(Burkhard Bilger’s post from THE NEWYORKER on 28 July 2025.)
Mexico’s Molar City Could Transform My Smile. Did I
Want It To? More than a thousand
dentists have set up shop in Los Algodones. Their patients are mostly Americans
who can’t afford the U.S.’s dental care.
Los Algodones was built on leaps of faith. A short
walk from the United States, it’s a place for the poor, the afflicted, the
huddled masses without dental insurance. On weekday mornings in late winter,
they start to arrive before dawn. They drive in from Arizona or California,
catch a shuttle from Yuma, or park their car in a lot in the Sonoran Desert and
cross the border on foot.
The path for pedestrians follows State Route 186, past a pair of Jehovah’s Witnesses offering free Bible courses, along a twisting corridor of razor wire and chain-link fence, through passport control, and into Los Algodones.
By noon, more than a thousand people will have
walked from the United States to Mexico, in the shadow of the thirty-foot wall
that divides them. They come on bicycles and in wheelchairs, pushing walkers
and leaning on canes. They come to be healed or transformed or to put an end to
their pain, preferably at deep-discount prices.
Los Algodones is part Lourdes and part Costco. It
has no cathedral, shrine, or holy well, yet it draws more than a million
pilgrims every year. For most of its history, the town has had little to offer
the average visitor. It sits with its back to the Colorado River, in the empty
floodplain where the Quechan people first raised crops—algodón means “cotton”
in Spanish.
Ranch hands and migrant farmers arrived in the eighteen-hundreds, followed by bootleggers, bartenders, drug runners, and pimps. In the nineteen-twenties, when all of Yuma had gone dry with Prohibition, Los Algodones had forty-eight bars and strip clubs a ten-minute stroll from the border.
I spoke to one local man who grew up in San Luis
Río Colorado, twenty-five miles to the south. As a teen-ager, he recalled, he
used to ride to Los Algodones on horseback, swim across the river to the United
States with a backpack full of weed, and return home to Mexico, flush with
cash. “It was all whorehouses and cantinas here,” he said.
Then came the dentists. In 1969, Dr. Bernardo
Magaña, newly graduated from dental college at the National Autonomous
University of Mexico, set up shop directly across the street from border
control. Within a year, he was treating dozens of patients a day, most of them
Americans. It would be more than a decade before many other dentists joined
him.
The town was just too rough, Magaña’s son,
Bernardo, who now runs the practice with his brother and his mother, told me.
“So my dad took it upon himself to clean it up.” In the early eighties, Magaña
was elected mayor of Los Algodones. Backed by the state government in nearby
Mexicali, he cracked down on vice and shuttered the most notorious
establishments in town.
Year by year, the bars gave way to dental clinics, the partygoers to patients. According to Roberto Díaz and Paula Hahn, who run a website about medical tourism called Border CRxing, Los Algodones now has the highest per-capita concentration of dentists in the world: well over a thousand in a population of fifty-five hundred. It’s known as Molar City.
When I first arrived, on a Sunday evening in March,
the clinics were all closed. At the Quechan Casino, on the Fort Yuma Indian
Reservation just across the border, the slot machines were thronged with
patients killing time before their appointments or flights home.
Myron Arndt, a former tire-shop owner from
Minnesota, was hunched over a Rich Little Piggies machine. He was scheduled to
get four new front teeth the next day. Mike Sherer, a tinsmith from Michigan,
was having some dentures and implants put in, and Terry Bussard, a retired
magnesium-plant foreman from Utah, was sporting two new plates of dentures.
One of the few without an appointment was Conny
Everett, who runs a pretzel stand at local fairgrounds. She needed a cavity
filled but couldn’t bring herself to go. She has a tendency to gag during
procedures, she told me. “Last year, I got in the chair—it was all paid for—and
I just chickened out. I’m, like . . .” She put her fist in her mouth and
widened her eyes.
It has been more than a century since the invention
of Novocain, but dentistry is still the stuff of frayed nerves and bad dreams.
The recumbent chair and whining drill, the blinding lights and masked faces
overhead, the needle, the spit basin, and the X-ray film clamped between your
teeth—every detail seems designed to inflame our fears.
“My family dentist when I was a kid, there was
something wrong with the guy,” James Murphy, a retired bookstore clerk from
Rhode Island, told me, between spins on a Dragon Link slot machine. “He drilled
every tooth in my head. That’s what made my teeth rotten. But he was Irish, and
you got to go with the Irish guy.”
Murphy was due to fly home the following day with a
full set of implants in his upper jaw, and he’d be back in three months to do
the bottom teeth. The total cost would be seventeen thousand dollars. “I’ve
never smiled so much,” he said. “Back home, it would have been thirty-nine
thousand just for the top. And they wonder why people are coming here.”
Crossing the border can be a little daunting the first time, some said. “Took us three years to work up enough nerve,” Ken Foshaug, a retired Coast Guard engineer who was staying at a nearby Sleepy Hollow R.V. park with his wife, told me. “All the guys holding guns and checking you out. Plus the whole thing of going to a foreign country to let someone drill into your teeth.”
But Molar City was built on leaps of faith. It’s a
place for the poor, the afflicted, the huddled masses without dental insurance.
Just a short walk away, on the other side of the wall.
Ifirst heard about Los Algodones from my friend
Todd, who lives in Mexico for part of the year. He’d been reading about the
town for a while and thought I was made for the place—cheap, poorly insured,
mouth a mess.
