Nothing to smile about: not everyone who needs dental care can get it.

There's a lot of pain. There's a lot of disfigurement. People can't even get jobs if they have bad teeth. No one is going to hire a person who has to hold a hand over their mouth when they talk because their teeth are so bad."

So speaks Marcia Brand of the federal Health Resources and Services Administration, Office of Rural Health Policy.

And West Virginia Delegate Barbara Evans Fleischauer concurs. "During our evaluation of welfare reform, we asked people who had difficulties getting jobs why they had problems. Twenty-one percent said it was because of their teeth."

The price of rotten teeth is troubling:

* Tooth decay and associated pain interfere with daily activities for 4 million to 5 million children and adolescents a year.

* Chronic oral infections can lead to heart and lung diseases, diabetes and stroke, as well as premature births and low birth-weights, according to the U.S. surgeon general's report, "Oral Health in America."

* The elderly lose their dental insurance when they retire, and Medicare does not pay for routine care. Hence, nearly a third of those over 65 have untreated cavities.

* About two-thirds of the states cover adult dental care to some extent through Medicaid. But 25 states are reducing or eliminating dental benefits; 27 are restricting eligibility; 17 are increasing co-pays; and 37 are freezing of reducing payments.

In rural areas, the lack is especially evident. Children, adults and the elderly with bad teeth face special challenges to better health--lack of dentists, an even lower number of dentists who accept Medicaid or other discounted fees, and reluctance by dentists to participate in managed care programs. Rural populations tend to be marked by poverty, limited education, cultural differences, lack of transportation, and the absence of any kind of coordinated screening and referral processes.

PREVENTION WORKS

Perhaps two of the easiest and most cost-effective solutions to today's dental crisis are preventive: fluoridation of community water supplies and sealant programs.

Researchers discovered as early as the 1930s that people living with naturally fluoridated water had fewer cavities. Today, water fluoridation costs less than $1 per person per year. And it's estimated that every dollar spent on supplementing drinking water with fluoride averts $38 in dental care, according to the Journal of Public Health Dentistry.

Despite proven benefits, more than 100 million Americans do not drink fluoridated water. San Jose; Portland, Ore.; and Honolulu are among the large cities that don't provide fluoridated water. Fewer than 25 percent of the water systems in Utah, Hawaii, New Jersey and Montana are fluoridated. In California, Wyoming, New Hampshire, Idaho and Mississippi, water supplies are only 25 percent to 50 percent fluoridated. California did pass a 1995 law mandating that large cities fluoridate their water, so San Diego and San Jose have been in the process.

Dental sealants are another low-cost, effective way to prevent cavities in children's teeth. Sealants are plastic material applied to teeth that protect against decay. Unfortunately, only 3 percent of low-income children under 8, and fewer than 25 percent of children overall, have received them.

The Centers for Disease Control and Prevention (CDC) have offered grants for coordinated school health programs to encourage states to increase dental sealant use.

The Wisconsin Department of Health and Family Services established Seal A Smile, which made available $60,000 in state money for sealant projects. Two nonprofit groups, Oral Health America and America's Promise, will provide a million dental sealants to approximately 225,000 children by 2010.

NOT ENOUGH DENTISTS

One of the main reasons Medicaid patients don't receive necessary dental care is because few dentists accept them, according to Dr. Steven Steed, Utah dental director. Dentists don't participate in Medicaid because of low reimbursement rates, difficulty in administration and patients failing to keep appointments (more than 30 percent, Steed found).

Five years ago, Utah set out to change those patterns:

* Urban dentists got a 20 percent increase in reimbursement rates if they treated more than 100 Medicaid patients a year.

* Rural dentists received a 20 percent reimbursement increase for all Medicaid patients treated.

* The state expanded the number of dental clinics it operated.

The rate hike initially resulted in some increases in the number of Medicaid dental providers and improved access to care, especially in rural areas. The number of urban providers who treated more than 50 Medicaid patients increased.

In its Oral Health Improvement Act, the Legislature also established an early intervention, prevention and awareness program and set up a case management program to help Medicaid clients.

