An American Dental Association survey released in August reveals a struggling industry: Nearly 39% of dentists saw their patient billings decrease in the first quarter of 2011. In addition, only 16% of dentists added to their patient base, while the rest stayed the same or had a decline.

There is also a huge variation in dental costs and access in the country. People in rural areas, the poor and minority communities are suffering from a severe lack of dentists, said Cathy Dunham, the executive director of the Children's Dental Health Project, an advocacy organization. Also, costs for many procedures vary greatly. The cost of a dental crown can be anywhere from $600 to $1,800, depending on the type of material, where it's made and the dentist's experience.

"We're talking apples and oranges," says Dan King, the marketing director of the Atlanta Center for Cosmetic Dentistry. "A lot of people think 'a crown is a crown is a crown,' but they're not. . . . It's like comparing the Ritz-Carlton or the Hilton to the Motel 6."

To cope with the changing industry, many dentists are offering cosmetic procedures, but in the past few years, cosmetic dentists have been some of the hardest hit. "A few years ago, you had people taking second mortgages or using their credit cards to pay for procedures. That easy credit has dried up," said Dr. John Sullivan, the president of the American Academy of Cosmetic Dentistry. King said the flow of customers to his Atlanta practice had gone from a "fire hose" to a "garden hose," but the practice held up its bottom line by halving its staff.

Askari faced the choice that confronts dentists around the country: either invest in expensive new equipment to expand the procedures offered or risk a "race to the bottom" on prices for basic services such as teeth cleaning and cavity filling, which could lower the quality of service.

"It really is a tale of two cities," said Bassim Michael, a CPA who works with more than 30 dental practices across the country. "The practices that are doing well are the ones that are very growth-oriented," Michael said. "They've put more money in marketing, and they're investing in new technology."

The low end of the dental market is served by discounters such as Brighter.com, a website that includes 25,000 dentists who offer reduced-price services, such as crown work that would normally cost $1,340 for $595. Askari, the dentist from Michigan, said such "rock bottom" prices make it extremely hard to remain profitable and require a practice to have very little overhead.

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Minch, the dentist in Maryland, said that while discounter services fill a niche, it's important to keep in mind that dentists are running businesses and have fixed costs they need to meet. The cheaper the care, the more likely some corners will be cut.

"Dentistry is a labor-intensive operation," he said. "It's hard to do it on a heavily discounted basis. You'll likely get heavily discounted work."