My bottom teeth lean this way and that in a
wandering line, like first graders on a field trip. The top row is reasonably
straight on the left, but, on the right, one rogue tooth is tilted back so far
that it’s half hidden by an incisor. In pictures from that angle, I have a
gap-toothed grin, as if I’ve just come from a bar fight or a remake of
“Deliverance.”
“Snaggletooth” is the term that my wife likes to
toss around if I annoy her. When we first met, in fifth-grade orchestra, we
were a perfect pair: she had big buckteeth. But by the end of junior high,
after her braces came off, her teeth were as straight and prim as everyone
else’s. Mine only got snagglier.
A succession of dentists of varying skill and
congeniality have worked on my teeth over the years, to no great effect. When I
first moved to Brooklyn, the best I could afford was a gruff woman in a
practice misleadingly labelled as “modern” above the door. A Russian émigré,
perhaps accustomed to patients of a doughtier nature, she was stingy with
anesthesia, I felt, and barked through her mask when I fidgeted.
A few years later, when I lived in Germany, the
health-care system there paid for regular visits to a gleaming, high-tech
office in a lofty penthouse. At my first appointment, the dentist peered at an
X-ray of the metal post that my Russian dentist had planted in my jaw and shook
his head: “When was this work done? The nineteen-fifties?”
Still, technology has its downsides. The more
advanced the imaging system, the more expensive the visit, and the more
problems it can find with your teeth. Last year, at a routine checkup in
Brooklyn Heights, I mentioned that one of my teeth had been feeling a little
sensitive. My dentist spent the next hour searching for the cause: he rapped
the tooth with a metal tool, had me chomp down on a stick, and, when I still
didn’t feel any pain, sent me to the next room for a panoramic X-ray of my
skull.
He eventually found a hairline fracture in the
tooth’s root. It was so faint that I could hardly see it, even under extreme
magnification, but he urged me to get a root canal and an implant for three
thousand dollars. I kept the tooth and haven’t felt any pain since. What stuck
with me, instead, was the sight of my skull. It looked like something unearthed
by paleontologists in Tanzania: ancient, battered, encrusted with minerals.
When the dental assistant sent the picture to my phone, she glanced up at me and
said, “This is what you’ll look like when you’re dead.”
The truth is that our ancestors had much better
teeth than we do. Neanderthals and other early humans, like the aptly named
Nutcracker Man, had burly, oversized molars for grinding down tough stems and
coarse grasses. Modern teeth are much daintier, yet they were still built for
diets heartier than ours.
Eating was meant to be a workout. Chewing raw
plants and sinewy meats both strengthened and lengthened the jaw. Without that
exercise, our oral growth tends to be stunted. The soft, processed foods we eat
offer so little resistance that our jaws end up shorter than they should be,
our teeth overcrowded—ninety per cent of us have some misalignment.
Early humans didn’t need orthodontia. Their
incisors fit together tip to tip, and their wisdom teeth were ten times less
likely to be impacted than our own. Their teeth also lasted a lifetime. The
food they hunted and foraged wasn’t laced with sugar, so their teeth weren’t
infested with bacteria that exude acids that eat through enamel. Our ancestors,
for all their lack of flossing, rarely had cavities.
Dentistry is a losing battle between form and
function. Our teeth were ingeniously shaped by evolution, just not for the way
we use them now. Most of medical history reads like a long, triumphal march:
surgeries refined, diseases vanquished, life spans extended.
But dental history—in books like “Evolution’s Bite,” by the paleontologist Peter Ungar, or “The Smile Stealers,” by the historian Richard Barnett—always seems to lead backward as well as forward. Agriculture is invented, only to wear down farmers’ teeth with grit from the stones used to mill grain.
Food production is industrialized, only to riddle
our teeth with cavities. Anesthesia is perfected, only to encourage people to
get rid of their imperfect teeth and replace them with less durable implants,
crowns, and veneers. And each advance, at least initially, makes dentistry more
exclusive, more expensive, more out of reach for the average patient. Hence the
crowds at Molar City.
Every morning at the Hacienda Los Algodones, guests
gather over breakfast to trade stories about their teeth. The hotel is owned by
the same family that owns the area’s largest clinic, Sani Dental, and most of
its guests are also patients. They get a free night at the hotel for a thousand
dollars in dental procedures, two nights for two thousand.
The Hacienda is a rambling villa on the outskirts
of town, with arched walkways, shady courtyards, and adobe walls painted a rich
annatto yellow. It was once the private residence of Enrique Jiménez, the
founder of Sani Dental, and his wife, Adriana. Enrique’s brother Jorge and his
sister Mayra also own dental clinics in town, as do his daughters Marcela and
Angelina. The Jiménez family is dentists all the way down.
The Hacienda’s guests are mostly
snowbirds—Northerners who migrate south to Arizona and California every winter,
following the sun. They’re a restless, nomadic folk, usually retired, who
descend in vast numbers on the R.V. parks and rentals of Yuma, Quartzsite, and
surrounding towns. (The population of Quartzsite balloons from less than three
thousand to more than a million in the winter.)
Theirs is a community built on chance encounters
between campsites, so they’ve learned to strike up acquaintances quickly—to
plop down beside a stranger at an open table and start telling stories. And
they all have stories. If they’ve made it to Molar City, they’re adventurers of
a sort, and the town has become a bargain hunter’s El Dorado. Cut-rate
pharmacies, opticians, dermatologists, massage therapists, hair-transplant
specialists, and exotic medical practitioners line the streets around the
dental clinics, promising deals unheard of back in the U.S.
