A new smile at half the price

Northeast Magazine, May 2004

By Jeff Schult

The artist wanted to admire his work. "No, no, not like that," he counseled. "Don't bite down, it looks fake. Relax ... that's it."

Sitting up in the chair, I was looking at a mirrored wall and at my cheery dentist, for whom I was trying to manage a smile, despite a serious lack of muscle control over my upper lip. Lots of Novocain will do that. Everything inside my mouth felt somewhat out of place. I ran my tongue slowly over the backs of my upper teeth, the new ones.  

The image in the mirror was startling. I looked like an ad for toothpaste - big, bright-white bicuspids and incisors, a toothy smile, had replaced my quirky, crooked, mysterious, all-purpose expression of ambiguous approval.

I wondered for a moment about what I had given up. That other smile, the one that did not show my misshapen, deteriorated teeth, had its own charm. Why had I come to dislike it so much? It could not be good, I thought, to look this happy and friendly all the time.

My face looked implacably confident. I would have to work on the nuances.

The dentist, Josef Cordero, called out down the hall to his wife, also a dentist. "Telma, come look at Jeff."

Telma Rubinstein swept into the little room.

"Let me see," she said. I tried my smile again, not biting down, not fake.

"Show me the lowers." I could manage that. My teeth were bared in what could not be a smile. It had to be a snarl, I was sure of it.

"What a difference," she said. "They are perfect; they look terrific. You look fantastic."

She was right. I forgot about the old smile. I suddenly felt very smart, having found these dentists in Costa Rica. I had looked everywhere for the best talent at the best price.

I had looked in the United States, too. Sure, the talent is available. But I couldn't afford it.

I had never especially liked or disliked my teeth. I took them for granted. I did not have them braced and straightened as a child; my dentist and parents deemed it unnecessary. My teeth came in, straight and true, with an overbite that hindered neither eating nor smiling. I had a spate of cavities - seven at one time! - when I was about 12 or 13, in my new, adult permanent teeth. These were filled with metal. I was told to brush more thoroughly, to take care of my teeth; that they would have to last me. Flossing was not yet being emphasized.

I already was brushing thoroughly, I thought. In any case, that year was an aberration. There were no more cavities. My adult teeth were a little small, perhaps, in my big mouth, in my slightly oversized head - the latter of which was the butt of a few jokes. A special, extra-large football helmet had to be ordered for me to play on the freshman team in high school. In 1970, in western Pennsylvania, I was far more concerned about the mandatory crew cut than I was about a slightly crooked grin. Braces were not a birthright then, as they seem to be now.

My wisdom teeth showed up when I was around 18, crowding my other teeth slightly forward. At the front, they competed for the limited space available. I did not take particular notice, nor did anyone else that I recall. I suppose, looking back, that I was not so bad to look at, in a goofy, lanky, redheaded sort of way. Some girls thought so. I had no complaints worth mentioning now.

When I was 27, a Massachusetts state trooper broke one of my front teeth. It was New Year's Eve day. I was driving my old Volkswagen Beetle from Boston to Storrs, where my youngest brother attended UConn and was having a party. Snow was coming down heavily and the windshield wiper motor gave out on the Massachusetts Turnpike near Sturbridge. It was unsafe to drive on. Actually, it was impossible to drive on. I left the car, determined to hitchhike to Storrs, and to worry about the car on another day.

I was arrested, charged with hitchhiking and jailed. I did not have the cash to post bond and they would not take a check. I was a noisy inmate, demanding the telephone every few minutes. My brother's line was busy. Eventually, the arresting officer walked into the cellblock and beckoned me close to the bars.

He reached through and grabbed me by the sweater, near the throat, and yanked hard, slamming my face against the bars. He swore at me, told me to adjust to the fact that I would be spending the night. He left. I tasted blood, and a piece of tooth.

I banged on the metal walls and yelled some more, and another officer entered the cellblock.

"Your buddy out there just broke my tooth," I told him.

"Oh, boy. That isn't kosher," he responded. I was let out, permitted to wash out my mouth, allowed to sit by the phone and call and call until I got through to my brother. His roommate, Jim, came and fetched me. The hitchhiking charge disappeared. I later filed a lawsuit, which came to nothing, in the end.

