#84 – The Expat Files: Dentistry in Latin America and Beyond

Automatically transcribed from the original recording; names and wording may contain errors.

[00:03] Hi everybody, I'm Johnny Mueller and you're listening to The Expat Files, living in Latin America. The show that tells you what it's really like to live, work, play and or retire in Latin America. I tell it just like it is, not the version they give you in those glossy travel magazines, or the picture they paint for you in those international traveler websites, where they're only trying to sell you something. What's it really like for expats living in Latin America? Well, it's time to take off those rose colored glasses and find out. So let's get started. And now, by very, very popular demand, I'm going to talk about dentistry down here in Latin America. Ever since I started the show, I've been getting a lot of requests on that subject, specifically because so many of you first worlders and expat wannabes out there are queued in on

[00:50] the fact that medical tourism is a huge thing down here, and of course that includes dentistry. So if it takes me one, two or even three shows, I'm going to give you the real load down and tell you everything you ever wanted to know about third world dentistry, and whether or not you should trust your mouth to the professionals down here. And you might even want to listen to this report twice, because I'm going to tell you some stuff right now that you certainly never knew about dentistry, and maybe never wanted to know, but you should really pay attention to if you want to be an informed consumer. So here goes. Now, first of all, you might have heard how cheap dentistry is down here. And for example, a capped tooth or a porcelain crown, as they're called, that costs a thousand to fifteen hundred dollars up in the first world, and I'm talking about high quality crowns now, the stuff you want in your mouth. Anyway, a comparable crown or porcelain cap down here might only cost one hundred fifty

[01:39] to three hundred dollars. And as unrealistic as that sounds, it's absolutely true, which means, in fact, you could get dentistry down here for twenty to twenty five percent of what it costs in the first world. So, you can imagine, if you're sitting in a dentist chair up in the first world, and you get the bad news that you need six crowns, let's say, to the tune of six to eight thousand dollars. Now, simple math will tell you that you can come down here to Latin America, get those six crowns done for a thousand dollars. And for the trip down here, pay maybe two thousand dollars for the airfare and hotel for the three weeks or so it takes to do the work, and you still save three thousand dollars or more, and get a really nice sun and fun vacation out of it to boot. And that's why dental tourism down here to Latin America is becoming so popular. And believe me, tens of thousands of people are doing just that.

[02:24] However, it's a lot more complicated than you might think. So, before you jump on a plane to Argentina, Costa Rica, or Brazil to have your dental work done, and let's not forget Mexico, which is just a quick hop across the border. Anyway, listen very carefully because you could be doing yourself a great disservice. Now, let me start out by telling you, down here in Latin America, there are really three types of dentists. The first being, and the only ones I recommend for expats, are the high-end dentists that have offices that almost look first-world. They do work that's almost first-world quality, and they offer almost all the first-world services including dental implants, mouth guards for people who grind their teeth, cosmetic dentistry like bleaching and porcelain veneers, and so-called full-mouth dental restoration, which means rebuilding a mouth that's in bad condition by doing the work in large sections

[03:13] at a time with crowns and bridges. Now, these higher-tier dentists that offer to do all that consist of only about 5% of all the dentists down here, and these guys in the nicer offices and the nicer locations are higher priced than the average dentists down here. Their services cost about a third to a half of what you'd pay up in the United States. So, you might ask, is there any difference between one of these high-tier dentists down here and the ones up in the first world? What about the quality of the work? Is it the same or nearly the same as what you could get from one of the dentists up in your own hometown? And will the job look as nice and last as long? Well, the truth of the matter is, if you walk into one of these guys' offices down here, the high-end dentist that is, to the average first-world visitor or expat, the whole experience looks and feels a lot like a dental appointment up in the first world.

