now, my new Cuenca dentist was actually suggesting that I forgo the use of Novocain while she took a drill to my teeth. My abdominals tensed. My heart rate jumped. Bad memories were screaming in my mind. In college, a dentist had tried this. He probably still had the sternum dent from my knee. Maybe I’ve made the same mistake again. No numbing? Is this little woman kidding? Luckily, my mouth was occupied while she continued her careful examination. The words of anxiety stayed home in my stressed brain. She started to work. My existing Dr. X crown came off with minimum effort. As she prepared to begin reshaping the tooth, she gently placed her hand on my shoulder and made this point: “Here, the patient is the boss. If you want to be numb, I will do it. But many people are surprised because it’s not needed. Should we see how it goes?”
Somehow, a timid “OK” left my mouth. I don’t really understand what happened next. I could hear the high speed whining of the drill. The usual smells where all present, along with the powdered bits flying around. All the standard tools, vibrations and sensations were there, just no pain. How is this possible? Could this be just technique? I have no idea. Magic is my only answer. The total discomfort during several hours of work on two teeth amounted to about a half second. They were little zingers, less than the sting from the usual shot of Novocain into my gum. To say I was impressed, is not enough. Amazed works better.
I was also now the proud owner of a custom fitted hard, inert polymer mouth guard. In very little time, my wakeup headaches were gone, and no more pistol shot jaw cracking to disturb our meals. After years of discomfort, I had found welcome relief for just ninety bucks.
Then, with perfect timing, a textbook comparison presented itself. Straightforward “A” versus “B”, the kind expats love. Two countries’ dental systems shown side by side. Sharon, a good friend from America was visiting Cuenca for a short time. She also suffers from TMJ. “I’ve got an appointment scheduled with a specialist back home,” she replied when I suggested she call my new Cuenca dentist. Sharon is an expert in the obscure, arcane world of U.S. medical insurance. TMJ is rarely included in any dental plan since there are limited profit margins for the insurance carriers. “I think I’ve got an angle to get it covered,” she explained. Buried in the fine print of her insurance was a clause mentioning TMJ as a symptom of sleep apnea. Back home, her subsequent story was far too typical of what dental care in America has become — when people can get it at all. Although Sharon has no sleep issues, off she went to the plush, resort-like sleep disorder lab to prepare for an overnight stay with dozens of electrodes hooked up, computer monitoring, and a detailed analysis of her non-existent apnea condition. “You’ve done your homework,” was the comment from the attending physician, referring to her deep knowledge of insurance minutiae. Amazingly, he then blatantly coached her to sleep on her back during the test, and come with a bottle of wine — already consumed. It’s the type of behavior, from both patients and doctors, that’s being forced by the devolving American health care industry. In short, start drinking and try to scam the system. Sharon was diagnosed with mild sleep apnea. It’s now a permanent part of her medical history. She’s getting emails and advertisements pushing all the related equipment. For her TMJ “symptoms,” she also acquired a custom fitted, inert polymer mouth guard. It looks almost identical to mine. Total retail price: $3,500. Out of pocket cost with insurance deductible included: $450. In America, cases of sleep apnea are on the rise. It’s a beautiful system, but just for the people who own it.
Want to insure your Cuenca dental experience is the best possible? Most importantly, be patient and make yourself available. This is not America where convenience sells better than competence. My dental work required a total of eight visits to the office, sometimes twice a day. My new crown is truly custom fitted, and it makes a difference.
Gringos are born impatient. Here, you need to fight that impulse. Why put hurry up pressure on your dentist? When asked, my standard line was, “I’m retired. I’ll be here whenever you want me.” I did the very pleasant 30 minute walk to the office numerous times. Nobody was ever rushed. There was also no sales pitch or promotional freebies. The total lack of marketing was refreshing. The main emphasis is on actual dental care, not generating revenue. Almost shockingly, I never heard the words X-ray, brush or floss. They seemed to realize I had figured out hygiene. As we finished, my new dentist shook my hand and said, “Many Americans want only one visit. Thank you for being such a good patient.” I walked out wearing that comment like a badge of honor.
Maybe it was an omen for expat wannabes. It was at least a small episode with a big inner satisfaction. These come all too rarely with advancing age, which is all about looking harder for humor. We were back in the States. My phone rang. It was my American dentist:
“Hello Scott. This is Dr. X. How are you doing?”
He made patient calls personally, no doubt based on his marketing consultants advice.
“We’re very busy, but I’ve got a chance to get you on the schedule for that new crown.” he offered.
I stayed cool and tried to speak slowly:
“….yeah…. well actually…. had it done in Ecuador…. tooth didn’t really need a crown…. yeah….. it was just a shallow cavity….”
The long gap of silence was awkward, but a fun awkward:
“….to be honest…. also had the crown you did for me replaced…. came off real easy.… didn’t fit very well….”
I didn’t wait for a response. Now I couldn’t stop:
“….got a new custom mouth guard too…. for my TMJ…. works great…. learned a lot…. whole shebang for way under 500 bucks…. yeah…. really….”
I could sense our conversation was coming to an end soon. The truth comes easy, so I laid on the topper:
“…. my dentist down there…. lady’s a real pro…. yep…. lots of fans…. got a rare touch…. did it all with no Novocain…. no kidding…. I’m serious…. true fact…. yeah…. a first for me…. it was amazing…. she’s the crowning jewel of Cuenca…. yeah…. corny but true…. you got a nickname?”
I could think of a few for him, but why pile on? Then, just before he said goodbye, I was able to slip in my new favorite question. It was certainly one he had never been asked:
“Why put chemicals in your body if you don’t need them?”
All photos by Dee Fugit.
Scott Fugit retired recently to study leisure, travel writing and Ecuador. His goal is to bring real experiences and entertainment to articles relevant to expat life. He and his photographer wife Dee are Cuenca wannabes.