To Rosa Toledo's neighbors in her gated Naples, Fla., community, she seemed like your average householder. She kept up her hedge, she had a family and she made home improvements.
But what some neighbors didn't know was that behind the division in Toledo's garage, hundreds of people were allegedly getting drilled, scraped, poked and fitted for crowns.
Officers booked Toledo, 56, Tuesday on charges of practicing dentistry or dental hygiene without a license. Police say they found a reclining black chair, a cabinet full of dental castings, molds, crowns, bridges and a patient ledger book with names, procedures and allergies in her garage.
"I live right beside them, and I didn't see any evidence of it going on," said Theron Trimball, Toledo's neighbor.
"I was aware that they converted their garage, I assumed it was another bedroom," he said. "The front part of the garage was only 5 feet deep and had only lawn equipment and exercise equipment ... you couldn't see what was behind it."
It's unclear whether Toledo, who works as a dental assistant in a local office, had any kind of formal training.
"It's part of an open investigation," said Kristi Lester of the Collier County Sheriff's Office. "She had said to us that she had practiced in Mexico."
The idea of illegal dentistry in your own backyard may be new to Toledo's neighbors, but those within the American Dental Association say it's a chronic problem. Adding to that mess, some community health care groups say getting any kind of unlicensed health care to save money is a growing trend.
"Basically, it is people [patients] who lack resources," said Dr. Laura Neumann, senior vice president for education and professional affairs at the American Dental Association.
"One of the problems we find is they're charging less money because they're cutting corners on infection control, they're cutting costs on equipment ... basically they're passing along those cost savings to their patients," she said.
Neumann said unlicensed dentistry practiced by immigrants with dental degrees from other countries is especially common.
"We've seen that with the Polish-speaking community, sometimes in Asian communities, in Hispanic communities," Neumann said. "In some cases, I think these folks don't even try to go through the license procedure."
Questionable Medical Treatment a Recent Trend?
A spokesman for the ADA said the association does not keep track of illegally operating clinics, but health care professionals have said, anecdotally, that more and more people are looking for back-alley, illegal or do-it-yourself treatments rather than pay full price in the recession.
This March, the story of a Colorado woman who superglued her own teeth for lack of funds prompted health care providers in other communities to comment on their patients more questionable measures to get health care without paying in full.
"I hear more and more people buying drugs on the street and not just for the people who are addicted," said Ellen Hadaway, a clinical social worker at the University of Michigan Health System in Ann Arbor.
Although expensive, she said, the cost of black-market oxyContin is nowhere near the bill from an emergency room visit to diagnose the pain.
"I am personally seeing an increase in the number of people who are taking other people's medications," said Dr. Richard O'Brien, spokesman for American College of Emergency Physicians and a doctor at the Moses Taylor Hospital in Scranton, Pa.
O'Brien said the pills can range from old pain pills to a family member's leftover antibiotics -- all taken by people who are willing to risk problems instead of seeing their doctors.
"The antibiotics thing I see all the time," he said.
The police report did not specifically list antibiotics as one of the medications officers say they found in Toledo's garage. The report does list finding lidocaine, "suspected chloroform" and Novocain in the garage.
Neumann said licensing requirements for immigrant dentists are controlled by each state's dental board and, in the past 15 years, the rules have changed with many states becoming more stringent.
"We have a huge volume on inquiries of international dentists," Neumann said. "It's pretty common knowledge of what it takes [to become a dentist] in general. This is not a secret."
Florida requires an immigrant dentist to "complete educational programs, which are offered at both Florida dental schools and some specialty residency programs and sit for the Florida licensure exam," according to the Florida Dental Association's spokeswoman Niki Pocock.
"The Florida Dental Association fully supports the Department of Health's efforts to prosecute unlicensed activity," Pocock said.
Neumann of the ADA said most states require the immigrant dentist to retake the last one to two years of a U.S. accredited four-year dental school. Then, many have to complete the written and clinical (meaning working on patients) exam.
But differences between states abound.
Long Road for Dentists Immigrating to the U.S.
"Usually, it's the last two years of dental school. But it can range anywhere from one to three," Neumann said.
In previous years, she said, some states ran into trouble with licensing. California, Neumann said, used to allow immigrant dentists to take a written test, with multiple tries before passing, and then go straight to the clinical test -- which means working on real patients.
"The California Board of Dentistry that was administering these exams saw some patients were being harmed," she said. As a result, California moved to a test on mannequins first.
Neumann said Minnesota, too, had its share of problems years ago when it was just required that some immigrant dentists submit their "foreign credentials" to start treating people.
"But it's really hard to evaluate foreign credentials and they started getting complaints from the public about substandard care," Neumann said.
"There's a lot of pressure on the government. They [immigrant dentists] go to the government and say, 'Hey, you know I'm driving a taxi and there are people here who speak my language who need my care,'" she said.
"It just got to be so cumbersome -- on average, the [three-year class requirement] is the best system that's been found so far for protecting the public."