[04:01] Almost interchangeable. However, there are some big differences, which I'll go into in a second, besides the fact that they just don't have dental hygienists down here. And I mentioned that in a previous show. Anyway, but note that you'll find these higher-tier dentists in all big cities in Latin America, mostly in the high-rent business districts called the Zona Rosa and the Zona Viva, which I've talked about in past shows, where you'll find international hotels like the Marriott and the Radisson and the Hilton, as well as upper-scale restaurants and embassies, basically in the wealthy business sections of Latin American cities. And you'll find a high concentration of these upper-tiered third-world dentists in high-volume tourist areas, too. Like Acapulco, Cancun, Costa Rica, and around the high-rise beach strip areas in Rio and in all internationally popular beach resort areas.

[04:48] Because in those areas with so many foreign tourists, they can charge a higher price than the average dentist, because tourists in those areas are almost always in a higher-income bracket than the average local and can pay the extra price. Which is another reason why these dentists have offices that are much nicer than the average dentist's office down here, because tourists and foreigners expect that. So now you might be thinking, if you can find one of these higher-end dentists, even if you pay a third to a half of what you'd pay normally up in the first world, if you need a lot of work, you'd still be saving a ton of money and come out smelling like a rose, and of course, get a free trip out of it. But here's the problem with that logic. Even though these guys look almost first world, and their offices appear almost first world, and their equipment resembles that of the first world, you're not going to get honest

[05:34] to goodness first-world dentistry, no matter what you've heard. And you're not exactly going to get third world dentistry, though you'll certainly get third world dentistry when you go to the other two kinds of dentists down here, but I'll explain those kind of dentists in the next show. But as for these guys, who seem nearly first world and cater to an upscale local clientele, people with money, by that I mean white-collar businessmen, politicians and their families and the like, the thing is, if you really look at their offices and their operations with a critical eye, you'll see they have an outer sheen of being first world, but they're really not first world at all, and they suffer from the same basic chronic problems that almost all businesses suffer in Latin America, namely, they're short on cleanliness and hygiene and just don't pay much attention at all to detail. And unfortunately, dentistry is all about the details.

[06:22] You have to remember one thing, these dentists went to dental school down here in Latin America, where the schools are less than mediocre, and all the hundreds of dental and medical schools down here have almost no ranking internationally. And people that graduate from these schools pick up a lot of bad third world habits along the way, including lower standards in just about every department, including cleanliness and hygiene, and poor organizational skills, and all of that doesn't make for a very good dental professional. And you think that the ones that were lucky enough to go up to the United States or Europe and study their specialty further, and believe me, a lot of them have, you just have to look at their diplomas. And of course, these are the guys I always recommend that you go to, even though dentists who go to first world schools suffer in some respects. So what happens when you find a guy who's taken some first world dental training?

[07:10] Now that in itself should make you think these guys are first world all the way, but they're not. They come back down to their countries with good first world habits all right, and they know all the latest techniques and how to use all the latest equipment, but they soon fall back into some very third world habits, which in some cases is really not their fault at all, because they're working in an environment and an office with mediocre people. And the real problem here is that they have to send out their work to be made, like crowns and bridges, to be fabricated by less than mediocre lab technicians, in less than mediocre substandard dental laboratories. The truth is, dental laboratories that make the crowns and bridges down here for dentists never would pass muster with dentists up in the first world. The quality is just very poor to mediocre. And dentists up there wouldn't

[07:56] think of cementing that stuff into a person's mouth. But 1960s to 1970s dentistry is actually the state of the art for dental labs down here, which is pretty pathetic. Now you're probably wondering what I'm talking about here. You're thinking, well a porcelain crown is a porcelain crown right? Wrong. Now just because a crown looks like a nice lifelike tooth, and some of the labs down here can really make them look nice, that's not the problem. A beautiful looking crown can be a complete failure once it's cemented into a person's mouth. A lot of things could be wrong with it even if it looks great. It could have all the wrong contours and be a food trap and therefore cause periodontal disease around it in the future, which is oh so common with crowns placed down here in Latin America, let me tell you. Even though nobody talks about that. Even first world people

