Mexico’s Molar City Could Transform My Smile. Did I Want It To?

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.

Sani Dental’s Dr. Sofia Terrazas fits a patient for a veneer, matching the color to insure it blends with the surrounding teeth.

“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.”