A New Smile (cont.)
That night, I skipped the casino and bar, got a tuna grinder from Subway across the street and spent the evening with e-mail, CNN and my book. Theroux was cruising down the Yangtze River with a collection of millionaires. Nice work if you can get it, I thought, as I fell asleep.
Friday, I walked around San José, all day, as I might any city new to me. It is a cacophony of Spanish and I felt deaf and dumb, which gave me a headache; it had not occurred to me that the background sound of English being spoken was something that I would miss. Despite the bars on the windows and the gated driveways, I felt safe everywhere I went. I ended up on Telma and Josef's doorstep just after 7 p.m. They were still working, and it was nearly 8 before we left for dinner.
We had lots of seafood, priced ridiculously low by U.S. standards. We picked at each other's plates. Telma and I consumed more of Josef's "big fish" than he did. Fried whole, including the head, it was perhaps 18 inches long, hanging off both sides of his plate. I was far from the first patient with whom they had socialized.
"Many people come here - the women, especially - they are alone, maybe a little afraid to go out," Josef said. "We don't like to think of them sitting in their hotel rooms at night."
I slept in the next day, feeling as though I was finally on vacation. I had nothing in particular to do for the next four days; on the fifth, I would get my permanent teeth, and on the sixth I would fly home.
For Sunday, I booked a "combo tour," a day trip that included stops at Poás Volcano National Park, La Paz Waterfall Gardens, a trip through coffee-growing country and a river excursion. It was a lot for one day but all worthwhile, even though the volcano crater was shrouded in mist.
On the tour bus, I sat next to Yailky Ubieda, a Venezuelan woman who, in one of those ridiculous vacation coincidences, turned out to live in Stamford, Conn., and work out of New York. Seated in front of us was Ricardo Quiroga of Bolivia, who works for the Inter-American Development Bank in Washington, D.C. - and earned his doctorate in economics at UConn.
At last, I was doing the "tourism" part of my "medical tourism" trip, but there was not nearly as much time to wander about Costa Rica as I might have liked. On this trip, anyway, I would see neither the Caribbean nor Pacific coasts; I would not see lava flowing from Mount Arenal, or bathe in its hot springs; I would not stalk elusive and increasingly rare jaguar and puma with a camera from an RV.
There would be another time, I promised myself.
Tuesday, I got my new teeth.
Josef had said the hard work was done a week ago. I shouldn't have believed him. My first clue as to what lay ahead came when he filled my upper gums with Novocain again and took out what looked suspiciously like a mallet and a chisel. Those were what it took to dislodge my temporary teeth, of which I had grown fond. We were back to the pointy-teethed orc look again.
One by one, Josef pushed the porcelain teeth that Roman Alvarez had made for me in the lab onto the carefully prepared pegs that used to be my upper teeth. Very fast-acting cement is used, and, in the quick struggle to seat the crowns and align them properly before the cement dries, a patient's comfort is the first victim. Sometimes, this flat-out hurt, the pain cutting straight through the anesthetic.
But we were so near the end, the pain was almost anticlimactic. My teeth - my new, real teeth! - were in, solid, by mid-afternoon. Josef fussed inside my mouth, cleaning off cement, nipping and tucking, perfecting my new, real, bite. I could not recall a time when they met evenly on either side. I had trouble making them do so automatically; it seemed unnatural.
The entire office rejoiced when he pronounced himself satisfied. I went from room to room, smiling on demand as best I could. My teeth looked as good as those of any of these toothpaste poster children, I thought, but I kept that to myself.
I asked Roman if he ever signed his work. Did I have the initials "R.A." somewhere on the back of a molar? He laughed. Josef was momentarily horrified at the idea.
I had one more day, and one last trip to see my dentists. Technicians still had to make a mouth guard, from a mold of my newly installed teeth, for me to wear at night. It would keep my bionic, hard porcelain upper teeth from destroying my lowers. "You grind them," Josef had said. This would not be left to chance. The mouth guard would cost another $350. I tried not to think of the bill as I rode in a cab, not back to my hotel but to Las Cumbres for dinner.
Elke was thrilled for me, as was Nina, who was starting to look the way she had hoped she would after the face and neck lifts. Sandy and Vicki were long gone but there was a new group of kids for Elke to cater to, and a few more husbands in evidence.
Between smiles, I managed to chew a few mushroom crepes from Elke's kitchen, despite the lingering Novocain and some general soreness. We all felt smart for being in Costa Rica, for having found out about this.
With but one day left to myself, I took a morning bus tour of San José, which I'd recommend to any visitor with an interest in the history of the city and the country. Cortez and Columbus are honored with statues here; the beautiful National Theatre was completely restored after the earthquake in 1991. The hospitals and universities are pointed out with pride. The Gold Museum displays pre-Columbian art and craftwork. That the coming of Europeans to this land, starting with Columbus in 1502, heralded the end of another way of life, another culture, is somberly noted.
I walked to Prisma Dental that afternoon, for the last time. I arrived late, and sopping wet. The skies opened up, suddenly, in a tropical downpour. The rainy season was due "any day," Elke had said last week; well, here it was. I carried no umbrella. I wrung out my shirt in the bathroom sink.
Telma stifled her laughter at my appearance and, after Josef had made sure my mouth guard fit properly, we took photos. I looked dreadful, half drowned, except for the great teeth.