[08:42] who've had cheap dentistry done down here like that only talk about the great deal that they got on their work. They're not experts so they never know what's really happening inside their mouths. To most of them, as long as it looks good, they got it cheap and it doesn't hurt, it was worth the trip down. But let's talk about the third world dental laboratories down here. Something the average first and third worlder know nothing about, and it's the weakest link in the chain. So it really deserves some discussion here. The laboratories who make these crowns don't pay much attention at all to the very most important part of the crown, and that is where the final seal is. Where the end of the crown meets the tooth, right at or below the gum line. Now if this seal isn't very nice and perfect and smooth, it's a place where bacteria and plaque always collect and 99% of the time you don't even know it. And even in a very badly done junction like that, it almost

[09:32] never hurts. But when you floss or brush around it, you always get a little bit of blood, which means there's a constant little infection going on around where that tooth and gum meet. Now since it doesn't hurt and people get used to the fact that the gums bleed a little bit once in a while, they think nothing of it until some years later when their dentist tells them they need periodontal surgery because they have gum disease. And the person is surprised because they say they've been brushing and flossing, but no amount of brushing and flossing can stop the accumulation of plaque and bacteria around a crown with a bad seal at the gum line. And how does the dentist check to see if it's a good or bad seal before he actually cements it on your tooth? Well he takes one of those little steel probes that he checks your teeth with. You know, those evil little pointy things he probes with. And before he glues that tooth in, he slips that crown or bridge on the prepared tooth and runs

[10:22] that probe right along the margin where the end of the porcelain tooth meets the gum line and the root. And if it's a nice smooth transition, well it's ready to cement because plaque doesn't like smooth surfaces. It likes rough surfaces and ledges. So that means if there's a ledge or that little probe falls into a groove, it's a bad seal. And if it has a defect like that, and the dentist cements that crown on anyway, even if the cement fills in that void temporarily, after some years it washes out and you've got a big problem because bacteria make a nice home for themselves in there, causing eventual decay along the root surface, sensitivity, a little bleeding, gum recession, bone loss, advanced periodontal disease, and eventual loss of the tooth. Now dentists hate to cement crowns on

[11:10] teeth when they have defects like that because they know there's going to be nothing but problems in the future. And in the first world the laboratories have much higher standards, so they do their best to prevent that from happening. And when a first world dentist gets a crown back from the lab and he tries it on the tooth and it doesn't quite fit right and those margins aren't perfect, he often sends it back to his lab and has it remade. But in the third world there are always problems with those margins and the dentists, no matter how conscientious they are down here in the third world, end up cementing those teeth anyway because the labs just do not give him a high quality product. So it doesn't take long for a new dentist getting out of school down here to lower his standards completely. Now you might be wondering why I'm going into all this business. Well it's just that dentists know they shouldn't cement a crown that has a bad margin. But the dentist doesn't make the

[11:59] crown, it's a laboratory that makes that crown. It's the dentist's job to prepare that tooth for porcelain crown and send a rubber impression of that tooth to the laboratory and they make the crown, not the dentist. And the lab takes it from there, pours a mold, gives it a metal or porcelain substructure, finishes the part that you see in porcelain and sends it back to the dentist. Now all labs can make a nice looking tooth because they know how to work porcelain. It's an artistic technique that they learn. But once it's cemented in your mouth your body doesn't care how nice looking the porcelain is. All it cares about is the way it contacts the other tooth, the shape of the tooth that is, and it cares a great deal about that little margin at the gum line. Is it sealed? Is it closed off solid and tight? Is it smooth? Well the unfortunate fact is laboratories down

[12:46] here in Latin America are not into the details. Just like every other business down here in Latin America, you go into a bathroom, it's dirty, there's no toilet paper, there's no towels, there's water only part of the time, the light switches and plug outlets are filthy and grimy, the carpets are bare, the furniture stained, the windows are cloudy, filled with layers of dust, some are cracked and broken, every third fluorescent light above your head has either burnt out or it's flickering and ready to go. And that's what you see if you walk into 95% of the back rooms of any business down here. And that's exactly what you see when you walk into a dental laboratory down here too. It's as if no one's taken a broom to the place in 20 years. And when you need to make crowns like that under exacting conditions, dust and grime and bad lighting are your biggest enemies. Now if you go to a dental lab up in the first world, it's not