On my first morning at the hotel, I looked up from
my eggs and beans to find a tall, craggy-looking man standing beside me. His
name was Denvy Larson, he said, and he had just driven down from Oregon with
his brother. He was a devout Mormon, seventy-nine years old, and had done
mission work in the Philippines.
But he wasn’t here for that. He’d come to Mexico to
turn his pickup into the truck of his dreams. “I want leather bucket seats and
pearlescent paint with metal flakes on the bodywork,” he said. “It’ll have live
flames in front that taper into ghost flames.” At the next table, Donna
LaTorre, a middle-aged woman from North Carolina, was talking about the
stem-cell infusion she was getting later that day.
She had long, platinum-blond hair, thick eyelashes,
and a slight tremor in her hands from Parkinson’s disease. She used to be a
bodybuilder, she told me—“a hundred and twenty-three pounds and built like a
truck”—but had refused to take growth hormones, so she couldn’t make a career
of it. She blamed her Parkinson’s on the pesticides at a tobacco farm where
she’d once worked. “Last July, I couldn’t walk,” she said, but she was back on
her feet now thanks to the infusions.
Guests like these were the outliers, though. Most were here for their teeth. I met Billy and Nancy Martinez at dinner on my first night. Nancy, who was seventy-three, had long dark-brown hair parted in the middle like Joan Baez and spoke in soft, falling cadences. Billy, four years younger, was short and round and full of vinegar. He would nudge me with his elbow when he told a story, then roll around in his chair laughing at the punch line.
They were from Red Cliff, Colorado, an old mining
town two hours west of Denver. Billy drove a snowplow and other heavy equipment
for the public-works department, and Nancy was a retired customer-service
representative for an electrical coöperative. They showed me pictures of the
abandoned railroad track where they liked to walk their dog, Miner Jack.
Then Billy leaned over and bared his gums at me. He
was getting two implants and a few crowns in the morning, he said, yanking his
mustache sideways so I could see the gaps between his teeth. He grinned like a
ten-year-old on the night before his birthday. I glanced over at Nancy, who was
picking at her plate. “I’m just going to have a consult,” she said. She’d
always been self-conscious about her smile, she said.
When she was a girl, she had a small, fanglike
canine that jutted between her front incisors. The other kids used to call her
Dog Tooth. “Oh, yeah, it was cool!” Billy said. Nancy wrinkled her lips: “I
didn’t think so.” She finally had the tooth taken out twenty-three years ago,
when she turned fifty.
But now there was a gap where it used to be, and
the edges of the teeth to either side were stained. She still imagined people
were staring at her. Two years ago, she and Billy had managed to save enough
money to put new crowns on those teeth. But then Miner Jack got cataracts, and
they used the savings for his eye surgery. “It’s a standing joke,” she said.
“Oh, when we have money, we’ll get your teeth fixed.”
Molar City seemed to be the solution: the prices
were a fraction of those at home. But she wasn’t quite convinced. “I thought
maybe I’d think about it but not actually do it,” she said. Billy and Nancy
weren’t especially vain. They just wanted “to face the world with dignity,” as
Brett Kessler, the president of the American Dental Association, put it
recently, when I asked him about the goals of dentistry.
Good teeth have become a social norm in America.
The more money you have, the straighter and whiter they’re expected to be. It
wasn’t always so. For centuries, the wealthy had terrible teeth. In the
sixteenth century, when sugar first made its way to England in large quantities
from Brazil, it was an aristocratic indulgence.
By 1700, the country was importing twenty-two
million pounds a year, a disproportionate amount of which was consumed by the
upper classes. When their teeth rotted, they had no choice but to see a tooth
puller or a barber-surgeon—sometimes just a blacksmith with a side gig. If his
iron pincers didn’t work, the preferred tool was a pelican: a fearsome-looking
device with two hooks to grasp a molar and a lever to wrench it out.
In France, the most famous of the tooth pullers, le
Grand Thomas, plied his trade on the Pont Neuf, in Paris. He took as his motto
“Dentem sinon maxillam”—“The tooth, and if not, the jaw.”
It was an egalitarian sort of torture: even
monarchs fared no better. Queen Elizabeth I was so fearful of dental work that
she lived with aching teeth for years. It wasn’t until the Bishop of London
volunteered to have one of his own teeth pulled, as proof of the procedure,
that the Queen consented to do the same.
In France, a courtlier breed of tooth pullers began to cater to the affluent in the late seventeenth century. Known as dentistes, they had milder manners and better tools—the pelican was replaced by the tooth key, a corkscrew-like device that could fasten onto a tooth and twist it out of the jaw—but only marginally improved results.
When Louis XIV had a tooth pulled at Versailles,
his dentist yanked at his jaw with such zeal that he tore a hole through the
palate and into the nasal passage. For a while after that, any liquid that the
King drank would come spraying out of his nose. To plug it closed, his surgeon
had to cauterize the hole with a red-hot iron.
Dentistry would have its own parade of progress
eventually. Anesthesia was introduced in 1846, the pneumatic drill in 1868,
dental X-rays in 1896. Ether gave way to cocaine, Novocain, lidocaine,
articaine, and laughing gas for the lucky few. As always, though, there were
unintended consequences.
Dentures, carved from walrus ivory or other
materials and tied in place or mounted on sprung-steel plates, were
excruciating to wear and reeked after use. Nonetheless, the ones made with real
human teeth were so popular that some parents were said to pull their
children’s teeth to sell them.
In morgues and on battlefields across Europe, the
dead were scavenged for donations—“Waterloo teeth,” they were called, after
Napoleon’s great defeat in 1815. Well into the twentieth century, preventive
dentistry was beyond most people’s means.
