COLUMN ONE : A Dental Crisis for the Poor : The decline of Medi-Cal’s dentistry program and curbed local funding reduce access to quality, low-cost care. Ignorance about preventing decay is a part of the problem.

For months, Dora Fuentes’ face was swollen, her mouth bleeding and infected. Finally, the 42-year-old went to the dentist--for only the second time in her life.

At a clinic in West Los Angeles, the mother of five conceded to an alarmed dentist that her teeth were literally crumbling. Pieces broke off when she ate.

“I knew there was something wrong,” Fuentes said. “But we didn’t have any money for the dentist. I just tried to ignore the pain.”

While dramatic improvements over the last two decades have given most Americans the best dental health ever, poor people such as Fuentes have not shared in the gains. The upper class and middle class have begun to take good teeth for granted; the poor are finding it more difficult to get low-cost, quality dental care.

Easily preventable disease and decay remain pervasive among low-income adults and their children--largely the result of continued immigration from poor countries to the United States, widespread ignorance about routine preventive care and a public health crisis in California and throughout the country.

“There are segments of the population where disease patterns are rampant. They resemble earlier decades of the century,” said Dr. James Freed of the UCLA School of Dentistry.

Dr. David Farkas, who found widespread decay in screenings of low-income students at two Los Angeles elementary schools recently, said: “By the time they are 30 or 40, these kids will need dentures. Many recent immigrants, like our grandparents from Europe, will lose their teeth.”

The consequences of bad teeth go well beyond the cosmetic. In extreme cases, untreated cavities and gum disease cause infections that can travel through the bloodstream to organs, including the heart and brain. Neglected abscesses lead to swollen faces, persistent and debilitating pain and tooth loss. Fuentes faces root canal treatments and the extraction of as many as four teeth.

There are other penalties in a society that prizes physical beauty. Children do not want to smile. Adults’ chances for employment are jeopardized.

“In another country, having very bad teeth may not be an issue in getting hired,” said Diane Chamberlin of the Valley Community Clinic in North Hollywood. “In this country, it’s an issue. It’s one of the things that keeps people where they are, keeps people in poverty.”

In California, the crisis in low-cost dental care has arisen partly from the virtual collapse of the dental component of Medi-Cal, the state medical insurance program for poor people.

A federal lawsuit has produced evidence that patients in rural counties must drive for hours to find dentists willing to treat them for the state’s fee. Infections in the mouths of some Medi-Cal clients become massive because of delays in treatment. A patient in Alameda County is said to have lost the use of an eye because of an untreated infection.

In November, a federal judge ruled that Denti-Cal, Medi-Cal’s dental program, had shut out those it must serve. He found that dentists are deserting the program in rebellion against the state’s reimbursement rate, which averages about 40% of private fees.

“The fee schedule is ridiculously low,” said Dr. Bevin Richardson, chairman of the California Dental Assn.’s Council on Dental Care. “Dentists can’t even make their overhead costs when they treat Denti-Cal patients.”

The judge ordered the state to revamp Denti-Cal, working with the public interest lawyers who sued on behalf of the program’s 3.3 million clients.

Even if Denti-Cal improves their lot, it will do nothing for another 4 million people in Southern California without dental insurance, many of whom are working poor immigrants. They often seek dental treatment only by showing up in pain at public emergency rooms, losing teeth that could have been saved.

“They are not going to go in for regular checkups and cleaning if they do not have food on the table,” said Dr. Miguel Montes, a dentist who is setting up a free clinic at a Catholic social agency in the Pacoima barrio in the San Fernando Valley.

Moreover, publicly funded dental services have dwindled as cash-strapped local governments are forced to make choices about what medical care to fund and what to abandon--inevitably opting for care that saves lives over teeth cleaning and repair.

Los Angeles County has cut staff and spending at dental clinics by about 50% over the past 10 years. “We’ve simply had to prioritize and cut in areas that are not life-threatening,” said Larry Roberts, deputy director of the county Department of Health Services.

In other Southern California counties, which generally have smaller dental programs than Los Angeles County, funding for dental services has also decreased or failed to keep pace with demand, officials said.

San Diego County offers emergency dentistry at three clinics with a budget of about $500,000 that has not increased, said county spokesman Ron Yardley. He said dental services face a bleak outlook in a county health system whose funding has shrunk as the caseload has grown.

In Orange County, dental services traditionally have represented a negligible share of the public health budget. In Ventura County, the county medical center’s dental budget has declined slightly to about $25,000, said Dr. Richard Ashby, the center’s administrator.

At the eight Los Angeles County health centers with dentists, the waiting period for new patients is three to eight weeks. Community and free clinics are also swamped.

“We get phone calls every day from people wanting dental care,” said Chamberlin of the Valley Community Clinic, which does not offer dentistry. “There is just nowhere for them to go. It is a crisis when people can’t get preventive care.”

At the free Oscar Romero Clinic in the Pico-Union neighborhood near downtown Los Angeles, volunteer dentists treat a large Central American immigrant community. They see 20 patients a day, and there is a two-week waiting list.

On a recent day there, Marta Ramos, 32, waited to have a tooth extracted in the busy three-chair dentists office. She said it had been bothering her for three months. It was the first time in a dentist’s chair since childhood for Ramos, who came from El Salvador two years ago and works part time cleaning houses.