MOBILE DENTISTS

Because rural residents often have to travel long distances to get dental care, states have literally put dental offices on wheels, moving mobile units across the rural landscape. These programs include the national Smiles Across America, sponsored by the nonprofit Oral Health America organization; Healthy Kids and Seniors, Phoenix; Miles for Smiles, Colorado, Nevada and Maine; and Miles of Smiles, Illinois.

These mobile clinics offer school-based preventive care, including sealants. Staff also visit nursing homes, assisted living communities, the homebound and disabled.

Diane Brunson, Colorado dental director, notes that traveling units provide services to children who might otherwise never see a dentist, as well as raise oral health awareness.

Although it is difficult to find "mobile" dentists and get communities to spend the $2,000 necessary to install 50-amp connectors, the programs are successful. Colorado Miles for Smiles, for example, served 5,438 patients between August 1999 and June 2003 with one van traveling to clinics in five areas of the state. That was 605 days of patient care for people who may not otherwise have been able to see a dentist. Washington Smile Savers has six units serving 30,000 patients a year.

OTHER THINGS STATES ARE DOING

Brand of the federal Office of Rural Health Policy emphasizes that though there is federal help by way of grants and research funding, "there is enormous demand. The solution lies in the states, and they have been extraordinary in addressing the issue."

West Virginia Delegate Fleischauer says that by combining State Children's Health Insurance (SCHIP) and Medicaid money, "every state should be able to help kids from birth and help raise a generation that is cavity-free."

In fact, West Virginia instituted a pediatric screening program at each of its community health centers that screens newborns to 2-year-olds for "early oral health intervention," Fleischauer says.

"We have dentists at each community health center, and we have doctors cooperating with them," she says. "And they've actually trained several hundred people to help patients improve their oral health. It's a unique pilot project and has a lot of potential."

WHAT STATES CAN DO

Obviously, the news about rural dental care is far from rosy. Compounding the problems in all areas is the worry of aging practitioners. Thirty-five percent of all dentists are over age 55. By 2014, the number retiring will exceed those entering the field.

But there are things state and local policymakers can consider, including using loan repayment programs for dentists and hygienists and exempting volunteer dentists from liability for work in mobile, community or rural health centers.

Policymakers also can work with high schools and colleges to recruit new dental students and establish scholarships. Besides adding dental services to rural and community health centers, revolving loan funds can be started for rural practices, as well as grants for equipment upgrades.

And high tech can be added to the mix. "Teledentistry" via e-mail of video can save trips by patients and mobile units.

Making sure all citizens get good dental care can be difficult, but states, communities and volunteers are helping bring back the smiles.

STATE ACTIONS TO IMPROVE DENTAL HEALTH

1 Minnesota allows guest licenses for out-of-state dentists and hygienists.

2 Nebraska formed a Midwest consortium to fund dental student education for rural practices in Kansas, Nebraska, South Dakota and Wyoming. It also has mandated water fluoridation for towns with populations greater than 1,000. The state offers tax incentives for dentists to treat Medicaid clients, as well.

3 Nevada created a hospital-based dental residency program to take care of those children brought to emergency rooms for teeth problems and established its first dental school, which began accepting students last fall.

4 Maine has a loan forgiveness program for newly licensed dentists who agree to practice in rural or underserved areas.

5 Utah pays rural dentists an extra 20 percent over standard reimbursements if they see Medicaid patients.

6 Vermont nearly doubled the number of children having access to dental care by expanding its Tooth Tutor program from 61 to 111 schools. Tooth Tutor sends dental hygienists to school to screen students and match those not receiving routine care with a local dentist.

7 Arizona developed a training program to teach dentists to help special needs children.

8 Oregon expanded preventive programs for low-income pregnant women and children.

9 South Carolina teamed up with the African Methodist Episcopal Church to screen children at various church events and refer them to dentists.

10 New Mexico received $200,000 in federal funds in 2003 to study establishing a dental school in the state.

Dianna Gordon is an associate editor for State Legislatures Magazine.