Days after the incident, the tooth was repaired by my parents' dentist. It needed a crown, really, but that was too expensive for me even then. I had saved the broken-off piece of tooth and the dentist cemented it back in place. He said the repair work would probably not last more than a few years.

The piece finally came loose again 20 years later, just months ago, falling into my mouth on a January morning as I brushed my teeth.

I remember peering into the mirror and thinking that it really didn't make much difference. Time had taken an inexplicable toll on my smile, and the broken tooth fit right in with its jagged, worn-down neighbors.

I don't know exactly when I lost my smile. Of course, it did not happen in a moment, but it could not have been that long ago relatively. I have a picture from 1995, a year I remember with some fondness; I am smiling in the photo and the teeth are there. If I still had my 1995 smile at the beginning of 2001, my dentist would not have said to me, at the end of a routine checkup and cleaning, "We can fix your teeth, you know. We can give you a great smile."

I took this somewhat personally.

"What do you mean?" I said, though, on some level, I am sure I knew exactly what he meant. I had to have known. I look now at pictures of me taken in 2001 and there is just the hint of a smile. I had evolved a new expression to show happiness or well-being, at least for the camera. In the photos, my lips part and the corners of my mouth turn up. But there are no teeth.

In the mirror, that day in 2001, I confronted my teeth. The view was less than horrifying but more than worrisome. The enamel, the material that is supposed to protect teeth for a lifetime, was gone, my dentist said. We speculated why. I said I did not grind my teeth, as far as I knew. He did not argue with me, but we could not otherwise account for the wear.

The cause was not pinned down, at least in my mind, but it didn't really matter much. My teeth, in particular my upper teeth, were seriously worn and would only get worse. I agreed to consider their reconstruction. My dentist took impressions to be made into molds, which would suggest the course of treatment.

After looking at the molds, my dentist said I could have my smile again, better than ever. I just needed 12 porcelain crowns to cover my upper teeth, and whatever ancillary work might be needed to put them in. The price for the crowns was $800 apiece. I did the math - $9,600, to start with.

"That's simply not going to happen," I said.

We went on to discuss my dental insurance, which conceivably could have paid up to $1,200 of the cost, the maximum allowed on my plan for a calendar year. It still seemed an insane expense to bear, an extravagance for a single parent with a son in parochial school, and college tuition payments looming in the not-so-distant future.

The insurance company rejected the possibility of a claim, in any case. The work was cosmetic, as unnecessary as braces had been in my childhood.

At later, routine appointments, I inquired, without any real hope, about the possibility of less expensive alternatives. I am sure they would have been offered if feasible. My dentist said, with regret, there was no such solution he could recommend. Fixing just some of the problem would cause others. My teeth were an all-or-nothing proposition.

I did some checking around, halfheartedly, with other dentists. The price quoted to me was about average for around here, as far as I could determine. There were no sales, no "buy one, get one free" marketing gimmicks in dentistry.

I put my teeth out of my mind, as much as possible, even when brushing them. If they showed up badly in a photo, I retouched it - thank goodness for digital imaging. I wondered, sarcastically, if insurance would pay for any percentage of the dentures I was surely going to need in a few years.

I don't know if my dentist was aware, in 2001, that less expensive dental care might be available overseas. If he was, he certainly didn't mention it.

And he declined to be interviewed for this article. "You're asking me to discuss the outsourcing of my business overseas," he said, when I asked if he would evaluate and comment on the work I had done in Costa Rica. "I think it's understandable that I would not want to do that."

Prof. David Farber, currently affiliated with Carnegie Mellon University in Pittsburgh, has curriculum vitae of such accomplishment that he has been called the "Grandfather of the Internet," without anyone raising a ruckus. Thousands of people who have never met him call him "Dave" rather than "Professor Farber" because one of the best-known things he has done is to publish the "Interesting People" mailing list, which has chronicled technology issues, news and anything else Dave finds interesting, daily since 1993. More than 20,000 people around the world appreciate Dave's filter.

On the evening of Feb. 16, I was minding my own business, not thinking about my teeth and reading the latest e-mails from Dave. The topic was the outsourcing of technology jobs overseas. Jim Warren, a computer professional and longtime online activist, went off on a mild tangent about how it is not just technology jobs that are leaving the country.

