A few years ago, Dr. Bernie Villadiego saw 15 to 20 patients a day, made treatment decisions based on what insurance companies would reimburse, and, ultimately, grew cranky and bored.

Today Villadiego, a Chatsworth dentist, averages between six and eight patients a day, performs any number of state-of-the-art procedures and bills for what the treatments are worth.

Most of all, Villadiego, says, he's happy.

"As far as my life, it's more enjoyable. There's less stress. And I can develop relationships with my patients by spending more time with them," Villadiego said.

What has made the difference is an emerging specialty, esthetic or cosmetic dentistry, that describes a range of procedures from making teeth whiter and brighter to reshaping a smile.

So far, only about 200 dentists nationwide have been certified in the specialty by the American Academy of Cosmetic Dentists. But as demand for these services increases, many dentists like Villadiego are flocking to continuing education programs to hone the craft.

Two-year-old Esthetic Professionals, the only school in the San Fernando Valley providing such courses, has seen enrollment grow from 40 students when it opened about two years ago to a projected 250 in the coming fall semester. Courses at the Woodland Hills school have expanded from three to 26 in the same period.

"In medicine, plastic surgeons do a lot of discretionary treatment," said Dr. Bruce J. Crispin, a board-certified esthetic dentist, who opened the Woodland Hills school after heading up the UCLA Center for Esthetic Dentistry for more than 10 years. "This is a reason why dentists want to do esthetic dentistry. They want to separate themselves from control of insurance."

Until the advent of the new technologies that make cosmetic dentistry possible, dentists used metals to fill teeth and attached crowns with wires to reconstruct damaged teeth. The result was often unsightly, and the materials broke down over time. At the same time, dental insurance reimbursements have not kept up with increasing costs.

"When insurance first became popular in the 1960s, the maximum dental benefit was $1,500 to $2,500,and those maximum benefits are exactly the same today," said Dr. Sherwin Rosen, a Palos Verdes dentist and member of the communications committee of the California Dental Association. But the cost for a crown today is about $900, nine times the cost 30 years ago. "So you can see that what insurance used to pay for doesn't begin to pay for much today," Rosen said.

Dentists whose practices are dominated by insurance plans have been forced to adjust their charges accordingly, using less-expensive materials, spending less time with patients and often performing only the procedures that are allowed by the plans. The result is what many call a drill, fill and bill practice that keeps them hopping from one room to another, treating an average of 25 to 30 patients a day.

But patients who opt for cosmetic procedures pay for most of the services out of pocket. Freed from the shackles of insurance plans, these dentists say they can earn the same amount of money with half the patient load and offer better service in the bargain.

Instead of cutting down a tooth to fit it with a crown, as is accepted practice for teeth that have large, deteriorated fillings or other problems, esthetic dentists may opt for inlays or overlays made of porcelain or other expensive materials that not only look better, they also allow the patient to keep more of the original tooth.

Some practitioners simply hang out a shingle calling themselves cosmetic dentists. But increasingly, dentists are opting for special training in the field. At Esthetic Professionals, the most popular course, Contemporary Esthetic Dentistry Residency, is a 24-day program of lectures, lab work and clinical practice, at a tuition cost of $6,300.

The tuition fee is only the beginning of the investment the specialty requires.

Cameras that allow patients to view the inside of their mouths on a video screen can cost upwards of $10,000. Along with other high-tech equipment needed for the specialty, the setup costs for an esthetic practice can range anywhere from $50,000 to $200,000.

But once they recoup their investment, dentists estimate that their billings can increase by 30 percent to 40 percent over what they would generate in a typical insurance-driven practice. Tooth bleaching, one of the least expensive esthetic procedures, can range from $300 if the patient does most of the work at home, to $1,000 for a procedure done in the office. Veneers the overlays used to reshape and repair teeth can range from $500 to $3,000 per tooth.

Most of all, dentists say they get far more job satisfaction because patients appreciate what they do.

"If you think about it, when I was a child going to the dentist, the people who came in were in pain," said Dr. Mike Malone, a dentist in Lafayette, La. and a board director of the American Academy of Cosmetic Dentists. "(Patients) were there because they had to be there. When I go to work in the morning, my patients are glad to see me. When we're done, I have patients that are so happy, they're actually crying. It's fun and it's enjoyable."

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