For the average American who can pay, dental health is a modern marvel, with new generations growing up nearly cavity-free because of advances in care.

But for those without money or insurance, dental health remains a ”silent epidemic,” according to a U.S. Surgeon General’s Report on Oral Health in America.

And Florida is doing slightly worse than the national average in dealing with it, receiving a C- in a new study that breaks down the surgeon general’s findings for the first time on a state-by-state basis. The report was written by the Chicago-based advocacy group Oral Health America.

”With fluoridation and sealants, we really have the potential to eliminate dental decay in children,” says Harry Davis, dental executive director of the Florida Department of Health. “The real issue is that low income people and racial and ethnic groups are not receiving care.”

That lack of care is particularly evident in Florida, with funding about to run out even for emergency tooth extractions to relieve pain for adult Medicaid patients. With Medicaid-enrolled children here losing baby teeth to decay, permanent teeth come in crooked. And the same kids then are losing permanent teeth to untreated decay.

”A lack of funding creates a lack of service,” says John Tabak, chairman of the community dentistry department of Nova Southeastern’s new Dental College. His students see the problems first-hand when they serve as residents in medical clinics in poor areas of Miami-Dade and Broward counties as well as clinics that serve migrant workers in Immokalee and other farming communities.

“And when a small cavity gets out of control, it gets to the point of decay reaching the nerve, creating pain; it interferes with their ability to eat.”

Oral Health America’s new National Grading Project gives letter grades to each state in various aspects of dental care:

Statistic: Only 24 percent of Medicaid-enrolled children in Florida get a yearly dental visit.

Grade: C.

”It’s a national problem,” says Davis. “Only about 10 or 15 percent of dentists in the country participate in Medicaid care, because the fees are so low.

“Dentists have overhead; you can actually lose money if you provide care.”

The last increase in Medicaid reimbursement to dentists was in 1998, says Connie Ruggles, senior management analyst for Medicaid in the Florida Agency for Health Care Administration.

”We submit a request every year,” she says.

Another problem is red tape, says Coconut Grove dentist Steve Parr.

”Many dentists treat Medicaid patients and think they’re within the guidelines,” Parr says, ‘and then one-fifth to one-quarter of their reimbursement applications get lost in the bureaucratic quagmire. You hear, `Sorry, you must resubmit.’ ”

Statistic: Florida has one dentist for every 2,256 residents, well below the national average.

Grade: D.

Florida is below average in part because its state dental exam is particularly difficult, Tabak said. But this, too, is part of a national problem, he says.

”Around the country in the past 10 or 12 years, half a dozen dental colleges have closed,” Tabak says. “Emory. Northwestern. Georgetown. It makes fewer dentists for a growing population.”

Dental schools are expensive to run, he says, and universities often feel they can make better use of the money and facilities to run their medical school programs. When Nova’s dental school opened in 1997, it was the first in more than 25 years, Tabak says.

Statistic: Less than 65 percent of Florida’s population is on fluoridated water supplies.

Grade: D.

Almost every resident of Miami-Dade and Broward counties gets fluoridated water. But less than half of Palm Beach County’s water is fluoridated, and Boca Raton recently voted down a fluoridation proposal, with some expressing doubts about its safety.

”It gets a little bit controversial,” Davis says. “But the general consensus of the scientific community is that it is safe.”

In one voluntary program, Boca Raton Community Hospital and Nova’s dental program give fluoride treatments to about 250 seventh- and eighth-grade students each year.

Statistic: Just under 9 percent of Florida high school males used spit tobacco 30 days prior to the survey.

Grade: B.

The study credits Florida’s relatively high grade in this category to its aggressive anti-smoking programs. Spit tobacco is associated with higher risk of oral cancer.

Statistic: Only 48 percent of Floridians making less than $25,000 per year see a dentist in a given year.

Grade: D.

”There are very limited public resources for adults,” Davis says. “The adult Medicaid dental program was eliminated by the Legislature, then restored, but with nonrecurring funding.

“We’re waiting to see what the Legislature does this year. If it doesn’t restore the money, then the adult Medicaid dental program won’t exist after the end of June.”

Prospects are poor, says Ruggles.

”The dental adult program was always very limited,” she says. “It pays for pulling teeth and getting dentures, or for emergency extractions.”

A small amount of money is included in the state House appropriation bill, but nothing in the Senate’s appropriation bill, Ruggles says.

“It looks like it’s going away this time.”