My mother-in-law, who grew up on a farm in Nebraska
during the Depression, lost most of her teeth by the age of fifteen. Her
parents couldn’t afford fillings, so any tooth with a cavity was pulled. When
she married, she had partial dentures on top and bottom—a fact my father-in-law
didn’t learn until years later. “It wasn’t hard to fool him,” she told me. “I’d
take them out after he went to sleep. Or I’d wake up, take them out, and go
back to bed.”
Any neighborhood dentist is capable of miracles
nowadays—even root canals can be relatively painless. And more wonders are in
development: gene therapies that grow new teeth, stem-cell treatments that coax
teeth into filling their own cavities, nanoparticles that loosen teeth so that
braces can realign them more easily.
But the gap between the best care and the worst has
only grown. Less than half of all Americans go to the dentist in any given
year, the American Dental Association estimates, and the procedures they most
need are the ones they can least afford. In 2019, for example, close to two
million emergency-room visits were caused by dental problems; oral cancers
alone—often detected too late—kill some twelve thousand Americans a year.
Whether by cause or effect, Peter Ungar notes in
“Evolution’s Bite,” poor oral health has been linked to Alzheimer’s, diabetes,
heart disease, H.I.V., osteoporosis, premature births, sepsis, and a host of
other conditions. “As your teeth and gums go, so goes the rest of your body,”
he writes.
The symptom most common to our dental shortcomings
is a seething resentment, occasionally flaring into rage. Dentists may be the
most abused professionals in the country, next to airport check-in agents. In
2020, in a survey by the New York University College of Dentistry,
three-quarters of dentists reported that they’d been verbally attacked by a
patient, and nearly half had been physically assaulted.
Dental students were treated even worse: eighty-six
per cent had been verbally abused in the previous year. The aggression toward
dentists was remarkably indiscriminate: age, sex, race, and years of experience
made no difference, nor did the number of patients that they saw per day. The
rate of abuse remained the same.
Three years ago, at a dental clinic in Tyler, Texas, a forty-year-old man began to berate the nurses working on his dentures. When a dentist asked him to leave and never return to the clinic, the patient pushed him to the ground. Then he walked out to his truck, came back with a handgun, and shot the dentist and one of his colleagues to death.
Two years later, in New Orleans, a
fifty-five-year-old woman was accused of stabbing her dentist in the eye. A
month after that, in a suburb of San Diego, police reported that a
twenty-nine-year-old man stormed into a dental clinic and opened fire with a
semi-automatic handgun. He hit the receptionist in the leg and the office
manager in the hand, elbow, and torso, then went looking for the dentist. When
he found him, hiding inside an office, he shot him multiple times in the upper
body.
The alleged shooter in San Diego, Mohammed
Abdulkareem, was Muslim; the dentist, Benjamin Harouni, was Jewish. Some
speculated that the killing was a hate crime, but the police found no evidence
of that. Abdulkareem had been coming to the clinic for months, complaining that
the dentures he’d been given didn’t fit. The office manager had taken to
intercepting him at the door because he frightened the staff.
The attack on the clinic may have been
planned—Abdulkareem had bought the gun five days earlier—but it was also
strangely impersonal. Harouni wasn’t the dentist who had fitted the dentures,
and he had tried to fix the problem at no charge. He was just twenty-eight,
less than two years out of dental school, and had made a point of working in a
clinic with poorer, subsidized patients. But none of that mattered. Abdulkareem
was angry and in pain, it seems, and he wanted someone to pay. Any dentist
would do.
“I’m a psychologist, and I deal with a lot of
dentists,” Harouni’s uncle, Daniel Sadigh, told me. “When this happened, every
one of them reached out to me. They were really scared.” Even with their modern
tools and targeted anesthetics, dentists see patients at their most anxious and
vulnerable.
The mouth is so close to the brain, so tightly encircled by sense organs, that drilling can trigger a fight-or-flight response. Get that damn thing out of there. For a long time, going to the dentist brought with it the certainty of pain. Now it brings a fretful uncertainty.
Will the scans uncover issues I can’t feel? Will my
dentist suggest a treatment I don’t need? Can I afford the one I do need? And
will it hurt after all? “That part of it I’m not so sure has gone away,” Sadigh
said. “Nobody goes to a dentist with pleasure.”
The walk to Sani Dental from my hotel was less than
reassuring. Every twenty or thirty feet, a hawker would shout and cross the
street to shake my hand, or step away from a storefront and fall in beside me.
“Hey, buddy, you looking for dental work? Pharmacy?”
Before coming to Los Algodones, I’d envisioned the
town as a kind of outlet mall: strip after strip of stucco-clad clinics, with
parking lots in between. The actual place was more unruly. The dental clinics
rose from the streets at regular intervals, some of them sleeker than any I’d
seen in Brooklyn (not a high bar, admittedly).
But the gaps between them overflowed with street
venders, curio shops, taquerías, liquor stores, and T-shirt stands, with the
hawkers scouting the crowds around them. “You need a root canal? Twenty per
cent off!”
The glass door to Sani Dental was outlined by a
giant tooth. Stepping inside from the clattering street felt like a jump cut in
an action film, with a subtitle saying “Miami” or “Dubai.” The lobby was hushed
and spacious, with two eager young receptionists in matching polo shirts. A
long arched corridor stretched behind them, soothingly lit like an undersea
passage. There were seventeen examination rooms on one side and a row of white
leather couches on the other, with waiting patients.