"Many Americans fly to Bangkok to get needed - or simply desired - medical and dental procedures ... everything from crucial transplants and sex reassignments to cosmetic surgery and liposuction. The surgery, hospital and drug costs are `almost nothing' by comparison to U.S. medical, surgical and hospital charges."

Warren told of a good friend who had a laparoscopic adrenalectomy - an operation to remove a benign tumor of the adrenal gland - that would have cost $30,000 or more in the U.S. In Thailand, she paid 100,000 baht - a little less than $2,600. The quality of care, he said, was outstanding.

Surgical - and dental - procedures for almost nothing! Hmmmmm ... Yeah, I was thinking about my teeth again, and I was perhaps on to something, and I was fascinated. Plug the phrase "cosmetic dentistry" into a search engine and you'll find pages and pages of stuff about American services, American dentists. But start looking for cosmetic dentistry and surgery in other countries and ... well, there's a whole 'nother world out there.

I soon ran across the concept of medical or health tourism - people going abroad and combining elective surgery with a great vacation for less money than the surgery by itself would have cost at home. You can get package deals - airfare, hotel, car, tours, meals, hospital stay and face lift, for example. Or you can go a la carte.

I made a list of countries where the health tourism business seemed to be booming or at least well organized, where prices were low, and where there was documented praise for the quality of service. Thailand made the list, of course. India. Singapore. South Africa. And, finally, Costa Rica. I looked briefly into Mexico, but did not turn up enough information to inspire confidence. For each of the other countries, there existed persuasive websites, doctors available to answer questions by e-mail, developed support systems and even government backing of health tourism.

Price was absolutely my first consideration. I would have had the work done locally if I could afford it. I didn't even know, for certain, what it would cost to repair my teeth here. But I had a three-year-old opinion that I needed, at the least, 12 crowns for $9,600. The cost of just the crowns was surely not the full cost, I knew; and I had determined that prices locally had gone up, if anything.

If I could get all the work done for substantially less than that, I decided, I would at least entertain the idea of traveling for my health. I looked into Costa Rica first, for no other reason than that it is the closest to home.

How does one generally go about picking a dentist? My whole adult life, I had picked my dentists based on where they practiced, from lists provided by insurers or from the yellow pages of the phone book. Doesn't everyone do that? It sounds a little crazy to say so, but I've never gotten a bad dentist by picking one this way. Then again, I've almost never had any work done beyond the call of routine dentistry - cleanings, X-rays, the occasional small filling. Part of the insular security of having dental treatment in the U.S. is the underlying assumption that there is a baseline standard of care, that service quality is nearly uniform. We mostly believe that. We trust them all unless we are given reasons not to.

As I always had, I chose my first prospective dentist from overseas from a list, this one on a website. The dentist had a nice site of her own, which gave the credentials of her and her partner. The site included a rave review in the form of an article from the Washington Times in 2002. A reporter on assignment in Costa Rica was stricken with a toothache, and was treated so well and professionally that he wrote about the experience under the headline "Cosmetic dentistry: The best Costa Rican souvenir."

All of this inspired confidence. I already felt I knew more about these dentists than I did my own. But the clincher, I think, was that the dentist was a woman. Rightly or wrongly, I felt that she would be more patient with my questions from afar, more communicative. In the back of my mind was still the thought that going overseas for dental work could be the mistake of my life - and I have made some dandies. I knew I would need reassurance.

I discussed all of this with no one. I was sure my family would think the idea of going abroad for dental work was preposterous.

I wrote to Telma Rubinstein, D.D.S., of Prisma Cosmetics Dentistry, San Jose, Costa Rica, on Feb. 18, telling her briefly about the condition of my teeth, asking for prices on crowns, telling her I could provide photos of my teeth, and inquiring as to how we might proceed. I was surprised to get a breezy, confident e-mail back within hours.

***

Hello Jeff:

Thank you very much for your interest in our services.

The treatment that you need can be performed perfectly.

This is what we do - all-mouth reconstruction. We have our lab on premises.

The cost of each pure porcelain crown is U.S. $350. Metal-porcelain crowns are U.S. $250 each.

I would appreciate very much if you'd send me the photos. Any other questions, we will be more than glad to answer.

