San José, Costa Rica, since 1956

Oral history: A Gringo goes to the dentist

There was a moment, just after the sheet was drawn over my head, when I thought, maybe I shouldn’t do this.

The sheet covered my eyes. It had an opening just large enough to expose my numbed mouth. I felt like a heretic at the hands of the Spanish Inquisition.

What are three rotten teeth? I thought. Couldn’t I do this another time – like in 10 years? Is all this really necessary?

But the Novocain had already been injected. The assistant had punctured me a dozen times, including three excruciating shots to the hard palette. I had already swallowed a pair of unidentified anxiety pills. They had already asked what kind of music I liked, and now the Beatles were playing from a nearby computer. A huge fraction of my bank account was wadded in my pocket. I had made the decision to have my teeth pulled in Costa Rica, and now it was time.

“Hello, Robert,” said Dr. LaMancha (not his real name) as his silhouette loomed through the fabric.

I tried to say “hola,” but because of the numbness it came out “oh-ah.”

“You are doing well today?” Dr. LaMancha said. I could hear the tinkle of tools, the squeak of a chair.

“Es-hoy dee-an,” I said. Estoy bien. Sort of.

I wondered whether the anesthetic would suffice, not because I doubted Dr. LaMancha’s abilities, but because I imagined some anomaly in my nervous system. Maybe I have hypersensitive nerves. Should I ask for more? Maybe they should have knocked me out. But aren’t there all those horror stories about people staying awake through their surgery? Why did I agree to do this?

“Now, Robert,” said the surgeon in a soothing baritone, “I am going to cut the tooth in half, so it is easier to extract. Are you ready?”

I heard myself slur the word “.”

And then a tiny saw started to whir.

mouthwash and painkillers

Mouthwash and painkillers. Please swish responsibly. 

Robert Isenberg


Ever since I lost my last baby tooth, my teeth have been a lifelong nightmare. They grew at freakish angles, which led to years of braces, plus the full orthodontic arsenal: rubber bands, a bite plane, special toothbrushes, the works. When the braces finally came off, I lost my retainer for six weeks and the teeth shifted back into place. A year later, I had my wisdom teeth out, and I suffered head-splitting migraines for a solid month.

Despite this, I’ve only needed one filling. Dentists are usually impressed by my hygiene, although they vociferously wish I would floss more. So imagine my surprise, in 2004, when my right molar suddenly broke. I was sitting in a computer lab in Pittsburgh, and when I bit down during an especially pensive thought, the tooth just collapsed. My tongue turned up a chunk of off-white bone. For years, I have dreamed of my teeth falling out – a common image, usually linked to anxiety – but now it actually happened.

The deterioration continued, first in the right molar, then the left, until each tooth was a kind of stub. No one could see these jagged, blackened remains, so I never gave them much thought. But the molars were tethered to an even worse problem: Because my upper wisdom teeth hadn’t been removed, they sometimes impacted the other teeth. Every six months or so, my wisdom teeth would remind me that they existed, and the pain was excruciating. For a full week, twice a year, I could barely eat an orange slice.

“Please,” my wife pleaded, “can you just go see a dentist?”

I don’t like dentists, of course, but that wasn’t the issue. Rather, I was a freelance writer and therefore uninsured. For 10 years, the American healthcare system was a completely foreign concept; I didn’t even know that dental coverage existed. Twenty-somethings don’t waste their money on oral surgery when they only make $15,000 a year.

When I finally did see a dentist, I could only afford it because of a Groupon deal. The place was wood-paneled and dark. The sign above the front door was a wooden tooth, weather beaten and barely legible. The dentist wordlessly cleaned my teeth until he reached the dead molars. He sat back, looked at the ceiling, and angrily sighed.

“Why do people do this?” he seethed.

“Ooh aht?” I said.

“Why didn’t you have these removed yet?” He sounded accusatory, as if I had insulted him with my poverty.