The clinic’s thirty-five dentists and sixty-six
support staff see more than nine thousand clients a year. (Sani also has branch
offices in Cancún and Playa del Carmen, as well as a plastic-surgery and
hair-transplant clinic in Los Algodones called Sani Medical.) At its newly
built, three-story laboratory, teams of designers create digital models of
implants and dentures, then fabricate the molds with 3-D printers. The finished
products are cast in ceramic, gold, titanium, steel, or chromium cobalt, then
glazed by local artisans to match the patient’s teeth and gums.
Being a patient at Sani Dental is a bit like being
a car chassis at a Ford factory. For the next three days, my teeth and I would
get passed from scheduler to diagnostician to clinician to lab tech, then back
to the clinician, and finally to an accountant to settle the bill. Each member
of the chain was expert at a given task and did it over and over again.
Depending on whom you ask, this assembly-line
method is either Sani Dental’s strength or its weakness. “They do things fast
and cheap and get you out the door quick,” one dentist in Los Algodones told
me. “But sometimes it’s detrimental of quality.” To Dr. Juan Carlos Miranda
Villa, my diagnostician at Sani, the clinic’s speed and efficiency only
increase its quality.
“When you do more, you have more skills to do it,”
he said. “If I was a patient and I had to choose between a doctor who does five
hundred surgeries per year and a doctor who does eighty or a hundred, I would
choose the one with more experience. Their hands are faster, their work is
better.”
Miranda Villa is a compact forty-two-year-old with a peppery beard and dark, probing eyes. He grew up in a family of doctors—his father was a gynecologist, as is his brother—and speaks with the melancholic air of a man accustomed to navigating his patients’ self-doubts and fears.
“You are a curious case,” he told me. “You have
that one tooth on the right side. It’s so far back that we could either pull it
or grind it, but it would take so much grinding that it might not be worth it.”
I had asked him for two assessments, one functional and one aspirational. What
did my teeth need to stay healthy, and what would it take to straighten them
out—to make them look like those on the posters in his office?
The second question seemed to bother him. “My
specialty is cosmetic, but function needs to be first,” he said. “If a patient
comes in and says, ‘I don’t like my crooked teeth. I want you to just pull them
and give me implants’—which is something we hear daily—we tell them no. We
won’t pull healthy teeth.”
Still, by the end of our session, he had answered
both my questions. To stay healthy, he said, my teeth would need ten fillings,
mostly to plug the gaps exposed by receding gums. Straightening them out would
take a little more work. All but four of my teeth—twenty-eight in total—would
need to be reshaped.
This meant grinding them down to little nubs of
enamel, like pegs on a cribbage board, then capping them with crowns. The Sani
lab would cast the crowns out of white zirconia, a ceramic much harder than
stainless steel, tint them to my specifications, and shape and size them to fit
my jaw. Then a clinician would cement them into place.
The ten fillings would be seven hundred
dollars—about a fourth of the going rate in Brooklyn. The full treatment would
cost fourteen thousand. Before I made my decision, though, Sani Dental would
mock up some plastic crowns that could fit over my existing teeth. “Smile
Design,” Miranda Villa called it. “It’s like trying on a suit before you buy
it,” he said.
When I left the examination room, I passed Billy
and Nancy Martinez, sitting on a couch in the hall. Billy’s cheeks looked a
little puffy—he’d had the first of his temporary crowns put in—but he managed
to twist them into a grin. His dentist was great, he said. “I think I got
lucky!” Nancy was less pleased. “I think you got lucky, too,” she said.
She had decided to go ahead and get her front teeth
fixed, only to be told that she needed a root canal as well. “She had some
pain,” Billy said, glancing at her. Nancy nodded: “My dentist kept saying,
‘Oops!’ ” Her front incisors were now capped with temporary crowns, so the gap
between them was gone.
When I asked if I could take her picture, she
laughed and said no, covering her mouth. “I’m definitely not photogenic.” The
temporary crowns did look oddly artificial—like the plastic vampire teeth that
children wear, except more elegant. Costume jewelry for the mouth.
The line between medicine and cosmetics isn’t
always clear when it comes to teeth, and insurance companies have smudged it
further. Nancy’s crowns were mostly cosmetic, Billy’s mostly functional, but
neither would have been covered by dental insurance. Most policies pay for
preventive care, like fillings and teeth cleanings, but not cosmetic work, and
major procedures like root canals are largely charged to patients.
Dental insurance is the opposite of health insurance: the more serious your condition, the less likely your plan is to pay for it. An abscessed tooth can kill you, but if you can’t afford to get it treated you may have to wait until the infection sends you to an emergency room—at which point your health insurance will kick in.
Even if your dental plan does cover it, it will pay
only a small part of the cost: reimbursements are usually capped at one to two
thousand dollars a year. It’s no wonder more than seventy million Americans
don’t have dental insurance—three times as many as lack health insurance.
The more sophisticated our medicine, the more
demanding our health standards. We expect medical insurance to cover everything
from a balky knee to Ebola. “But there is no established minimum standard for
oral health,” Brett Kessler, of the American Dental Association, told me. “If I
had mouth cancer, Medicare would pay to remove the tumor but not to replace my
teeth. If I have a hip problem, I can get a hip replacement. Why can’t I get a
tooth replacement?”
This unnatural divide goes back to the beginnings
of medicine and dentistry. Physicians insisted on it at first—they didn’t want
their work tainted by tooth pullers. Then dentists followed suit: by the late
eighteen-hundreds, they had their own schools, offices, and specialized
equipment, and little interest in being governed by doctors.