[13:35] the cleanest place in the world either because they're grinding and polishing and mixing chemicals and carving. But visiting a first world dental lab is like visiting another planet compared to visiting a lab down here in the third world. And there's a very important item missing in the third world lab that makes all the difference in the world too concerning the detail of those all important margins on crowns that I'm talking about. And that is up in the first world, every lab technician is using high-powered magnifying lenses clipped to his glasses like jewelers use. And not only that, first world labs have binocular microscopes on the premises so they can look at the finest details and make a good inspection before they let that crown go out the door. That's what you call quality control. And that's why up in the first world, dentists are willing to pay their laboratory people from two to four hundred dollars for a finished crown.

[14:24] You heard me two to four hundred dollars. Which makes you wonder how a dentist down here in the third world could ever manage to sell you a crown for two or three hundred dollars. That wouldn't even cover the cost of the lab on a crown up in the first world. But the labs down here don't charge anything near what the labs up in the first world charge. A lab down here will charge from fifty to a hundred dollars for a porcelain crown. And there's two reasons for that. The average lab technician up in the first world makes eight or ten times that. And another reason they can keep the price so low down here in Latin America is there's virtually no quality control, like I said. And when you don't have much quality control you can shove things out the door fast and dirty. Not to mention the labs down here use some of the cheaper porcelains because cost is

[15:11] everything. Now I visited dental labs up in the first world and I visited dental labs down here in the third world. And I can tell you when you go to a lab down here there are no magnifying glasses, no binocular microscopes. And in fact what you do see is a kind of a grimy dirty dental laboratory that reminds old-time first world dentists of how laboratories used to be back in the 60s and 70s. Before anyone in the first world ever used magnifying glasses for anything in dentistry. Whether in the dental laboratory or in the dental office itself. So by now I'm sure you see the problem. You have a small five percent of dentists down here in Latin America, a quarter of them who may even have taken some training up in the United States. Now they know how to do good dentistry and even have the right equipment. But as soon as they send their work out to a dental lab

[15:57] the patient in effect gets the short end of the stick. So the bottom line is if you have crown and bridge work done down here in the third world you're getting 1960s or 1970s dentistry. Don't fool yourself into thinking you're getting cheap discounted 21st century dentistry. You are not. No matter how modern and up to date your dentist's office looks down here even if he's wearing expensive magnifier loops. My advice is do not let him do expensive porcelain reconstructive dentistry on you. But for common drill and fill dentistry and even the occasional simple single crown you should be just fine. And that includes extractions braces and root canals. But forget about coming down here and having anything complicated done. When you do that you're taking a big chance. So although medical tourism down here can be a great deal plastic surgery and such

[16:45] and it's often done to the highest first world standards. But that's only because there are no laboratories involved. There is no middleman or third party like a laboratory that the plastic surgeon has to deal with when he does your beer belly liposuction or gives you a nose job. He does all the necessary work himself in his operating room and then you're done. But when dealing with a dentist and expensive reconstruction porcelain work I don't care how good your dentist is or what schools he went to. His laboratory is the weakest link and it is a very weak link. Now of course your dentist down here could send his dental porcelain work up to a first world dental lab but he's just not gonna do that because he's gonna pay three or four hundred dollars a crown like a first world dentist pays when he sends his workout. And if he gets charged three or four hundred dollars a crown and adds his own profit onto that he'll have to charge near first world

[17:35] prices and he'll go bankrupt in the process. And besides the average person even the above average person knows absolutely nothing about dentists and their relation to dental laboratories or practically anything I've been talking about so far. And if first world people know absolutely nothing about margins and crowns and the things that I've been discussing you can imagine how clueless third world people are about that kind of stuff. Even educated third world people. Up in the first world most dentists do very nice work and we've all been taught to trust them because it's easy to see that year after year the state of dentistry is always improving. And things are improving of course down in the third world too. However before warned they're still serving up 1960s and 70s style dentistry. And you know what that's absolutely all right. If all you need is basic

