The economy remains reasonably good, more people than ever have dental insurance and cosmetic dentistry has caught on with the middle class.

Most Alabama dentists are as busy as they want to be.

“You can call this the platinum age of dentistry,” said Dr. Mary Lynne Capilouto, dean of the dental school at the University of Alabama at Birmingham.

But good times for dentists mean even harder times for groups that struggle to find dental care, including children from low-income families.

The problem isn’t just that the dental care pie is unevenly divided, with the poor getting a meager slice. The pie is also, experts say, way too small.

“There’s a shortage of dentists in Alabama, particularly in the rural areas,” said Dr. Charles Hall, a Huntsville dentist and past president of the American Academy of Pediatric Dentistry. “And there’s a terrible shortage of pediatric dentists.”

In the 1960s and ’70s, federal money poured into U.S. dental schools so they could expand enrollment to keep up with the swelling population. That soon led to concern about a glut of dentists. Federal money dried up. Many dental schools cut back on enrollment in the 1980s, and five schools across the country closed.

“There were classes of nearly 6,000 new dentists a year, and we’re graduating less than 4,000 now,” said Richard Valachovic, executive director of the American Association of Dental Schools. “There’s no way we’re replacing those that are retiring.”

The surgeon general’s “Oral Health in America” report, issued this past summer, warned of a possible national shortage of dental caregivers in the near future. Alabama feels the pinch already.

Alabama ranked 44th among states in actively practicing dentists per capita in a survey two years ago by the American Dental Association. The top state, New Jersey, had one dentist for every 1,456 residents. Alabama had one for every 2,640 residents.

Already, 25 Alabama counties (including Mobile) have been designated federal “dental health care shortage provider areas” because they don’t have enough dentists for the county population or don’t have enough willing to treat the county’s low-income residents. Other counties will join the list once an evaluation is completed, said Clyde Barganier, director of the state health department’s office of primary care and rural health.

“Practically the whole state will qualify,” he predicted.

The dental care shortage is acute for children. Some general dentists do not treat kids, and many don’t treat kids under age 6. Alabama has only about 80 pediatric dentists, the specialists trained to treat small children with rampant tooth decay – a chronic problem among low-income groups.

“And a bunch of those are about to retire,” said Rick Simpson, a pediatric dentist in Tuscaloosa.

Adding to the problem is a geographical imbalance. A full 30 percent of the state’s dentists are in Jefferson County, the urban and suburban county that encompasses Birmingham and UAB. That county has more dentists per capita than New Jersey, and also has dental clinics for the poor run by UAB and the county health department.

Those clinics are swamped (UAB’s draw from around the state), and they turn away many people who don’t fit the narrow eligibility requirements. But as things go, Jefferson County is Alabama’s promised land for dental care.

“We feel very fortunate,” said Ron Elliott, who directs the dental care program for the Jefferson County Health Department.

By contrast, rural Monroe County, north of Mobile, has seven private practice dentists for a population of 23,960. That’s one per 3,422 residents. But two of those dentists spend half their work week in another county and none regularly sees Medicaid patients, according to officials at the Monroe County Hospital who researched dental care in the county while seeking a federal grant to improve the situation.

Pauline Asberry of Monroeville can attest to the squeeze in Monroe County. She has three daughters – Tiffany, 6; Laura, 8; and Tina, 11 – who are covered by Medicaid, due to the family’s low income. For lack of a local Medicaid dentist or local public health clinic with a dentist, the girls have had no real dental care.

Tiffany and Laura have never been seen by a dentist, though Laura has cavities. Asberry said she paid $49 to have a local dentist look at a gaping cavity in one of Tina’s lower back teeth.

She said the dentist decided the job would require both a complicated extraction and follow-up treatment to make sure the girl’s developing permanent teeth weren’t misaligned by the gap from the extraction. He referred her to a specialist in Mobile who doesn’t take Medicaid payment and wanted more money up front than she had, Asberry said.