We are going to attend a dental meeting in Chicago, so we won't be answering e-mails until Monday of next week. We are looking forward to hearing from you soon. All the best,

Dr. Telma Rubinstein D.D.S.

Prisma Cosmetics Dentistry

***

It sounded almost too good to be true. As did Telma - the informality and openness of even her first communication were what I was looking for from my dentist. I was painfully aware that I speak no Spanish at all, beyond pleasantries. I needed my dentist to speak English.

The math of it worked. Twelve crowns would cost $3,000 to $4,200. I started to look into airfare and accommodations. My mind was not made up; but fixing my teeth, restoring my smile, finally seemed financially possible.

As I had promised, I took pictures of my teeth to send to her. Deliberately photographed from a distance of inches, they looked awful, even disgusting to me. I took the precaution of also sending a small photo of my whole, unsmiling face, lest she think she was agreeing to work on a monster. She wrote back that I was "very handsome" - gratuitous and perplexing flattery, but kind.

In a short time we became friends, e-mail buddies.

In addition to the photographs, I obtained my dental X-rays and the three-year-old molds of my teeth. I shipped them to Costa Rica. After examining them, Telma's tone in e-mail turned cautious. On March 30, she wrote:

"These are not the best X-rays I have seen in my life. They are very dark ... From what I can see, I would go for 10 pure porcelain crowns U.S.$350 each. It's difficult to diagnosis if you would need some root canals. The premolars seem to be very decayed.

More or less, Jeff, I still need to see you to give a final diagnosis, but in general, this will be the idea."

Fair enough, I thought. I was forewarned.

Though I told myself I had not yet made up my mind, I went ahead and renewed my passport. I discovered I could use my American Airlines frequent flyer miles, which had been gathering dust since my days of crisscrossing the country for SBC/SNET, to pay for the airfare to Costa Rica, saving about $350. Telma helped me with arrangements for a place to stay - Las Cumbres Inn surgical retreat, where Elke Arends would be my host. I did not really need, I hoped, the full range of services provided at Las Cumbres. Elke caters more specifically to clients who are in Costa Rica for elective and cosmetic surgery, as opposed to "just" dental work - but I thought it would be an interesting and convenient place to stay for at least a few nights. For $75 a day, Elke promised three meals, a nurse on the premises, a friendly and relaxing environment and a great view of San José from a mountainside. Why not?

Telma told me I would need to stay in Costa Rica for eight or nine days, to allow for the time it would take technicians to fashion the crowns for my teeth.

I did the math. Airfare wouldn't cost cash, just 30,000 of my hard-earned frequent flyer miles. Accommodations, meals and a few day trips would not cost more than $1,000, surely. Though I had no firm estimate for the cost of dental work, I had a preliminary estimate on the crowns - $4,200 on the high end. The bill for the entire trip to the dentist, theoretically, would fit on one credit card. I wasn't thrilled with my buy-now, pay-later approach to dentistry but had convinced myself that - no matter what the insurance companies said - vanity was only perhaps half the reason for the trip. My original teeth probably didn't have many years left.

I decided I was going.

I booked the direct flight for April 12, the day after Easter, out of New York, returning with a stopover in Miami on the 22nd. I reserved a room at Las Cumbres for the first two nights of my stay, with Telma's help. Elke or someone from her staff would meet me at the airport and take me to the dentist.

I didn't sleep the night before. The plane would leave at 8:30 a.m., and overseas travelers are asked to be at the airport three hours before flight time. I left the house at 2:45 a.m. to catch a 3:35 a.m. limousine out of Bridgeport to JFK airport.

I was nervous and my imagination was working overtime. But I did not have any anticipation that, by 9 p.m. Costa Rican time, nearly 20 hours later, Telma would be finishing up my sixth root canal.

We landed at San José International Airport in Costa Rica a half-hour after noon - six hours in the air. I had never been south of Texas or Florida in the Western Hemisphere before.

I passed through one customs checkpoint with my carry-on bag and laptop, then recovered a suitcase. Juan awaited with a piece of cardboard, my misspelled but recognizable name printed on it. He welcomed me, in English, and loaded me into a van, a Toyota Previa.

