When the economy turned sour last year, some experts said they thought the recession might actually be good for the country s roughly 160,000 dentists. After all, people would be grinding, gritting and damaging their teeth as they sweated about layoffs and plunging portfolios. But grinding or no grinding, the business boom didn t materialize for many dentists, as cost-conscious consumers decided that when times are tight, tooth care can be optional.

The most recent annual survey by the American Dental Association found that 48 percent of dentists said their net income was dropping. This summer the Kaiser Family Foundation, a health-research group, reported that more than one in three consumers were putting off dental care and checkups because of cost. And some cosmetic dentists those once-popular crafters of Julia Roberts style pearly whites say their revenue has sunk 30 percent.

Mark A. Babbitt, a dentist in Ventura, Calif., says that three or four years ago, he took it for granted that new patients would always be streaming through his door, many of them looking for expensive cosmetic treatments like porcelain veneers. Now he goes whole mornings without appointments and reads inspirational books to stay positive. If he can book somebody, he ll even work during his lunch break doing the cleanings while his dental hygienists eat. And that s why he recently decided for the first time in his 13-year career to send out care packages to loyal patients, each one featuring a coffee mug with his name emblazoned on it and a handwritten note reminding his customers to refer friends. Sometimes it feels like 28 Days Later, Babbitt explains, referring to the zombie flick. The world s ended, and all the people disappeared.

Welcome to the apocalypse or something that feels a little like it to many dentists. Their financial pinch is playing out in strange ways for patients. Some dentists have taken on unfamiliar roles, filling in for their own assistants and striking bargains with customers. Others are offering the kind of freebies and reward points that seem less serious medical office and more all-inclusive Cancun getaway. But some are putting their patients in uncomfortable positions. The Better Business Bureau says dentists are among the top 50 professions consumers complain about, topping even lawyers. Last year the number of complaints rose 9 percent, to 3,570. Consumer advocates say some desperate dentists are up-selling their patients, telling them they need $1,000 crowns and tooth sealants they could easily do without. It s a very vulnerable place you sit in as a patient, says Anika Ball, executive director of the American Society of Dental Ethics and some dentists may be taking advantage.

Fallout from Dental Debt

Dentists have always faced huge financial hurdles. According to Raymond Willeford, president of the Academy of Dental CPAs, buying an existing practice, a popular way to get into the business, can cost as much as $850,000.

Dental school for specialties like periodontia, the study of gum disease, can cost another $300,000. And in the past decade, the number of dentists doing cosmetic work has more than doubled by some estimates, inspiring an expensive technology binge. A machine capable of making crowns and veneers, for instance, costs $100,000. Things have gotten so bad that Willeford estimates 85 percent of dentists are in significant debt. It s very nerve-wracking, admits Leonard Tau, a cosmetic dentist who borrowed heavily to buy his practice in Philadelphia. I have a big nut to crack.

In this recession, those piles of debt are contributing to shifts that can change the focus of an entire practice. Some specialty offices are doing more traditional work like checkups or root canals. More dentists are laying off hygienists to cut costs and rolling up their sleeves to perform routine cleanings themselves. Experts say the switch might feel a little rougher to patients, since hygienists are much better-trained in comfort techniques, like angling hooked instruments so they don t rip patient s gums. If you were in an amphitheater watching a dentist clunk around in your mouth, you d be horrified, says Howard Strassler, director of operative dentistry at University of Maryland Dental School in Baltimore. Strassler adds that patients with gum disease are better off with a trained hygienist.

Even as they do more, some dentists are charging less, sometimes wiping the slate clean for patients with small tabs. These days you have to be more flexible with people, explains Diana Shieh, office manager for New York City orthodontist Mark Bronsky. On rare occasions, she says, her Park Avenue office has discounted treatment for longtime, faithfully paying patients, though she exercises discretion. If you re wearing a 5-carat ring, Shieh says, forget about it. Even dentists unwilling to bargain will often sub in less expensive treatments. Tau says that depending on the situation, he ll now do fillings instead of crowns for patients who ask, although he never considered such substitutions previously. (Reason: Fillings won t last as long.) Other dentists may be willing to provide retainers with a temporary tooth instead of a full implant or bridge. Both procedures can easily slice a patient s tab in half.

After getting a crown in January, Joyce Pritchett was taken aback when she received a bill for $916, almost double what she d paid for another crown just a few months before. Her husband, Jason, appealed to the dentist s office manager; when he learned it wasn t a mistake, Jason asked if they could work something out. The Rosamond, Calif., couple expected they d be offered a monthly payment plan. But within a week the dentist had agreed to waive $175. We were totally shocked, Joyce says.

Other patients are finding that just getting in the chair can earn them a dizzying array of freebies, like free tooth whitenings and electric toothbrushes. In suburban Atlanta, dentist Bill Williams says his practice is having a strong year financially, but to hedge his bets, he s signed up with Loyal Patients Inc., a company that lets him give customers reward points they can redeem for discounts on DVDs and Cole Haan handbags. Showing up to an appointment on time (75 points), enduring a wait in the lobby (50 points) and choosing an elective procedure (200 points) would give a patient roughly enough points to take a three-day vacation at Orlando s Blue Heron Beach Resort for $142 per night a 40 percent discount. With pocketknives going for 10 points plus $1 in cash, says Williams, you could take care of Christmas gifts for all your little cousins pretty easily!

Fillings for Friends, Freebies for You

The fastest route to a freebie may be the referral: Because such recommendations are typically considered the best source of reliable patients, consumers can often get perks for bringing in their knitting-circle buddies. When Laurie Baggett, a 28-year-old human-resources consultant in Chesapeake, Va., recommended her dentist to a friend, the doctor thanked her by sending a bouquet of flowers to her office. My husband has never even done that, Baggett says.

Revenue-hunting dentists don t always leave their patients feeling so warm and fuzzy. When Susan Inge, a 40-year-old full-time mom, moved to the Tampa, Fla., area this winter, she went to a local practice for a routine cleaning. She says that even though she d gotten a clean bill of dental health six months earlier, the new dentist told her that she had three cavities and needed four sealants, protective tooth coatings often used on children. Inge says the dentist also suggested that she replace two veneers she d had since her teenage years. They were basically trying to sell me an extreme makeover in my mouth, Inge says. She says that a hygienist even persuaded her to buy a $100 ultrasonic toothbrush and a $20 bottle of mouthwash. I escaped, she says, when they were trying to sell me a tongue cleaner. The practice s office manager says the practice doesn t push products and that recommending sealants is its standard procedure for some adult patients.

Although complaints of up-selling are hardly unique to dentistry, experts worry that consumers are particularly vulnerable when it comes from a dental authority figure. Dental professionals have always operated with fewer definitive, diagnostic tests than medical doctors, putting patients in a position of taking them at their word. And as more patients skip the dentist, the financial pressure to extract more money from each patient becomes more intense. There are salaries to pay for hygienists and assistants, mortgages to keep up with, and six-figure equipment loans to pay off. You want to believe overtreatment isn t happening, Ball says, but almost every hygienist has seen it.

Of course, most dentists hold themselves to high ethical standards and wouldn t overtreat. But for now consumer advocates and warier patients are coming up with some self-defense tactics. Some are asking their dentist for copies of their X-rays so they can get low-cost second opinions. Others are paying close attention to how the dentist discusses their treatment. Because few painless conditions require same-day intervention, Strassler says, consumers should be leery of practitioners who say otherwise. But in general, more salesmanship at the dentist office may just be becoming a new fact of life. We re still getting the same business in this economy, says Williams, the Atlanta dentist. We re just battling harder to get it.