That was a year ago. Tina still has the large cavity.

“It doesn’t hurt her every day, but when it hurts, it hurts bad,” Asberry said.

Such stories are hardly peculiar to Alabama. But as states go, Alabama seems ill-positioned to address the shortage of dental care.

For example, UAB produces the great majority of the state’s dentists, and it is one of the dental schools that has shrunk, going from 70-plus graduates annually in the 1970s to about 55 now. That’s smaller than most dental schools.

Capilouto said any increase in the school’s size would require significant new funding, because dental education is expensive. As it is, the school has trouble filling faculty positions. That’s because practicing dentistry (which brings an average net income of about $155,000, according to the American Association of Dental Schools) pays much better than teaching dentistry.

Enticing more dentists to accept Medicaid patients is one obvious way of extending care to the underserved. But, again, the brisk pace of small town dentistry in the state presents a problem.

Since 1969, Dr. Thomas Parish has practiced dentistry in the small, southeast Alabama town of Geneva, near the Florida border. He treats some low-income children but dropped out of the Medicaid program years ago because he had so much trouble getting paid.

Reimbursement rates are up, and Medicaid officials insist (with some dentists backing them up) that claims processing has greatly improved. But that’s probably not going to bring back Parish.

Even though Geneva has remained stagnant in population, and hundreds of its textile jobs have melted away, Parish is busy as one of only two dentists in the area.

“I’ve got all the work I need,” he said.

Medicaid is a troubled program nationwide. But in other ways, some say, Alabama has hamstrung its own ability to extend dental care.

For example, Alabama is one of 16 states that do not allow “reciprocity” for dentists licensed elsewhere and wanting to practice in Alabama. A dentist wanting to relocate to Alabama – even to a rural, underserved area – must pass a clinical exam given just once a year.

Wayne McMahan, executive director of the Alabama Dental Association, said that requiring the exam is “the safest way” of making sure entering dentists are qualified.

But Phil Ives, who tries to recruit dentists for federally funded health clinics in Alabama, said lack of reciprocity is a serious impediment to addressing the dental care shortage in the state.

“I’ve had a number of dentists who have declined to come to this state because they did not want to have to re-take the test,” said Ives, chief executive officer of Central Alabama Comprehensive Health, which runs clinics in five Alabama counties. “I had a young lady I thought was going to be terrific. She had been practicing 10 years in the (military) service. She said, ‘Phil, I’m sorry. I’d love to come to work for y’all, but I’m not going to do my clinicals again.'”

Alabama also is one of just 14 states that let a dental hygienist work on patients only when a dentist is on the premises. That’s what’s called in dentistry “direct supervision.”

Most states allow “general supervision,” where dental hygienists go into public schools and nursing homes to clean teeth and screen cases that need immediate treatment by a dentist. Dentists must authorize such visits, but the hygienists go on their own.

In North Carolina, for example, the state health department employs 50 dental hygienists who screen every kindergarten pupil and fifth-grader for serious oral health problems.

“Here in Alabama you have a cadre of 250 degreed, licensed dental hygienists who, with a longer tether, could serve the disenfranchised population, always under the auspices of a dentist,” said Christine Foley, a dental hygienist for the Jefferson County Health Department, in testifying recently before a state legislative review committee.

McMahan said the Alabama Dental Association does not now support general supervision. But he added, “It’s something we continue to look at.”

There is at least one modest and non-controversial step that could be taken to extend dental care in Alabama, Capilouto and others say. That’s to follow the lead of Texas and other states by creating a loan forgiveness program for dental students willing to practice in rural areas and treat Medicaid and other low-income patients.

The federal government has a similar program – the National Health Service Corps – but funding has been shaky in recent years. Alabama once had 15 corps dentists working in clinics that serve the poor.

“We’ve got six now,” said the state health department’s Barganier. “We could fill 11 more spots right away, and that’s without even advertising.”