One day this past March, Paul and Leeann Houston put their year-old daughter Haley into the car for a trip to the dentist. A rotten tooth was making her miserable and stunting her appetite.

Unfortunately, the trip took five hours. That’s because they were driving from Mobile to a dental clinic at the University of Alabama at Birmingham, their last resort. Mrs. Houston had tried for two months to find a local dentist who would accept Medicaid payment and treat children Haley’s age.

Kenya Banks of Evergreen, midway between Mobile and Montgomery, is still seeking care for her 7-year-old son Marquese. With his mouth closed, he looks perfectly healthy. But when his mother tells him to open wide, he reveals teeth that look like bottom-of-the-bag popcorn kernels, they are so discolored and riddled with cavities.

Since April, he has been on the waiting list of the one local dentist who accepts Medicaid patients. There’s no telling when he’ll get called.

“I see two or three children a day who need immediate dental care,” said Dr. Marsha Raulerson, a Brewton pediatrician who treats Marquese and about 2,000 other children covered by Medicaid, the government health insurance program for the poor. “My staff spends half its time trying to find a dentist who’ll see them.”

Across the country, times are good, and more children than ever grow up cavity-free. But when poor children smile, the picture is often disturbingly different. Studies show that the poorest 25 percent of the country’s children and adolescents have 80 percent of the cavities.

The dental divide is acute in states like Alabama that have many poor children and a low tax base, and struggle to provide social services. In Alabama last year, only 21 percent of 350,000 eligible children got dental care under Medicaid, according to the agency’s figures.

Neglectful parents bear some of the blame. But many low-income parents make a good-faith effort to get their kids care, only to see them languish on waiting lists for months because of a shortage of dentists in rural areas, an overall shortage of dentists willing to accept Medicaid patients and a decline in the number of county health departments offering dental care.

Even at UAB, where little Haley finally did get her rotten tooth removed, there’s a three-month wait for a non-emergency appointment with one of the resident dentists. Most days, the waiting area outside the clinic is filled with parents and kids.

“They call me from all over (the state),” said Gwen Turner, who supervises the clinic’s admissions.

UAB is just one place to look for a backlog of poor kids seeking dental care. The wait to see Dr. Donnie Russell, a Selma dentist who has a large Medicaid practice, can stretch to six months for a non-emergency. He treats as many as 220 kids a week in Selma and at a satellite office 54 miles to the south in Thomasville.

“You can’t pick a place a place between here and Mobile where we don’t have a bunch of patients,” he said in an interview from his Selma office. “I just do the best I can because nobody else will see them. And we’re not talking braces or any of that fancy stuff. This is just basic care.”

Little comprehensive research has been done on the extent of oral disease among Alabama’s poorest children, and all of it is dated. But there are recent and alarming snapshots.

The Jefferson County Health Department’s screenings of pre-kindergarten Head Start children this September found about 27 percent had some tooth decay, 19 percent needed to see a dentist and 11 percent needed to see a dentist immediately because of extensive decay or abscesses. Federal research consistently shows that children from poor families have about twice as many baby teeth cavities as other children.

Pediatricians are passionate witnesses of the dental care needs of poor kids. So are school nurses.

“This morning, I’ve seen three at one school. Two of them had horrendous cavities,” said Tina Dooley, a school nurse in northeast Alabama’s Etowah County and president of the state school nurses association. “With one of them, half the teeth were missing. I said, ‘Baby, no wonder your mouth hurts.'”

Failure to get dental care can affect children’s growth, self-esteem and educational progress. By his mother’s account, Marquese Banks missed four days of kindergarten last year because of painful toothaches.

Neglect of dental care can even be life-threatening.

“We probably hospitalize three or four kids a year with acute abscesses and swelling,” said Dr. Stephen Mitchell, a pediatric dentist who supervises residents at the UAB dental school. “They have to be hospitalized with IV antibiotics, because by the time they get to us, they’re severely swollen. Swelling from a tooth infection in a child can blow up much quicker than in an adult.

“If you get the swelling and it’s headed north, then the eyeballs can be at risk. If it’s headed south, that’s the worst-case scenario, because it can get in the glands and elsewhere in the neck, and can block the airways.”

Somewhat less serious hospitalizations of children for dental problems take place 20 to 30 times a month at UAB, Mitchell said. Many of those children have “baby bottle tooth decay,” a condition caused by prolonged exposure to soft drinks, formula and other sugary liquids.

Taketa Dailey of Peterman, in southwest Alabama outside Monroeville, said she knew soft drinks were not good for a baby’s teeth. But she thought that if she diluted them with water, there would be no problem for her little son Johntavius. To her alarm, he developed rampant tooth decay. He ended up having some of his baby teeth pulled and others fitted with steel caps.

The lack of basic understanding about dental care among many Alabamians has recently prompted Alabama Arise, a nonprofit group which lobbies on behalf of the poor, to call for a “massive” education effort through schools and health departments.

“I see so many children that have been on the bottle too long,” Russell, the Selma dentist, said. “They’re 2 and 3 years old, and their top teeth are decayed down to the gum line. We take out what we can’t save.”

No one pretends there was ever a golden era of dental care for poor children in this state. But Dr. David Merritt, a pediatric dentist in the northwest Alabama city of Florence, thinks the situation has worsened in the last decade, even as the overall oral health of Alabamians has improved because of fluoridated water and private dental insurance.

Merritt runs a state-of-the-art clinic. His young patients settle into comfortable dental chairs, don headphones and gaze at the ceiling where TV screens play Disney cartoons. At the end of a no-cavities checkup, Merritt announces the fact and joins his hygienists in warm applause.