In 2010, the Affordable Care Act declared that
children up to the age of nineteen have an essential right to dental insurance,
but adults were left off the bill. By 2019, eighteen per cent of adults
couldn’t afford dental care. Kessler believes that medicine and dentistry
should be part of a single health-care system—“It’s time to reconnect the mouth
to the body,” he says.
But it’s a long-term project: the American Dental
Association’s latest strategic initiative is called Oral Health 2050. In the
meantime, having healthy teeth will be part right and part privilege, with
dentists walking the uneasy line between them.
I have a clear memory, from when I was eleven, of
sitting in a dental chair in a sunny examination room, watching with a rising
sense of panic and entrapment as a dentist told my mother that I needed braces.
My mother looked concerned but unconvinced. Why braces? The dentist frowned, as
if to say, Isn’t it obvious?
Then he tried another tack. Without them, he told
her, I was likely to get gum disease. This was debatable. The evidence for the
health benefits of braces has never been very strong. In 2008, a review of
twelve studies found that orthodontia had actually increased gum recession and
bone loss.
Another review, in 2020, looked at eighty-seven
studies and found “an absence of evidence” for the connection between dental
health and misaligned teeth. Braces bring their own risks: they can build up
plaque, inflame gums, and erode enamel. If wearing them is worth thousands of
dollars and years of discomfort, it’s rarely for medical reasons. It’s because
they make your teeth look nice.
My mom promised to make an appointment with the
orthodontist, but she never did. She had five children, each with teeth in some
state of disorder, and couldn’t afford to refurbish us all. I doubt she would
have even if she could. In Germany, where she and my father were born, crooked
teeth were just another intrinsic feature, like a big nose or protruding ears.
You would no sooner change them than change your eye color.
Americans are a little more finicky. As many as three-quarters of all teen-agers now wear braces at some point—up from thirty per cent in the eighties and five per cent in the fifties. Two-thirds of today’s Germans have worn them, but only a third of the French and even fewer of the British.
When I was in seventh grade, my father took a
sabbatical in southern France, and my parents put us in public schools for two
years. I remember looking around at my new classmates—skinny, sardonic,
unashamed of their strange knitwear and meandering teeth—and thinking, My
people.
These days, my people all seem to have straight
teeth. If not, they’ve probably thought about fixing them. Cosmetic dentistry
has become a four-billion-dollar industry in the United States, according to
one estimate, and it’s projected to double in size by 2034.
When I first went to Sani Dental, I had no
intention of getting any cosmetic work done. It was just a thought experiment,
I told myself. But after talking to Miranda Villa the idea was almost
tempting—at least compared with getting braces. The process would take three
days rather than three years, he said, and with enough anesthesia I would
hardly feel it. I could leave Mexico with new teeth.
Dr. Sofia Terrazas, the clinician in charge of my
fillings and Smile Design, was the same dentist who was working on Billy—the
one he’d felt so lucky to get. She was thirty-three years old, born in
Mexicali, and trained in dentistry and prosthodontics at the Autonomous
University of Baja California and the Technological University of Mexico, in
Mexico City.
She had a high, piping voice and big round glasses
that gave her a look of perpetual surprise as she bustled from room to room,
chatting with patients and staff. Procedures at the clinic sometimes ran
through the night—the record for the latest was four in the morning—but
Terrazas never seemed to tire. “We look like a factory,” she told me. “But you
see me—I take one patient and stay with them for two or three hours, and the
next day the same. I do nothing quick.”
Terrazas’s examination room was surprisingly
bare-bones, given the clinic’s often state-of-the-art equipment. Her dental
chair had no faucet or spitting basin, and the office’s side walls were
partially open to the rooms next door. “I haven’t taken my amoxicillin yet!” I
heard a patient say, while Terrazas was placing my fillings. “I need it for my
heart murmur before the cleaning.”
Then, a few minutes later, in a higher voice: “I
thought the bridge was supposed to go on the other side!” Terrazas chuckled and
kept on working. She put in six of the ten fillings in a little less than two
hours, yet managed to be more attentive than any dentist I could remember.
“Pain?” she kept asking, “Pain?” But my mouth was too swollen to answer. She
had shot it so full of anesthetic that my right eye and nostril had gone numb,
too.
The Sani Dental lab, meanwhile, was working on my
mockup crowns. On my first day at the clinic, Terrazas had run a handheld
scanner around my mouth, then projected the 3-D images onto a screen. When I
looked up, my teeth and ragged gums were smiling back at me, as if ripped from
my mouth by an alien predator.
During the next two days, the lab used these scans
to create the molds for the plastic crowns. When they were ready, on the third
morning, Terrazas filled them with a gooey white resin and pressed them onto my
teeth, pushing out any air gaps. A few minutes later, when the molds came off,
the new crowns encased my teeth like hard shell on a row of tiny ice-cream
cones.
Terrazas spent the next twenty minutes chiselling
off any rough edges and seams. It was an oddly claustrophobic experience: I
felt like a statue trapped inside a piece of marble, slowly getting released by
a pick and a drill. When Terrazas was done, she handed me a mirror. The crowns
felt rough and intrusive inside my mouth, so I expected them to look just as
unnatural.
But the reflection in the mirror was weirdly
familiar. The smile that the lab had designed wasn’t meant for some toothy ad
salesman. It was what I might have imagined as a boy, when I used to hide the
gap in my teeth behind my hand when I talked. The new crowns were a pale ivory,
as craggy and dully serrated as the old. They just happened to be straight.