[18:21] drilling and filling or if you need a root canal or your wisdom teeth extracted go ahead and feel free to get any of that kind of stuff down here. And you'll get it for a quarter of what should pay in the first world. And that goes for braces too because even if they do braces down here the way they did them back in the 60s and 70s the state of the art of putting on braces hasn't really changed since then. So you're absolutely fine. You can't go wrong if you get your teeth straightened down here not for a quarter of the first world price. The same goes for root canals. It's another technique that hasn't changed much since the 60s and 70s. In fact I've had a few of them done down here myself but I absolutely recommend you go to a root canal specialist. And don't let your general dentist do it. Because the fact is every general dentist down here they hate to send any kind of dental workout to a specialist. They'll try to do everything and anything on you even though they

[19:09] might not be very good at it. It's much different than up in the first world where the general dentist is so busy doing his own thing that he sends out root canals and braces and most oral surgery to a specialist. So don't fall over that and let your general dentist talk you into something like that. Because there are plenty of specialists down here and they're first world trained. So there's no excuse not to go to one. And nearly all of the end dentists down here, that's of course a root canal specialist, have taken their specialty up in the first world. So you're absolutely going to get first world style work. And because they do all the work themselves and don't need a middleman like a laboratory you don't have to worry about the quality of the service at all. And again most root canals these days the more complicated ones on molars cost about a thousand dollars or more up in the first world. And down here you can get the same

[19:58] thing done for around two to three hundred dollars. Now just as an aside I have to mention this too. There are really no disciplinary boards. No one's really watching over the professions. So if you have a complaint about a dentist or a physician for that matter you really ought to look. And though they do have their professional organizations. You know the plastic surgeons have their little group that meets for dinner once a month. As do radiologists and cardiologists and all the specialties including the dentist. But even if you complain to the president of one of those groups they have no actual power to discipline any one of their members. And the corrupt governments down here don't get involved in any of that either. Which is probably a good thing. So how do you find a good dentist down here? Well most people find them by word of mouth. Which may be all right up in the first world. Because you can also look on the internet up there and see if the guy that

[20:45] you're looking at has ever been sued before or has had any complaints filed against him with his state disciplinary board. Because up in the first world every state has a disciplinary board that has the power to pull the license of a dentist or a physician. In fact I know that in Illinois the state disciplinary board prints out a quarterly newsletter listing all the dentists and physicians that have been recently called up before the board and disciplined. Well none of that exists down here in the third world. So there's really no pressure from the government or otherwise for physicians and dentists to keep to the highest standards they can. It's kind of the honor system down here. And it seems to work well enough because it's very rare to read about a malpractice case in the paper. And the papers down here would just love to print that kind of dirt if they could. But you just don't

[21:30] see it. And let's face it no physician or dentist wants to do any harm. Though since they're only human it does happen. Just like up in the first world. But my recommendation for choosing a physician or dentist down here is never to go strictly by word of mouth. You should always do a google on their name and see what comes up of course. But your best bet is to always make sure that they've done some extra training up in a first world university. And they're always more than happy and in fact proud to advertise that fact in their websites and in their yellow page ads. And when you step into their offices the plaques and diplomas alluding to that fact will be everywhere. Because there's no greater feather in the cap of a physician or a dentist than to get a diploma or advanced training in a first world university. So really you can never go wrong if you find a doctor like that. But I also advise that you check those diplomas out carefully. Because a third world doctor

[22:20] will proudly display any first world diploma or certificate even if it's just a weekend CPR course in Texas where chances are he spent half the time golfing. So read the fine print and make sure he spent at least a few years up there in the first world. So as far as dentistry down here and dental tourism you should really save all the big complicated stuff for your dentists up in the first world. But for routine checkups, drill and fill, cleanings, root canals, wisdom teeth extractions and the occasional single crowns in porcelain veneers it's absolutely fine to get that stuff done down here. And I did say single crowns not multiple crowns at one time. Because often a single crown is a simple thing to do for a dentist. Even if his lab is not so great and the crown ends up mediocre which they almost always are you just might have to brush and floss that one a little bit more than