Soon after, a premolar collapsed as well, causing me to panic. The tooth was much more visible than the molars, and now I felt pain. I could only chew on the other side of my mouth. Every time I ate, I looked like Popeye.

When I finally received coverage through my wife’s insurance, I visited a significantly better dentist. The assistants were professional and kind – right up until the head dentist arrived. She looked hurried and annoyed. She ripped open my mouth, gave my teeth a cursory examination, and said: “Those have to come out.” She looked at the premolar and shook her head in disgust. “That one’s abscessed. It’ll have to come out, too.”

“Okay,” I said. “How much will that cost?”

“Well, it’ll probably take the rest of your insurance,” she said, snapping off her gloves.

“Can I replace the one? I’d rather not have – you know – a gap.”

She closed her eyes. She looked furious, at wit’s end. What kind of egotist was I? What was wrong with a visibly missing tooth? There were plenty of salt-miners and serial killers who had missing teeth. What made me so revoltingly vain?

“If you want an implant,” she said slowly, “you can’t do it here.”

“Okay,” I said, waiting for a follow up. When she said nothing, I added: “So, where then?”

“The University of Pittsburgh,” she said. “They can put in the titanium screw, but you’ll have to wait four months for it to graft to the bone. I can add the implant here.”

This was the first time anyone had suggested fusing anything to my skeletal structure, and the only thing worse than an obviously missing tooth was a spike jutting out of my gums. So I gave up on that idea. I could keep my rotting, pain-inducing tooth, because there was obviously no alternative.

When it came to dentistry, the American healthcare system had done a grand total of nothing for me. More than 20 years after my teeth grew in, they were still a crowded, unsightly mess, and every six months I had to subsist on soup and ice cream, because the pain was so unbearable.

Then we moved to Costa Rica, and dentists were everywhere. Our first apartment was surrounded by dentists’ offices. Expats gushed about the affordable cleanings and surgery. “When you see an expat,” said one gringo friend, “ask how his teeth are doing. Some people come to Costa Rica just to get a cleaning.” 

We found the practice online. We wanted an English-speaking surgeon, and we wanted someone with a good reputation. And so we found ourselves calling the office of Dr. LaMancha. During our first phone call, the surgeon’s assistant, Phil, talked with me for 25 minutes. (Also not his real name). He had lived in the U.S. for many years and spoke perfect American English.

“So you’re looking for three extractions and an implant,” Phil summarized. “We can do that. You can come in and we’ll give you an estimate. When are you available?”

The truth is, I still might have waffled for another decade. I was so weary of failed dental work, lofty expenses, condescending hygienists, and the thought of having my teeth pulled out made me glum. The real hero of this saga is my wife, who has been coercing me for years to get my mouth fixed. Each time I felt a wave of pain, she begged me to prioritize. “This is your body,” she said. “I’m not going to like you with dentures.”

So I went. The office was bright, spotless and intimate. I filled out some forms and waited only a few minutes. When I asked to use their WiFi signal, the receptionist smiled and said, “Of course.” They took me into a backroom, where a nervous young man took my X-rays. But instead of a single general X-ray, he took a dozen different close-ups.

The surgeon arrived, and I was blindsided by his appearance: Dr. LaMancha looked like the star of a telenovela. He was tall, handsome, and smiled reassuringly. At no point did he shame me for subpar brushing or bloated gums. He only asked questions and nodded at my replies.

“The truth is that I am one of the most expensive dentists in Costa Rica,” he said. “But I also can offer you excellent quality. I understand if you want to find another practice that is a little bit cheaper, but I think this is the best plan for you.”

He described this plan in minute detail: He would remove the three teeth, a surgery that would take only an hour. I would swallow a mild sedative, to ease any anxiety. He would replace the one tooth with a cosmetic replacement – the abscess was infected and would need to heal.

“This replacement is only temporary,” said Dr. LaMancha. “I will glue the tooth to the teeth around it. Maybe it will last all four months, maybe it will last only a day. I don’t know. About fifty percent of my patients lose this type of tooth. But if it falls out, I will replace it right away – for free.”

