LOS ANGELES -- 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," Ms. 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 like Ms. Fuentes haven't shared in the gains. The upper and middle classes 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 children -- largely the result of continued immigra
tion from poor countries, widespread ignorance about routine preventive care, and a public health crisis 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 University of California, Los Angeles, School of Dentistry.
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 swelling, persistent and debilitating pain and tooth loss. Ms. Fuentes, for example, faces root-canal treatments and the extraction of as many as four teeth.
There are other penalties in a society that reveres physical beauty. Children don't want to smile. Adults' job chances 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 Los Angeles. "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 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. One patient reportedly lost the use of an eye because of an untreated infection.
In November, a federal judge ruled that the Medi-Cal dentistry program, called Denti-Cal, 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 percent of private fees.
"The fee schedule is ridiculously low," said Dr. Bevin Richardson, chairman of of the California Dental Association's Council on Dental Care. "Dentists can't even make their overhead costs when they treat Denti-Cal patients."
Meanwhile, people who can afford it have better teeth than ever. Recent national studies show dramatic reductions in cavities, gum disease and toothlessness 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 percent in 1980.
"What we are seeing," a health official said, "is the beginning of the end for a disease that has plagued mankind throughout history."
But that does not tell the whole story. Sixty percent of all tooth disease and decay occur in 20 percent of the schoolchildren, according to epidemiologist Janet Brunelle, author of the research institute report. Ms. Freed noted that a 1987 study by the same agency showing dramatic improvements among U.S. adults was based mainly on data from people with medical insurance.
Few studies have focused on low-income people, said Dr. Peter Damiano, a public health professor at the University of Iowa. He argues that shrinking access to dental care for poor people is aggravating severe problems in dental health.
He and others cite a variety of studies:
* California, Oregon and Washington constituted the only region in the 1988 study of schoolchildren where rates of decay for children aged 5 to 9 had not improved since 1980. In explanation, Ms. 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 with 25 percent in the general population, according to a 1987 article in the American Journal of Public Health.
* A congressional study released in September concluded that Medicaid programs in seven states have failed to provide basic dental services to disadvantaged children.