[23:07] the rest of your natural set. So if you're aware of that and keep an eye on it that crown could last a good long time and not do any damage. But forget about multiple crowns and bridges then you're just asking for trouble. And here's a little thing that'll surprise you. When people do get crowns in bridge work down here and after five years or so end up having them extracted because they did get a case of gum disease around them or something else went wrong the dentist never ends up taking the blame for the failure. Because it's a firmly established fact down here that almost nobody uses dental floss. In fact I've been told by dentists that only about 10 percent of the women use dental floss and maybe two percent of the men. And that two percent consists mostly of dentists themselves and gay guys. And that's no joke dentists have actually told me that. And

[23:52] of course third world dentists advise their patients to floss all the time. But they know the vast majority will never do it especially the men. So here's the psychology of it and a great loophole for dentists down here. When a dentist places a crown or a bridge in a person's mouth he always tells them in order to make this thing last a good long time you have to floss every day. And the patient always claims that he will. And later on five or ten years down the line when that tooth has gone terribly bad and it's got to be extracted the dentist knows he's completely off the hook for the failure of that thing because the patient never flossed like he was told to do over and over again. So the dentists down here are forever extracting teeth that have been crowned putting the full blame on the patient for not flossing. And the patients know they're guilty and accept the verdict because they've been negligent. But in reality that's only a small

[24:41] part of the reason why the crown failed. Generally the gum disease component of it all started because the lab did a crappy job at the crown margins. And that's what they call in the first world iatrogenic dentistry. Iatrogenic means that the actual work the dentist did caused more problems than it solved. Now I've been speaking about the higher classes of dentists down here in Latin America. The ones that the average man down here just can't afford to go to. Now there are two other kinds of dentists down here which I'll talk about in the next show which are a lot cheaper than these upper scale dentists but also obviously inferior to the dentists I've been talking about in almost every way. Now I'm thinking that maybe you expect wannabes up there who have an eye for business have been taking a bit of what I said in this show to heart. If these dental labs down in the third world are so substandard crappy and backwards wouldn't that be a great

[25:30] business opportunity for an expat wannabe who's already a first world dentist or dental technician coming down training some people the right way and opening an entirely first world style dental lab? You know what that's a really good idea. And I think in no time once the word got out and you did a little marketing from dentist to dentist you'd be absolutely deluged with work. The flood gates would be open and you'd probably be a millionaire in no time. But the problem is it would be like owning a great restaurant. The owner can practically never leave the premises because when he does the cats away and the quality always suffers. And I've seen this problem so many times and it's often repeated especially with first world franchises down here. A first world team comes down whips everybody into shape gets the business going absolutely first world style.

[26:16] The first world team takes off to another location and suddenly a few months later the franchise starts falling apart. It starts looking ragged around the edges and not quite first world anymore. And that's why I think if you opened a truly first world dental lab down here you'd have to set up a cot and sleep there. Because although some of these guys down here are really talented and can do a terrific job if you don't keep an eye on them they fall right back into their third world habits. I mean all you have to do is look at the way they take care of their houses and their cars and their yards and their pets. Well they could spend all day long at your first world style lab making great product. But when they go home at night they're right back into the third world patterns. And that's their lifestyle and their major influence. But I really think that if someone came down and started a first world style dental lab like that even spending that little extra to

[27:05] outfit it with all the first world technology. They could still keep the prices way down in the range of the other crappy dental labs down here. Because those other labs are so damn inefficient and managed so poorly. Sure you'd have a one-time extra cost in high tech equipment like they have in the first world but those low low salaries of the employees would remain the same. Well I'm at the end of the show right now so stay tuned for more of the expat files guide to third world dentistry on the next show. You've been listening to the expat files living in latin america and don't forget you can email me on anything at all about latin america the expat files at gmail.com that's the expat files at gmail.com see you next time nos vemos