At the Washington Center for Dentistry, the scent of apple cinnamon aromatherapy fills the air. A concierge warmly greets you and offers lemonade or bottled water from a juice bar. Well-groomed receptionists peer at you, their matching crisp white jackets with sophisticated logos reminiscent of Neiman Marcus. Have a seat and place your feet on an electronic foot massager while you wait for an appointment.
Around Washington and nationwide, a confluence of demographic, financial, professional and technological factors has given rise to a new style of dental practice -- dental boutiques that embrace and flatter clients with soothing environments and high-end personal service, and specialize in such costly cosmetic services as porcelain enamel replacement for damaged teeth, bleaching, crown lengthening and implants.
And there is a lot of money out there. National expenditures for dental services are projected to exceed $60 billion in 2000, up from $53.8 billion in 1998, or about 5 percent of the nation's total spending on health care, according to the first Surgeon General's Report on Oral Health, which was released in May.
Dentists jockeying to dip into the cream of that business are redefining their jobs away from the "drill, fill and bill" professionals of the past to upmarket dental therapists for a pragmatic reason: It's hard to make a living just filling cavities and doing root canals. Strides in dental protection, specifically the use of fluoridated water, have resulted in nearly 55 percent of children between ages 5 and 17 showing no tooth decay in their permanent teeth, according to federal data gathered between 1988 and 1991. Only about 28 percent were cavity-free in the early 1970s.
With dentists no longer inundated with so many cavities to fill, the American Dental Association reports, eight out of 10 dentists now spend at least some of their professional time performing cosmetic services. Some dentists have opted to do only cosmetic work; others continue their conventional practices while building up their more lucrative cosmetic businesses. Many are savvy businessmen devoting serious time and money to study customer service techniques and marketing to help promote new dental treatment options -- options that are almost always paid for out-of-pocket by the patient.
"Cosmetic dentistry services are elective, and generally do not involve solving a health-threatening situation. Ethical dentists must be cautious to make sure they are not selling something to a patient, but rather providing a service that the patient wants," said Joseph L. Perno, a Voorhees, N.J., dentist and past president of the Academy of General Dentistry.
The new dental spas exemplify what is dubbed the second Golden Age of Dentistry. The first occurred after World War II, said Daniel Deutsch, one of the dentists at Washington Center for Dentistry. "In the 1950s and '60s, the introduction of . . . local anesthetics for pain control and a booming economy pushed people into the dentist's office to take care of disease and infection," he explained.
Several forces have created a second golden age: the middle-aging of the Baby Boomers, evolution of dental materials and technologies, the long economic boom and the growing acceptance of cosmetic surgery. According to a new study by the American Academy of Cosmetic Dentistry, during the past five years many dental patients are not just expecting elective cosmetic procedures, they've come to demand them.
While such elective dental surgery isn't only for the upper crust, the cosmetic dentistry academy reports that the majority of people seeking cosmetic dental care make more than $50,000 a year. And such services are extremely popular in Washington.
"It's a competitive world, and part of presenting well is looking like you're in the game," said Deutsch, whose clients include ambassadors, senators, cabinet members and an occasional movie star.
Staying in the game is important in a town such as Washington. "D.C. is home to a highly educated and demanding public," said dentist Eugene Giannini of McDermott, Giannini, & Gray Dental Associates. The practice's Wisconsin Avenue office was created by Austin, Tex.-based T.H.E. Design, an industry leader, and is often used as a "walk through" facility for area dentists reworking their spaces. "These are supportive dental environments for the patient to defuse the fear and maybe some of the hostility they used to associate with visiting the dentist."
For between $10,000 and $20,000, a typical person can virtually rebuild his smile, according to area cosmetic dentists. And while the study by the cosmetic dentistry academy indicated that the cost of such procedures tops patients' list of concerns--followed by longevity of the product and the pain of the procedure--that concern didn't stop Frances Mielach of Bethesda from spending $9,000 to have her smile fixed by Washington cosmetic dentist John Chick.