"No hablo Español." It was to become my rueful mantra in coming days. Juan was a little surprised but took it in stride.

"None?" he asked.

"Hola. Cómo está. Uno, dos, tres. That's about it," I admitted. He laughed, but not unkindly. It was warm out, but not as warm as I had expected. San José is in the tropics, to be sure, but topographically, I had come up in the world. We were 3,700 feet above sea level, in the Central Valley, where about half the 3.8 million Costa Ricans live. Eighty degrees Fahrenheit, in April, just before the onset of the rainy season, represented a heat wave.

We were in San José, a city of perhaps 350,000 people, no more than 20 minutes after leaving the airport. The city is low to the ground; I found out later the tallest building, the Banco Nacional, is just 18 stories high. It looks taller, looming over the city. The last earthquake of serious consequence was in 1991. Mountains, some of them volcanic peaks hidden by clouds, dominate the horizon, rising to more than 11,000 feet above sea level.

"Pizza Hut," I said suddenly, a little absurdly. I had spotted my first sign of an American influence in what, at first glance, looks to be a very American city, except that most of the signage is in Spanish.

"Burger King. McDonald's. Kentucky Fried Chicken. Taco Bell." Juan rattled off the names agreeably, waving further down the road.

I paused a second. "We're sorry about that," I say finally. He laughs, though I'm not sure he understood, entirely, that I was slighting my own country. A little later, he reminded me, without rancor, that we are all Americans, here in the Western Hemisphere.

I told myself to be careful, from then on - I am from the United States, Estados Unidos. Juan was right. To identify myself, here, as "from America" is either ambiguous or a little ugly. Perhaps it is both.

We arrived at Las Cumbres Inn, nestled in the hills on the outskirts of the sprawling, low city. One can see all of San José, clear to the opposite mountain range. Elke waited at the door, smiling.

There was time to drop my luggage and for a quick lunch. I had a dentist appointment, after all.

Juan drove again. Prisma Cosmetics Dentistry was only about 10 minutes away, in a newish, six-story building with a white stucco façade. Banco Uno is clearly the biggest tenant on the premises, but Prisma has a big sign outside, too, up high - a lipsticked mouth, pursed to be kissed, sits between the words "Prisma" and "Dental." It is inviting without being lascivious. But it is more about sex appeal than it is about teeth, for sure.

Juan parked and went inside with me, past the security guard, up the elevator to the third floor. The door opens to a sparkling, modern, well-lit space that could not be mistaken for anything but a dentist's office. Down a hall, through glass doors, I could see small rooms with dental chairs in them. I don't know what I had expected the place to look like, but this was just fine.

Telma, dressed in standard dentist wear, a half mask hanging around her neck, came into view and spotted me in the waiting area. I was glad I had sent a picture of my face along with the one of my shriveled, mottled teeth.

"Jeff! So good to see you," she said, and kissed my cheek to punctuate the greeting. It was by far the most welcome I have ever felt in a dentist's office. She stepped back a pace. "Let me see," she ordered. I bared my teeth. She smiled.

"We have work to do," Telma said.

It was about 2 p.m. An assistant ushered me into an examination room, where I was seated in a comfortable, slightly reclined dentist's chair with all the usual accoutrements. A bib was affixed around my neck and I was left alone.

I had a full-wall window view of flowering trees across the street, with mountains in the distance. I had brought a book, Paul Theroux's "Fresh Air Fiend." I opened it and continued where I had left off on the plane. Theroux was paddling a kayak from Cape Cod to Nantucket. It sounded like a far more dangerous trip than the one I was on.

I had been awake for 28 hours, though I'd managed a few naps.

A little later, the seat went back, the lights came up and Telma had a handled mirror and one of those other dentist tools in my mouth. Her partly masked face was close and her eyes were serious. She poked around for 10 minutes or so before stepping back and lowering the mask. She looked worried, maybe more than worried. Later, I jotted down in a notebook that she had looked appalled for at least a moment.

"You grind them!" she said, and I imagined there was a hint of despair in her voice.

"I don't think so ... I have been told I do not," I replied, giving the same argument I had given to my dentist in Connecticut.

"There is nothing there, nothing to attach a crown to," she said. Telma meant my top front teeth, I knew, which were the furthest gone. Perhaps she meant more than that. I got a little panicky.