Before the procedure, a photographer at the clinic
had taken a head shot of me baring my teeth in a big grin. Now she took
another. Once Terrazas had pried off my fake teeth, I texted the
before-and-after shots to my friend Todd, who had first told me about Molar
City. “Do it!” he said. All it would take was fourteen thousand dollars and the
destruction of my natural teeth.
One afternoon in early April, a month after my trip
to Molar City, I went to Beverly Hills for a second opinion. The dentist I
visited, Dr. Kevin Sands, does much the same work as Sani Dental but for very
different clients. In an era when closeups of celebrity teeth have become
objects of obsession on social media, Sands is the premier dentist to the
stars.
His patients have included Emma Stone, Justin
Bieber, Kanye West, Matthew McConaughey, Miley Cyrus, Robert Downey, Jr., and
members of the ruling families of Qatar and Saudi Arabia, as well as Steve
Jones, of the Sex Pistols, and Jiffpom, the celebrity Pomeranian.
Sands’s office is in Beverly Hills, on the ninth
floor of a building famous for its high-end dermatologists, plastic surgeons,
and anti-aging specialists. (Sands told a reporter from GQ that in 2001 he paid
the previous tenant four hundred thousand dollars just for the right to take
over the lease.) In the waiting room, the walls were decorated with framed
magazine covers scrawled with signatures and testimonials.
“Dr. Sands—I couldn’t smile in this pic bc I hadn’t
seen you in a while,” Kim Kardashian wrote on a picture of herself, glowering
on the front of Vogue. “JK. You’re the best dentist ever.” A light pop
soundtrack thumped along in the background as a succession of patients wandered
in and out: a pair of chatty actors, a raffish young man with golden lips and
glittery tattoos, an elderly woman blissed out on anesthesia, wobbling on her
granddaughter’s arm. After a while, a sylphlike receptionist named Chanel, clad
in chic black scrubs like the rest of the staff, brought me a glass of hot
green tea.
“Just a few more minutes and I’m all yours!” Sands
said, when he came to introduce himself. He bowed low and spread his arms wide,
as if accepting the crowd’s applause, then bounded back to his office. Sands is
fifty-two, with the fit look and insistently upbeat manner of a life coach or a
personal trainer. He has thick brown hair and a wide, flat grin that squeezes
his eyes into crescents. His own veneers are so true to life, he told me in the
examination room later, that his mother couldn’t even tell that he had them.
I asked him what it would take to straighten my
teeth and how much it would cost. “Smile for me,” he said. He took a quick
look, nodded—“All right, I already know what I’m going to do”—and left the
room. His assistant pulled out a pair of what looked like rotisserie skewers.
She clamped them into my mouth to stretch the lips apart and took snapshots and
X-rays of my teeth. Then Sands came back carrying a ring binder full of
pictures of former patients—like a Big Book of Dental Problems.
“Here is a gap you can drive a truck through,” he
said, pointing to a picture as he leafed through the album. “Here is meth
mouth—very common in this town. It just bombs out your teeth.” A brief tour of
gum recession and misalignment followed, culminating in an especially
unfortunate case: “This guy fell on his teeth. They’re worse than yours!” For
every unsightly before photo, he showed me a triumphant after, with rows of
shiny incisors redeemed through the artful deployment of porcelain and
implants.
Then he turned his attention to me. “Your teeth are
a little messed up,” he admitted. “See these spikes of plaque back here?” He
pointed to one of the X-rays. “And see how uneven your gums are? I’m going to
go in there with the laser to even that out. Your back teeth are ground down,
these front teeth are, too, and your molars are kind of chipped. It’s just
age—a lot of wear and tear. Honestly, in your case, a full-mouth reconstruction
is the best thing. Get your cusps back to where they were when you were twenty.”
When Sands had finished describing his plans, he
left the room again, and his office manager, Andrea Aro, took his place—the
good cop to his bad. Young and soothing in manner, with long black hair and
warm, wide-set eyes, she had perfect teeth, like the others—veneered by Sands
himself—and wanted the same for me.
“He is going to rebuild your bite with the magic of
porcelain,” she said. “And the prosthodontist will make sure that it works from
a mechanical point of view.” This office was only twelve hundred square feet,
yet a whole team of specialists would be working on my mouth, including tooth
sculptors of the highest calibre.
“We make it look easy, but it’s not easy,” she
said. “People don’t realize how many people are involved with one tooth.” She
smiled, lost in a reverie of Old World dental craftsmanship. “I could talk
about it all day,” she said. “I think it’s very special.” Then she handed me
the price list.
What are good teeth worth? In 1997, William
Ecenbarger, a reporter for the Philadelphia Inquirer and the Reader’s Digest,
had his teeth examined by fifty dentists in twenty-eight states and the
District of Columbia. Before his trip, Ecenbarger got a baseline diagnosis from
a panel of four experts, including a former dean of the University of Kentucky
College of Dentistry.
The panel agreed that his teeth were in good
condition, aside from one molar that needed a crown, and that the work should
cost less than fifteen hundred dollars. Four months and fifty dentists later,
the diagnosis was less clear. One dentist told Ecenbarger that he needed six
crowns, but not on the molar the panel had singled out. Another recommended
four crowns—again, not including the damaged molar—and nine thousand dollars in
cosmetic work. Others suggested five crowns, seventeen crowns, twenty-one crowns,
twenty-eight crowns, or a full-mouth reconstruction. Their prices varied from
less than five hundred dollars to nearly thirty thousand.