"This is no different to me than keeping myself up by working out, eating well to control my weight or even getting my nails done. Psychologically, this is a good opportunity to change something I've been unhappy about," said Mielach, who saved money for several years to pay for the procedure. "I didn't have a good dentist as a kid or teenager, and on top of that I had a bad orthodontist. Those experiences left me with stained teeth."
And like many adults who came of age in the 1960s and '70s, Mielach's cavities were filled with garish metal. She opted to have the metal fillings replaced with white resins. In addition, she had her teeth bleached and opted for porcelain coverings for some of her front teeth that couldn't be whitened enough with bleach.
Porcelain veneers are fingernail-thin shells that can be overlaid on the front of the tooth after removing some of the original enamel, described Chick. "Essentially it's a false facade. Your tooth is underneath the veneer, and the only amount of tooth that is removed is the thickness of what you're replacing," said Chick. Other materials used for veneers include acrylic and composite resins.
Porcelain veneers cost between $900 to $1,200 per tooth, and generally need to be replaced after several years. Changing old metal fillings with white, natural-looking resins costs between $145 and $275, according to Washington area dentists.
Mielach described Chick's care throughout the process as that of both a skilled artist and a master communicator. "Not only did he educate me about proper oral hygiene and my options, but he carefully followed my progress each week. He was like an artist working in miniature, since he had to accurately match the color" of my teeth and the porcelain, she said.
Matching colors is merely one part of the procedure. Dentists revising a person's smile weigh the contour of a person's lips, skin and hair color, as well as the shape of the teeth. Research shows that elongated, round and curvy teeth suggest femininity; while square, sharp-edged teeth give an aggressive impression, said Chick.
"It's like a picture: Your gums are the matting, the lips are the frame, and the teeth are the center focus," said Chick.
While most dentists send out photos of patients along with tooth molds to labs that fabricate veneers and other components, Deutsch's office opted for its own on-site laboratory. "It's easier for the lab person to produce a natural customized [veneer] if he actually meets the patient," said Deutsch.
There are also pictures for patients to view. In offices such as Deutsch's, dentists place miniature cameras in patients' mouths and then transmit the images onto screens hanging from the ceiling. It can be quite humbling to see every metal filling, stain and gap freeze-framed on the monitor. It also helps dentists deliver the message that your mouth is a mess.
"A picture is worth 1,000 words when you're telling a patient about their mouth," said Deutsch. "If there's a cracked tooth, the patient can see it up on the screen, and better understand why treatment is necessary."
Those treatments can include crown lengthening (for about $100 to $150 per tooth, a dentist uses either lasers or a scalpel to lift the gum to reveal more tooth), bleaching (using a peroxide compound to whiten the tooth), permanent dental implants (titanium replacements for adult teeth that are screwed into the jawbone and then covered with prosthetic crowns for between $2,100 and $6,200 per tooth) and air abrasion (a painless method to remove decay using high pressure bursts of air). "In a way, it's a dental sandblaster," said Deutsch.
Air abrasion's largest benefit is that patients aren't left for several hours with the annoying aftereffects that an injection of a local anesthetic produces: numb lips, gums and tongues. "In D.C., where many people use their mouths to make a living, it's considered a temporary disability to lose their lips or tongues--especially for bureaucrats and lawyers," said Deutsch.
Dentists work not only as artists and communicators, but sometimes wear the hat of armchair therapist.
"You must interview the patient and find out what motivates his or her desire for dental services. If the motivation is external--such as a spouse or a friend pressuring them to have some dental work done--then that patient will probably never be satisfied with the result. But if the motivation is internal--the patient hates the way his teeth look--the outcome will be better," said Chick.
Most costs for cosmetic dentistry generally are not covered by dental insurance plans because they are considered elective procedures, not essential health care. Because of that, many of Washington's cosmetic dentists run fee-for-service practices, which means the patient must cover the cost of the cosmetic procedure. However, for basic services, such as teeth cleaning, costs are comparable to a family dentist, with cleaning generally running between $75 and $95.
Giannini stressed that cosmetic dentists "must create a brand identity, and tap into what makes patients comfortable," he said.