"Is there nothing you can do? Am I too late?"

"No," she said, and her worried expression was gone. But she wasn't smiling. "I need to make a stone ... a mold. I need some time."

She left but was back in a minute with her husband, Josef, the other dentist. Telma introduced us. Josef smiled. I noticed that he, alone, of the people I had met in the office, did not have perfect teeth. He was wearing braces, inconspicuous but there nonetheless. I tried to guess their ages. Telma looked to be in her 30s; Josef was perhaps a little older, but the difference might have been the few years I add, sometimes wrongly, for a receding hairline. They talked in Spanish, and Josef examined my teeth.

"A grinder," he said to Telma, and the conversation in Spanish continued. I couldn't understand a word but listened, anyway. I detected no disagreement, but the tone was sharp.

They reached some decision.

"I will be back in a little while," Telma said. I looked out the window. Whatever it is, I'll find out soon enough. I went back to my book. Theroux was camping in the Maine woods, trapped there by an ice storm and fog, but not panicked.

Telma came for me after a while, and we walked down the tiled hall to her office. She sat at her desk and I sat across from her. She spoke; her English was very good but slightly accented, my ear not yet tuned to it. I listened and asked questions when I didn't understand.

My teeth were in bad shape, worse than my three-year-old, dark X-rays had indicated. This was no longer a simple matter of crowning, capping or covering - if it ever had been. Telma and Josef recommended extensive root canal work to save the worst of my existing teeth so that they could be fashioned into sturdy "posts" that would support new man-made teeth - crowns of porcelain, some with wire in them for additional support, some filled with gold.

I would need six root canals. I would need 14 crowns covering all of my upper teeth except the two furthest back on each side. The preliminary total cost for the work was more than $7,000, several thousands more than I had prepared myself to accept. Telma had a handwritten list, with the procedures and costs.

My lower teeth were not so bad, she said. There was some work to do but they did not need root canals and crowns. They might be shaped, slightly, and bleached white to match the new uppers, which would be perfect.

I hesitated, asking questions. Was there any other way? No, she said, and went back over her proposal, item by item.

I wondered to myself, yet again, just when my upper teeth had disappeared from my smile. They had been bad enough, three years earlier, for a dentist in Connecticut to propose 12 crowns, at least $9,600 worth of work. My teeth were surely worse now; Telma could not be wrong about that.

Telma was looking for a decision. I stalled.

I wondered if I trusted the woman sitting across the desk and her husband.

I did the math. The bill would not fit on one credit card, but it would fit on two. It was a lot of money, more than I felt I could afford - but I was quite sure that a dentist in the United States would recommend the same work and that it would be far more expensive.

"OK, let's do this," I said.

It was almost 5 p.m. I figured we would start the next day, but at 5:10 I was flat on my back in a dental chair and needles were pumping Novocain into my gums. We had a lot to do in the next nine days, and Telma and Josef work long hours.

"Are you OK? Do you want to stop?" Telma asked a few hours later. "This would normally be three visits, what we are doing here."

I was, in fact, exhausted. But I wasn't in any pain. I had heard root canals could be agonizing, but I was more worried about the stamina of the dentist. Such precise work, for such a long time, so late in the day.

"Don't worry about me," she said, and went back to my root canals. We spoke infrequently that evening. It occurred to me how little I knew about dentistry and I decided that was, in part, because there is no way to ask questions, to be my normal, curious self, while the work is being done. Telma chatted occasionally but maintained intensity.

She finished the sixth root canal about 9:15 p.m. Josef was the only other person left in the office. We made an appointment for the next morning.

"You can sleep in a little; we will start at 9:30," Josef said.

Telma called Elke at Las Cumbres, who arranged for a cab to pick me up. The inn was mostly dark and behind a tall, closed gate when we pulled up. Elke opened the gate and paid the cab driver; part of her service is taking care of transportation. The cab driver spoke no English, and I was happy not to be figuring out the fare. I had no colones, the local currency, anyway. How could I? I'd had time to drop off my bags, have lunch and go to a seven-hour dental appointment.