I couldn’t believe that a replacement was so easy to install, and told him so.

“Well, it is only for looks,” he said. “But I would not let you leave with a missing tooth.” Then he guffawed. “It would be very hard to be taken seriously like this, don’t you think?”

Yes, I thought. Imagine.

Four months later, I would receive the same titanium screw that my Pittsburgh dentist had described, and once it had grafted to the bone, Dr. LaMancha could affix the actual implant.

“This will be a long process,” he said. “But if you would like to work with me, I would be happy to do this.”

It made me wonder whether my Pittsburgh dentists had ever been happy to do anything. And then the crowning moment: The entire process would cost me about $2,000, over the course of eight months. I could do everything in this office, and Dr. LaMancha would perform all surgeries himself. This was an enormous sum for a youngish writer, but it was exactly the same price quoted back in the States. Not cheaper, but much easier and more attentive – and with a nationally recognized dental surgeon. To afford the U.S. equivalent, I would have to be a millionaire.

“You will not feel any pain at all,” reassured Dr. LaMancha, moments before he sawed my tooth in half and yanked its remains out of my face.

I felt calm overall, but two anxieties dogged me: First, that I had to stay awake through the entire procedure, fully conscious of what was happening. Both my wife and I had enjoyed general anesthesia during our wisdom tooth operations. Now I could hear the saw blade.

My second anxiety was far more frustrating: My entire life, I had been trained to fear any healthcare outside the United States. In the American worldview, any surgery that takes place beyond our borders must be performed with rusty gardening tools in a corrugated steel shack. We picture endless lines, floors smeared with blood, greasy rags to blot the wounds. This myth must persevere in order for U.S. healthcare to appear sane. As long as we presume foreign physicians are barbaric, we never question privatized medicine.

“The first one is out,” Dr. LaMancha said triumphantly.

I was in awe; all I had heard was a crackling noise. All I had felt was pressure, then release. I didn’t feel one iota of pain. The removal was so effortless that I almost looked forward to the second one.

The teeth all came out in about 45 minutes, and Dr. LaMancha offered comforting words throughout. “You are making this very easy for me,” he said. “You are very calm. Not every patient is so calm as you.”

Perhaps Dr. LaMancha said this to all his patients, even the ones he had to tranquilize, but I was grateful for some cheerleading. When the final tooth came out, I felt some patient’s remorse. It’s gone now, I thought. I had that tooth my entire life, and now it’s gone forever.

When his assistant came to glue the temporary tooth into place, she examined several sizes of teeth and grinned when she found the right one. The tooth felt weird—a little long and crusty with glue – but I was relieved to have it. When we met Dr. LaMancha in his personal office, he told my wife that I was “very brave.” This is not a descriptor I hear often, and in my post-surgery haze I felt positively valiant.

It was strange to pay Dr. LaMancha the equivalent of $900 in cash, and stranger still to watch him count it, piling 10,000-colon bills on his desk. But this was the one flaw of a Central American office: They charged a 5 percent fee for credits cards. I decided that visiting the ATM three different times was a small price to pay. So to speak.

A week has passed since the surgery, and the painkillers and bags of ice have worked wonders. My wife is so grateful that I finally acquiesced that she gleefully announces when I’m due for an antibiotic. The gaping holes in my gums have started feel normal, and the temporary tooth remains intact. According to Dr. LaMancha, my premolar collapsed because of my only filling, which was likely flawed, and my remaining teeth are in excellent condition. In four months, I return for my titanium screw, and four months after that, my brand new prosthesis – a ceramic tooth fashioned by German engineers.

The other night, my wife and I treated ourselves to Pizza Hut. We had enjoyed a full month of gallo pinto and fresh fruit, but we wanted something greasy and gringo. Halfway through my first slice, I realized that I felt no pain at all. I couldn’t use the temporary tooth to chew, but neither did I have to wince. And with that realization, I flashed a big, toothy smile.

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