Brand identity? This new breed of dentists understands marketing. Indeed, today's cosmetic dentistry is all about providing "value-added" service to patients, said Gary Alhadef, a cosmetic dentist in Dallas. Such touches include an office's aesthetic appeal to calm frayed nerves. Alhadef offers patients a 200-CD music selection to listen to on headsets, as well as an array of movies to watch while having dental work done.
Why not view a movie at your dentist's office, especially if a procedure may take several hours to complete? "If you're on an airplane for three hours, you expect to watch a movie," reasoned Roger Levin, a dentist and president of the Levin Group in Baltimore, which teaches dentists the business skills for running such a practice.
Washington's Shannon Holcomb, an art historian and graduate student, said similar services helped her relax at Chick's Washington office. Holcomb sat in a vibrating chair, had a warm blanket spread over her and listened to her own Nine Inch Nails CD to help distract her from the work going on in her mouth.
Holcomb, who had gold caps put on her lower front teeth and then covered with porcelain at a cost of $7,000, said that it was worth every penny. "It's changed the way I use my mouth. I smile more now because I don't hide my lower teeth. God gave us hair dye to look good, so why not redo our smiles?" she said.
With new technology making dental procedures less painful, and cosmetics more accessible, the practitioners of this new dentistry need a new skill: the ability to communicate the sometimes mind-boggling options to patients, said Deutsch.
It's the Ritz-Carlton approach to customer service, with front-line employees using phrases such as "no problem, it's our pleasure" to help assure patients.
And these dentists and their staffs don't shoot from the hip. Many practices invest up to $24,000 for a one-year customer service "boot camp" provided by Levin.
Levin's courses include education for the entire dental staff, customer service scripting for answering phones and talking with patients in person, as well as monthly financial monitoring of a practice. "It's the little things, such as checking on a patient every five minutes while they are waiting in the dentist's chair, that make a difference. Our research indicates that many times patients wait 24 minutes in a chair without having someone check in on them," he said.
Dentists who attend his programs experience growth in the practice of approximately 30 percent, he said.
Levin also stressed that dentists must have fun and enjoy their work and life. The idea is that the enthusiasm will rub off on patients, who will move beyond their fear of the dentist and become more relaxed during treatment. And for many dentists, it works.
Keeping the patient happy is important. Appropriately, word of mouth is the best referral source for the professionals, said Levin.
Regardless, many dentists devote 2 to 4 percent of their gross on marketing techniques, said dental marketing expert Mark Curtis of Minneapolis. Such tools include magazine or television advertising, newsletters and Web sites. "Unfortunately, radio doesn't translate well because you can't get a good visual through that medium," he said.
And women are the biggest targets of such literature or ads. That's because women make most of a family's health care decisions, said Curtis. According to the cosmetic dentistry academy, women make up 72 percent of a cosmetic dentist's practice.
The seeds for designing upscale dental boutiques were planted in the late 1970s by San Francisco dentist Jim Pride, said Pat Cunningham of T.H.E. Design. "Pride was the first dentist to take facility design seriously. He looked at both function and aesthetics, and worked with architects to bring his ideas to life," said Cunningham.
The increasing use of new tools that took much more space than the drills and X-ray machines of the 1960s and the new services being offered patients created a need for a new type of office, according to Cunningham.
Also, it began to dawn on patients investing $10,000 for a new smile that the cost and dingy office spaces didn't match, she said. "It's natural for people to wonder where dentists spend their money. Clearly, in the old offices, it wasn't on the space," she noted.
At the 6,000-square-foot Washington Center for Dentistry, five dental professionals share the overhead to defray the "almost seven-figure" construction and design costs, said Deutsch. The professionals can also easily exchange ideas. The practice includes an on-site periodontist, and offers all comprehensive dental care--not just cosmetic. "A patient doesn't have to leave our office, go to another address, and get to know someone all over again," said Deutsch.
So what's so different in the new offices? To succeed, design elements must incorporate color, lighting and structural details, said Cunningham. "You can put paint on the walls, but the space will look the same," she said.
To create a dramatic feeling, an office might opt to put an intense color, such as forest green, on the walls. For a restful space, muted gray tones help lower the anxiety of waiting for the dentist, said Cunningham.