“My economic situation hasn’t permitted it,” said Ramos, who said she goes to the dentist “only when my teeth are sick.”

Her story is repeated daily, clinic workers said. Examinations reveal teeth that must be pulled immediately. Patients usually cannot afford reconstructive work such as crowns.

Dr. Luis Zeledon, the dental director, paused between extractions to display X-rays of a man from a homeless shelter who sat nearby clenching a wad of gauze in his swollen mouth.

“See, this is a case where a guy got substandard care somewhere else,” Zeledon said through his surgical mask. “Whoever tried to pull these teeth left the roots in.”

Meanwhile, people who can afford it have better teeth than ever. Recent national studies show dramatic reductions in cavities, gum disease and tooth loss in the 1980s. In 1988, a study by the National Institute of Dental Research found that half of U. S. schoolchildren were free of tooth decay, up from 36% in 1980.

“What we are seeing,” a health official said at the time, “is the beginning of the end for a disease that has plagued mankind throughout history.”

That does not tell the whole story. Sixty percent of all tooth disease and decay occur in 20% of schoolchildren, according to epidemiologist Janet Brunelle, author of the research institute report. Freed noted that a 1987 study by the same agency showing dramatic improvements among American adults was based mainly on data from people with medical insurance.

Few studies have focused on low-income people, said Dr. Peter Damiano, public health professor at the University of Iowa. He argues that shrinking access to dental care for poor people in California is aggravating severe problems in dental health.

He and others cite a variety of studies:

* California, Oregon and Washington made up the only region in the 1988 study of American schoolchildren where rates of decay for children 5 to 9 had not improved since 1980. Brunelle cited an influx of immigrant children and the fact that California trails other states in water fluoridation.

* Seventy-seven percent of a group of Asian and Latin American immigrant children examined in San Francisco schools needed immediate dental treatment, compared to 25% in the general population, according to a 1987 article in the American Journal of Public Health.

* Denti-Cal clients in the 10 most urban California counties went to the dentist less than half as often as non-poor patients, according to evidence in a federal court case where Denti-Cal was found to have shut out those it should be serving. Just over 30% of people eligible for Denti-Cal received dental care in 1988, down from 39% a decade earlier. Among Americans with dental insurance, 70% saw a dentist that year, according to a University of Iowa study.

* Only one in six dentists in California treated new Denti-Cal patients in 1989, according to a UCLA report last year. There has been a steady decline in dentist participation since 1974. Fewer than 40% of the state’s 21,048 dentists treated any Denti-Cal patients in 1989. From 1987 to 1989, 4,317 dentists dropped out of the program.

* A congressional study released in September concluded that Medicaid programs in seven states, including California, have failed to provide basic dental services to disadvantaged children.

* A 1987 study of Mexican-American children in the Southwest found disease and decay as much as three times as common as among other children. Researchers at UC San Francisco found serious untreated problems among teen-agers, many of whom may have not been counted in school-based studies because they had dropped out.

Better education would help, experts say.

“There is a certain group of individuals who view dentistry as emergency medicine,” said Dr. Tim Collins of the Los Angeles County Department of Health Services. “They only go to the dentist when they are in pain. That cuts across socioeconomic lines.”

Parent-Teacher Assn. dental clinics provide care and education to poor children at nine Los Angeles schools, with payment on a sliding scale. The waiting lists are more than a month long, said Dr. Ronald Taylor, director of the United Way and PTA-funded program. Many parents fail to keep appointments for their children, he said.

“Until there’s a toothache, they are not educated,” he said.

Clinic personnel attributed extensive needs among small children to lack of regular care, too many sweets and tooth decay that results from prolonged bottle-feeding. Damage to baby teeth lays a bad foundation for teen-agers, they said. The costs of routine treatment, let alone for such services as orthodontics, become prohibitive.

Another partial solution may lie in the court-mandated improvement of the Denti-Cal program. If raising the reimbursement rates and reducing red tape draws more dentists into the program, more people will get the treatment to which they are legally entitled.

In negotiations with plaintiffs, state officials have proposed increasing the $100-million Denti-Cal budget by $77 million. The effect would be to raise overall reimbursement rates from about 40% to about 53% of usual dentists’ fees, said Ben Thomas, a Denti-Cal administrator.

Plaintiffs’ lawyers wonder whether the fee increase is big enough. They foresee tough negotiations with state officials because of state budget constraints.

Some observers fear that dentists will continue to shun Denti-Cal because of its tarnished reputation.

A cheap but historically controversial action would be adding fluoride to drinking water. Experts point out that Los Angeles and San Diego are among the few major U. S. cities that do not add the chemical, which prevents decay by hardening tooth enamel.

Fluoridating Los Angeles’ water was rejected by voters in 1975 after stormy City Council debates. Beverly Hills and Long Beach are the only cities in Los Angeles County that fluoridate their water, according to the Los Angeles Dental Society.

The water of 41 of the 50 largest U. S. cities is fluoridated, and it has demonstrably improved dental health, especially among low-income groups and children. Experts say drinking fluoridated water from birth can reduce decay by as much as 50%.