Elke wanted to make me some dinner and gave me a mother's arched eyebrow when I declined; but my mouth was numb and my face hurt from keeping my jaw wide open for hours. I admired my accommodations - a sitting room with wicker furniture, fresh-cut flowers on the table, a kitchenette and a door leading to a small bedroom and a bathroom. I flicked through the cable TV channels - both English and Spanish. The Cartoon Network is hilarious in Spanish, at least to me, and "Dexter's Laboratory" was almost as comprehensible to me as it is in English, despite my not understanding a word. I figured out the alarm clock and fell dead asleep on the bed, fully dressed.

It had been quite a day.

I woke up before the alarm, surprisingly, and showered in a large stall, built for wheelchair access. It reminded me that most of the guests at Las Cumbres are there to recuperate from cosmetic surgery on their faces and bodies.

Outside, day dawning, I took photographs of San José, set against its mountains, before going to the dining room for breakfast. I had coffee and incredibly fresh fruit - melons, mangoes and guava - while checking my e-mail on a communal computer. Costa Rica has broadband. Though I heard many complaints about the government-run telecommunications company, Internet access was pretty good, better than I had expected. I was even able to use my Internet telephone service, Vonage, to make calls home to Connecticut for no charge. I told a friend about having six root canals in one evening.

"Now you must know what childbirth is like," she said. I considered letting her think so, but then said it had not been so bad - "Grueling, not painful," I described it. She was frankly disbelieving.

Other guests trickled in, some of whom I had met briefly the day before. I was currently the only male in residence at Las Cumbres, though that was not typical. Couples are common; husbands accompany their wives when they go to Costa Rica for cosmetic surgery, and, increasingly, men are cosmetic surgery patients, Elke said, when I later had a chance to talk to her at length.

"It is good that men are doing this," she said. "Women work hard to look good. Men can put in some effort." She was smiling, but I think she meant it. Elke is 58 and looked 15 years younger than that, to my eye. She has "had work done," to use the accepted euphemism.

I stayed at Las Cumbres just three nights and cannot recall being thrown together with a more pleasant collection of strangers. They called themselves "Elke's Kids," and Elke did not seem to mind taking them under her wing. Most of the women I met were in their 40s and 50s. They had no particular vanity about them, no obsession with youth. They simply wanted to look better, feel better about themselves.

I chatted with a few of them over breakfast. Sandy Talley from California was nearly recovered from her nips and tucks; she was contemplating having her teeth bleached - "Might as well do it while I'm here" - before heading home in a few days. Vicki Duncan, a self-described vagabond, wore dark glasses to cover the work done on her eyes. She is a U.S. citizen but had lived frugally but comfortably in a Costa Rican village for most of the past 11 years.

Nina, who asked that I not use her last name, looked like she had been in a car wreck. She had had a face lift, a neck lift, a "medium chemical peel" and perhaps some other "work" that did not make it into my notes. That night, she showed me the estimate she had from a cosmetic surgeon in New York City for the major procedures she had wanted. It came to $22,400 - $18,000 for the face and neck lift, $2,100 for an operating room fee, $1,320 for post-operative nursing care and $1,000 for anesthesia.

Her entire doctor bill in Costa Rica would come to $5,700, she said. She had gotten a good price. But that morning, she was wondering if she would ever again look anything like she had looked before, let alone better or younger.

Sandy said she would. Elke said she would. They had "been there, done that." I didn't have a clue, but I said I was sure it was going to come out fine, anyway.

At 9:30, I was on my back in the dental chair again, listening to Josef apologize for his English, which sounded fine to me. He numbed my mouth thoroughly and started sculpting my upper teeth, one by one. I encouraged him to talk as he worked, sometimes by making grotesque gurgling sounds, more often with a wave of the hand; and he warmed up and chatted easily about Costa Rica, to me, while maintaining a running dialogue in Spanish with his assistant.

Eight hours later, most of which Josef spent wielding dental tools inside my mouth, we were nearly done. I had felt him turn all my top teeth into fence posts with no crossbars, gapped by little stretches of gum. He had taken molds of what was left, and sent them to the lab. I looked and felt like an orc in "The Lord of the Rings" - pointy teeth, mouth flecked with putty and drool, no muscle control.

I knew early on that it was very much too late to turn back. But I had been doubting my wisdom and sanity in coming to this place for most of the day.