But Merritt also is the local specialist who gets called when a Medicaid child has to be hospitalized for dental treatment. He is summoned several times a month, and keeps a thick album of slides of children he has treated, many showing swollen faces and mouths full of cavities.

Merritt tried a few years back to be a regular provider of dental care to children covered by Medicaid. He gave up. The demand overwhelmed him, he said.

“You get branded as a Medicaid provider,” he said. “We’d get 50 to 70 calls a day. We couldn’t take care of our regular patients.”

Medicaid is the first line of defense in dental care for the poor, and the first target for critics.

“On paper, Medicaid is a great program,” said Burt Edelstein, director of the Children’s Dental Health Project, a Washington, D.C.-based advocacy group. “The problem is, it has failed.”

While the problem is national, Alabama’s Medicaid program, along with a handful of others, got an “F” in a recent report card produced by Oral Health America, a Chicago-based nonprofit group devoted to improving dental care. The low grade owed in part to Alabama having about 18 percent of its dentists willing to see children covered by Medicaid. Only 93 Alabama dentists out of more than 1,800 are considered by Medicaid to be “significant providers” of care to children covered by the program.

Alabama dentists have a long list of complaints about Medicaid, beginning with reimbursement rates, which until a recent raise were about 50 percent of dentists’ “usual and customary fees.” Claims processing has been erratic with Medicaid, and the agency infuriated some dentists with its policies about which procedures were covered and which weren’t.

“Most dentists don’t even want to deal with the insurance companies, they’re so hard to deal with,” said Dr. Gary Silbernagel, a dentist who treats Medicaid patients at his office in Flomaton, near the Florida line. “And Medicaid makes the insurance companies look like a piece of cake.”

Silbernagel and some other participating dentists back up the agency’s assertion that claims processing has improved in recent months. Virtually all dentists in the state salute Gov. Don Siegelman for his decision in October to raise most Medicaid reimbursement rates to what Blue Cross and Blue Shield of Alabama pays for dental procedures.

But the improvements are so recent, and dentists are so busy with patients paying out-of-pocket or through private insurance, that it’s unclear what the effect will be.

“Even with the raise in Medicaid, we still, at this time, don’t have enough information to know if it’s going to help” recruit dentists into the program, said Dr. John Thornton, a pediatric dentist who teaches at UAB’s dental school.

Ideally, Thornton and others say, Medicaid should be backed up by public health dentists at county health departments. But while more than 40 Alabama counties provided some dental care at their health departments in the 1970s, now only four do, said Sherry Goode, acting director of the dental program of the state Department of Public Health.

Dental care proved too expensive for most counties. Another factor has been the difficulty of finding dentists willing to work for a relatively modest salary when they can make significantly more in private practice.

And while some states have made prevention of dental problems a priority – spending liberally on screenings, sealants and fluoride rinses – Alabama has done relatively little. The same report card that gave Alabama an “F” for its Medicaid program gave the state a “D” for its state dental program.

Of $60 million in annual discretionary spending by the state health department, less than $500,000 goes to the dental program. The program has had no director since July 1999. (Interviews are under way, said Donald Williamson, director of the Department of Public Health.)

Meanwhile, North Carolina’s dental program – held out as a model – spends about $6 million a year. As part that program, four dentists apply cavity-fighting sealants (plastic coatings) to poor children’s teeth, and 50 dental hygienists screen every kindergarten pupil and fifth-grader for serious dental problems.

Many dentists and pediatric dentists in Alabama have been cheered by the arrival of the federal-state Children’s Health Insurance Program, known here as “ALL Kids.” The program, just a couple of years old, is for children from low-income families that make too much money to qualify for Medicaid under Alabama’s tight standards.

In a surprise to program officials, dental care has been a huge part of ALL Kids, accounting for 20 percent of expenditures the first year and reaching almost 12,000 children. Officials say that testifies to the pent-up need for such care in Alabama.

But the sad irony is that ALL Kids appears to be drawing private practice dentists away from Medicaid, which covers the poorest children. Dentists willing to participate in one of those programs, but not both, are choosing All Kids, said Merritt, the Florence dentist. That’s because its claims processing has been simpler, its reimbursement rates higher and its children (from somewhat better off families) less prone to break appointments or misbehave in the dentist’s office.

Dr. Mary McIntyre, the physician in charge of Alabama Medicaid’s dental program, confirmed that she had heard from dentists who said, “‘I’m not going to take Medicaid anymore. I’m taking ALL Kids.'”

Two state task forces have formed to consider ways to improve dental care for poor children, and in a handful of counties, local leaders have raised money or sought grants to create part-time dental clinics. Siegelman has launched a “Smile Alabama” campaign to recruit dentists into the Medicaid program. And Alabama is one of eight states selected by the National Governor’s Association to be part of a “policy academy” for improving oral health care.

But for now, Alabama continues to be a state where access to dental care for poor children often means a long wait and a long ride.

Nicole Willingham lives in Albertville, in north Alabama, and has been unable to find a local dentist willing to accept Medicaid payment for treating her two children, Brittany, 9, and Jacob, 7.

On a recent Thursday afternoon, Ms. Willingham and her mother, Rebecca Whitehead, pulled the kids out of school and drove them from Albertville to Birmingham, so Brittany could have a long-awaited appointment at UAB for further treatment of extensive cavities. Jacob had cavities too, and they thought he had an appointment. But it wasn’t on the books, so they had to reschedule and plan another trip.

UAB has become the children’s regular source of dental care. The trip one-way is 79 miles, and there’s no telling how many dentists’ offices the Willinghams pass along the way. Ms. Willingham is grateful for the care her children get at UAB, but sorry it’s so hard to come by.

Dental care pilgrimage days are always long days, she said.

“We never get home till after dark.”

(Register Staff Reporter William Rabb contributed to this article.)