We said our goodbyes, with all the attendant promises. On the way out the door, I met an older gentleman who turned out to be Pete Shea, a retired anesthesiologist from Florida. He had witnessed the goodbyes and mistaken the hubbub for that which might surround a new patient.
"You're in good hands - these people are the best," he said. I flashed my teeth and told him I was done.
"My wife had implants done here; they did a great job," he continued. "$45,000 is what they wanted in Florida. It was $15,000 here. The doctors there, they don't want to hear about this. They'll tell you all sorts of things."
Chemotherapy had ruined Pete's own teeth. He was about to have the same kind of work that I had, maybe more. We wished each other well.
I rose early the next day, packed and took a shuttle to the airport for the journey home. Despite loving my new teeth, I still had nagging doubts, twinges of buyer's regret. Had I done the right thing? Was there another way to do this?
Dr. Thomas D. Taylor, D.D.S., M.S.D., head of the Department of Prosthodontics and Operative Dentistry at the University of Connecticut Health Center, entered the examining room.
"So, what's the story?" he inquired. I had called, and written, asking if he would check out my dental work. I told him where I had it done. I wanted to know what a United States dentist thought of the work. Even if it was after the fact, I wanted a second opinion, both for myself and for the story I was writing, the one in which my own dentist wanted no part.
I gave him the short version and we talked about the work. Then the chair went back, my mouth opened and Dr. Taylor began poking around, systematically.
He removed one small chunk of cement from high up on the inside of my new molars. After a few minutes, he removed another. I had not noticed either in inspecting my gums with my tongue, something I now did unconsciously, a little obsessively. Either piece of cement could have caused some irritation, Dr. Taylor said.
Finished, he sat down and told me a story about a woman who had gone to Germany for dental work. She was so pleased with the results, he said, that when she needed dentures a few years later, she went back to Germany to the same dentist. It took me a split second to get the joke - if the original work was so good, why did she need dentures soon afterward? But it wasn't a joke; the story had been in a national magazine.
"You want to know if the work meets professional standards," he said. "It absolutely does. It is high quality work ... the aesthetics are very good.
"You got a good deal."
He had a few concerns. One was finding the two tiny pieces of cement. They should not have been left, he said, but it was not an indication of sloppy work overall. He also questioned whether the new upper teeth had been adequately polished after the final adjustments to them had been made, telling me, as Josef and Telma had, that my new teeth were much harder than my old and could grind them down. More polish would help prevent that, as would the mouth guard.
Based on looking at the "before" pictures of my teeth and his examination, Dr. Taylor agreed with Josef and Telma's diagnosis and course of action.
(I later wrote to Telma, summing up Dr. Taylor's comments. She thanked me for passing them along - "They help a lot to make the work better." As to the cement pieces, she said, "That can happen in such a big case." The pieces would have been found in any subsequent checkup, and additional polishing could be done if deemed necessary, she said, by any dentist.)
Dr. Taylor said my gums had been through a lot in a short time.
"It'll take a while for them to heal," he said. "Ideally, I would want to see you in about a month to check on the gums."
I was relieved and pleased. I stopped second-guessing myself. The gamble - and I still considered it that, in some ways - had paid off.
My total bill at Prisma Dental came to $8,290. I spent about another $1,000 on accommodations, meals, incidental travel, souvenirs and a bit of fun.
I'll never know what my total bill would have been in 2001, beyond the quoted price of $9,600 for 12 crowns. I'll never know what sort of teeth would have resulted, beyond looking at the white molds that represented my Connecticut dentist's projection of what might have been.
Asking around, I concluded that the work Josef and Telma did on my teeth would have cost, at a minimum, about $19,000 in Connecticut and might have cost more than $33,000, depending on the dentist.
I also, perhaps, could have paid less than what Josef and Telma charged - in Costa Rica. Josef told me, candidly, that Prisma prices are mid-range for San José.
And Vicki told me, at Las Cumbres, that dentists in smaller towns in Costa Rica might do a crown for as little as $100. Are they any good? Could they do 14 on the top? I'll never know.
I'm not going to make myself crazy over it. I got a good deal, as Dr. Taylor said. If there is a dentist in Connecticut who would have done the same work for what I paid, or even close - well, I have not been able to discover that.
"Unfortunately, the public can't hope to find the most qualified type of dentist for their particular problem ... because it is such a complicated area that it's impossible for the average person to know where to turn for help," Dr. Taylor told me, in the course of my following up on all the "might have beens" of my adventure. And, whatever insurance companies might say, Dr. Taylor indicated that there is a significant difference between "cosmetic dentistry," which I thought I was having done, and prosthodontics, which is what I needed and, fortunately, got.
"Obviously you want an aesthetic outcome, but what you went in for was reconstruction, prosthodontics," he said. "Anybody can take a weekend course and become `accredited' in cosmetic dentistry, but that means nothing about how qualified or experienced they are in rebuilding a mutilated dentition."
Sitting at my desk in Connecticut, I chew on this assertion, its implication for the supposed risks I had taken, in seeking dental care overseas. I no longer think that all dentists in the United States are, more or less, interchangeable. I no longer, either, assume that the bar for medical competence is necessarily set lower elsewhere.
I realize, as I have several times recently, that I am slightly grinding my teeth - rubbing uppers and lowers together, reflexively, a nervous habit of which I am now conscious.
I put my mouth guard in.
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