Josef held my temporary crowns - plastic teeth made from his molds in one hand as he touched them up, delicately, with the same whirling, whirring tools he had used in my mouth. He was utterly absorbed in his work, and I forgot about my real teeth for a few minutes as I watched him finish making the fake ones.

I commented on how happily intense he looked, and he smiled.

"Some dentists, maybe, would not take so much care with the temporaries," he said.

He admired them a moment more, and then it was time for me to "open" again. It took just a few minutes to cement these plastic teeth over the carved posts in my mouth.

It hurt even to try to smile, but I tried anyway, and looked in the mirror. My mouth - my whole face - was transformed. I had teeth!

"Don't kiss anyone too hard with these," Josef advised.

"I don't know anyone here so well that I would be kissing them."

He paused. "That is not a problem in this country," he said. We left it at that. I asked if my permanent crowns would look as good as the temporaries.

"Better, much better than this," said Telma, who had come into the room to admire the work. We made another appointment for the next day. My lower teeth needed some shaping and bleaching to match the final upper ones that would be made in the Prisma Dental lab over the next week, from the same molds that had been used to fashion my plastic smile.

"The hard work is over," Josef said.

The next day, Wednesday, was pretty easy. I felt incompetent to select the shade of white I wanted my teeth to be, which exasperated Telma a little. But I made her pick, anyway. Josef shaped my lower teeth a little and filled two tiny cavities I hadn't known I had. I donned dark glasses for one round of laser bleaching, which I wasn't sure I wanted but allowed to happen. My lower teeth needed to be whiter, still. I was given a mouthpiece fitted to my lower teeth and a bleaching gel in syringes.

Telma helped me find a place to stay for the following night, the Quality Hotel in San José, about a 20-minute walk from the Prisma office. I was reluctant to leave the comfort and familiarity of Las Cumbres, but I also wanted to save a few dollars and was anxious to see Costa Rica from the ground. It is absolutely possible to go to Costa Rica for cosmetic surgery or dentistry and entirely avoid any real or imagined dangers or inconveniences - places like Las Cumbres make that easy to do - but I wanted to see San José and some of Costa Rica on my own.

On Thursday, I said my goodbyes at Las Cumbres and Elke herself gave me a ride downtown to the Quality Hotel in the Central Colón area. I considered it a big favor; I would have taken a cab, but she said she was happy to do it. She waited while I checked in and then drove me to the dentists' office. I said I would stop and see her before I left the country, and I meant it; and she told me to stop by for dinner. She is a friend, I think. I am sure many, even most, of those who have stayed at Las Cumbres over the years feel the same.

In the office, Telma inspected my lower teeth. "Much whiter, much better!" she said. We sat for a while, the same office where three days earlier she had delivered the bad news about the condition of my teeth and the expense to refurbish my mouth. It was only 5 p.m., several hours before her day would end. She had not had lunch. I told her that she and Josef worked "like dogs," a colloquialism that I was nonetheless sure she would understand, and she did.

From Josef, I knew they were both born in 1958, making them just two years younger than me and not 10, as I had guessed at first. Telma said they went to kindergarten together, which made them childhood sweethearts going back further than any I have ever encountered. They had gone through Costa Rican schools and university, to graduate school in Switzerland, to advanced training in the United States, together. For 16 years, Telma had taught at a Costa Rican University and Josef had worked as a dentist in the country's public health system while they built Prisma Dental on the side.

I had thought that, perhaps, their enterprise had been supported in some way by the government of Costa Rica. I had found websites claiming some government affiliation or sponsorship of health tourism, for the doctors and dentists with private practices who sought clients overseas. I asked about that.

She looked at me evenly. "We built this, Josef and I," she said simply. They had moved into these new offices, housing their practice, lab and dental supply business, just five months earlier.

It was worth it, she said, but there had been many sacrifices along the way. There had not been as much time for their two daughters, now teenagers, as she would have liked. Building a business with her marriage partner had also had its difficulties.

"We are both very competitive," she said. "Even with each other ... you learn to let the other person lead, sometimes." She feared that the workload had dulled her creative edge.

"I would like to do other things. I would like to be more involved in the marketing. But there is no time," Telma said. "Sometimes I feel like an automaton. The work is everything."