Fluorescent lights have been deep-sixed for softer, indirect lighting in waiting areas and along corridors.
Gone also are the sliding windows that formerly separated patients from the receptionist. Instead, the newer reception areas are open and airy, yet maintain a separate area to allow patients to privately negotiate their bills with the billing receptionist, said Cunningham. "Everyone can't pay on the spot, and it's embarrassing for a patient to admit that if a waiting room is packed with people who can hear such information," she said.
However, the traditional sounds of a dental office are more difficult to mute, since most working surfaces must be hard so they can be kept disinfected, said Cunningham. As such, most offices opt for carpeting and sound-absorbing ceiling tiles or other materials that pick up sound. Some new offices create variations of ceiling heights to capture sound better.
Consultation rooms are another addition to the offices of the new millennium. Fitted with comfortable chairs and desks and with walls lined with the dentist's diplomas, such spaces reassure patients that they are in good hands, said Cunningham. Many dentists choose to meet with patients in the consultation rooms to both learn more about the patient's dental goals and to explain treatment options.
It also solves a problem patients confronted in the past. "Sitting across from a dentist sure beats looking up his nostrils while he tells you about your teeth," she said.
Just another value-added benefit offered in the second Golden Age of Dentistry.
Therese Droste is a health and science writer living in the District.
Consumer Watch: Check Out Your Dentist
How do you distinguish between a good cosmetic dentist and a charlatan? It can be tricky.
The problem is that any dentist can call himself a cosmetic dentist, because the designation is not a specialty based on elective courses offered at dental schools, said Mike Malone, a dentist in Lafayette, La., and a board member of the American Academy of Cosmetic Dentistry (AACD). Traditional specialties, such as periodontics, usually require internships of one to three years, he said.
Since there are no training standards for cosmetic dentistry, an important question for consumers to ask their dentists is how many continuing medical education courses (CMEs) they take each year, Malone said. "If a dentist tells you that he doesn't need courses because he already knows how to do the procedure, that's a problem."
So how many CMEs represent a respectable education level per year? Again, there is no set standard. "Generally, if a dentist takes three to five courses annually, that's a good sign that he is devoting serious time and money to learn new dental techniques," Malone said.
In addition, experts recommend these tips for patients considering major cosmetic dental procedures:
* Take your time. Don't make on-the-spot decisions, said Joseph Perno, a dentist in Voorhees, N.J. "Go home and evaluate whether you truly need, desire or want the cosmetic dentistry your dentist talked about," Perno said. Balance your needs against the impact of the cost, and understand that most cosmetic dentistry is elective and not covered by insurance, he said.
* Trust your instincts. "If you have hesitations or concerns, get a second opinion," Perno said.
* Ask for photographs of the dentist's work. "It may help you visualize and be able to judge his work," Perno said.
* Don't be intimidated. Do you feel a hard sell? You may have run into a dentist with an expensive piece of equipment who is using it to push cosmetic dentistry services, Perno said.
* Check out your dentist's professional affiliations. The American Dental Association, dentistry's equivalent of the American Medical Association, represents 143,000 dentists. Requirements--if any--for continuing education are set by state chapters. The Academy of General Dentistry requires its 37,000 members to earn a minimum of 75 CME hours every three years to retain membership, said Perno, a recent past president of the academy. But understand that those 75 hours are not exclusive to cosmetic dentistry and include other dental topics as well. The largest organization in cosmetic dentistry is the AACD; however, just because someone is a member does not mean that he has specific expertise, Malone said. Your best bet is to check to see whether a dentist is not only a member of AACD, but is also accredited by the organization, he suggested. "The AACD's accreditation program is pretty rigorous. It includes a hands-on exam and requires dentists to demonstrate their work to an examining board," he said.
* American Academy of Cosmetic Dentistry: 800-543-9220 or www.aacd.com.
* Academy of General Dentistry: 888-AGD-DENT (888-243-3368) or www.agd.org. Consumers using the academy's Web site can post questions by clicking on a graphic of a big red grin. A response will be provided within 24 hours, officials said.