Ecenbarger’s dentists were from the same country,
but their suggestions were all over the map. My dentists were from different
countries, but their recommendations were the same: twenty-eight crowns and one
implant. The only difference was in cost. Sands wanted a hundred and nineteen
thousand dollars for the work—more than eight times the Sani Dental price.
The dentists in Los Algodones seemed as well
qualified as those in Beverly Hills, and their equipment was often more
sophisticated: Terrazas and Miranda Villa checked my teeth with a digital
panoramic X-ray machine and a handheld 3-D scanner; Sands used a
point-and-shoot camera, standard X-ray film, and a small mirror that his
assistant stuck in my mouth.
“We keep it old school,” Aro told me. “We aren’t
doing 3-D printing or A.I. That’s not going to be the same as a handmade
tooth.” To Sands, this was his biggest selling point. “I have real artists do
each tooth,” he told me. “And I have different ones make them for males,
females, and older people. That’s what separates me. The artist that did my
teeth will be doing your teeth.”
What are good teeth worth? To some of Sands’s
celebrity clients, the answer could be tens of millions of dollars. Their
handmade crowns, magnified a dozen times onscreen, may well look more shapely
and natural than Sani Dental’s computer-designed, assembly-line versions.
Whatever their price, veneers and crowns can crack or come loose if poorly
installed, and what’s left of the teeth beneath them can start to decay.
Like nose jobs and face-lifts, they can also look disturbingly artificial—oversized, rectilinear, glaringly white. Two years ago, fans of the actress and singer Selena Gomez became convinced that she’d had her teeth veneered. When Dr. Jordan Davis, a dentist in Utah with a large Instagram and TikTok following, posted a video with closeups of her teeth, it got nearly ten million views. They were too uniform, he said, too white, too opaque. “Her original smile, her natural teeth, I feel like, are much better,” he concluded.
Teeth are emblems of character, people have long
believed, whether consciously or unconsciously. “Clean, white, and
well-arranged,” they reflect “a sweet and polished mind and a good and honest
heart,” the nineteenth-century Swiss physiognomist and theologian Johann Kaspar
Lavater wrote.
Crooked or decaying, they bespeak “sickness or some
mélange of moral imperfection.” Richard Barnett, in “The Smile Stealers,”
contrasts Lavater’s quote with one from a booklet published by the American
Association of Orthodontists in 2000. Straight teeth demonstrate “a highly
visible commitment to self-improvement,” the booklet claimed. They express both
“the beauty of conformity” and “the beauty of achievement.”
Still, there’s something to be said for staying
crooked. The more I looked at the Smile Design picture from Sani Dental, the
more I knew that I’d miss my old biters. (My wife, for all her talk of
snaggleteeth, was appalled at the idea of straightening them.) If teeth are
emblems of character, mine seemed true to form—jumbled, contradictory, ground
down in spots but still good for chewing things over. They went off in every
direction but somehow got their work done.
In Beverly Hills, after Sands had enumerated my
dental flaws and Aro had told me the price to fix them, she noted that I’d
still have to wear a mouth guard at night for the rest of my life, because I
grind my teeth in my sleep. Then she smiled and added, offhandedly, that my
teeth were in good shape over all. “At the end of the day, this is all
elective,” she said. “You will live a perfectly fine life without it.”
I felt like I was eleven years old again, hearing
the dentist say that I needed braces. This time, I was the one who’d asked
about straightening my teeth, but Sands required little prompting. One look at
my teeth and he knew that they needed fixing.
It reminded me of something Miranda Villa had said when I last saw him at Sani Dental: “Pay attention to the TV commercials. All the actresses with the white teeth—that is what they are selling. But white teeth are not normal. Our teeth are yellowish. As long as they are working, they are nice. If they are straight or crooked, they are nice. It’s God’s creation.”
Before I left Molar City, I checked in on Billy and
Nancy at the clinic. Billy looked even more beat up than before. His upper lip
was swollen and bruised a mottled pinkish blue, and the skin on his face was
rubbed raw. He’d had three root canals that afternoon—“I got a piece of tooth
in my eyelash,” he told me—and a set of crowns had been put on his upper teeth.
Between procedures, he’d gone out to get a
microdermabrasion, a HydraFacial, and a hair-growth treatment. He bent over to
show me the bald spot on top of his head. He wasn’t a good candidate for plugs,
he said, so the specialist at Sani Medical had drawn some of his blood and
injected the plasma into his scalp to spur natural growth. “Next time you see
me, I’ll be like the jungle man!”
Nancy had just had her permanent crowns installed.
Milk white and smoothly sculpted, they were more natural than her temporary
crowns, but I still missed her old gap-toothed smile. Unlike Billy, who’d been
rolling through Molar City as if it were one long amusement-park ride, Nancy
looked spent.
Most of the patients at the clinic seemed happy
with their work, and my own fillings had gone in without incident, but her
visit had been a comedy of errors. At dinner the previous day, she’d swallowed
one of her temporary crowns. Then its replacement fell off, too. She was so
sore from the procedures by then that she told Billy she wished she’d never
done them. I asked her how she felt now—was it worth it after all? “Yeah,” she
said, with a wary smile. “But I have to wait and see.”
Billy put his arm around her shoulders. Earlier
that day, he’d pulled a ziplock bag from his pocket and shown me two pieces of
what looked like broken ivory. The dentist had just removed these old implants
from his jaw, he said. They’d cost him eight thousand dollars back in Colorado.
“I’m going to make Nancy a necklace,” he said, then laughed. “What an
adventure!”