Every few days, an agonized child or adult shows up at the emergency room of Berlin, New Hampshire's lone hospital, seeking relief from a pain that should have been treated elsewhere.
They have an abscess or a toothache, long-festering and suddenly unbearable. They turn to ER doctors, who can do little beyond supplying antibiotics, because Berlin - like hundreds of communities nationwide - has too few dentists.
Home to 10,600 people, just two of them dentists, in far-northern New Hampshire, Berlin is one of 1,480 areas in the United States designated by federal authorities as suffering from a dentist shortage. That number has nearly doubled since 1990.
In some areas, even patients with private dental insurance have to wait months for an appointment, or travel long distances to a dentist with an open slot. Many low-income families have it worse: Their Medicaid coverage often isn't enough to gain access to already busy dentists.
Loretta Morrissette, who runs an oral health program in Berlin's public schools, sees the damage close-up in children whose parents can't afford dental visits or can't find a dentist who accepts new patients. She cited one mother who called 22 dental offices in one morning, many of them in distant towns, without any luck getting an appointment for her child.
"If the children had early intervention, they could be helped before they get to the point of pain," said Morrissette, a dental hygienist with Coos County Family Health Services. "They end out with an abscess two years down the road, and a four-surface filling instead of one little one. It's traumatic."
Morrissette's program tries to help children in kindergarten through third grade get dental treatment, though more than 70 students with cavities had to be placed on a slow-moving waiting list this year.
"I get an unbelievable amount of calls from parents wanting services, hoping for something that I can't offer," she said. "If they have a child in second grade and one in sixth, it's very hard to tell them there's no access for that older one."
Dr. William Kassler, New Hampshire's state medical director, said nearly 20 percent of the state's 1.2 million residents live in communities with too few dentists. Many of those towns, Berlin among them, have unfluoridated water, causing higher cavity rates among local children who then lack ready access to treatment.
As one of 16 states with no dental school, New Hampshire struggles to recruit newcomers to serve needy towns or replace the many dentists now nearing retirement. The dentists who do come, like their peers elsewhere, generally prefer relatively well-to-do communities, not the rural areas and poor urban neighborhoods with the most need.
Like many others states, New Hampshire is trying to ease the shortages by offering to repay the student loans of young dentists willing to work in underserved areas. Under another new program, the state will pay the malpractice insurance and license fees of retired dentists who are willing to donate at least 100 hours a year to treat needy patients.
"All states are struggling with these issues," said Kassler, whose own family had to wait nine months for dental appointments after moving to New Hampshire five years ago. "It's something that cries out for national policy intervention."
Nationwide, there are about 152,000 active dentists, more than one-third of them over 55, according to the American Dental Association. Experts estimate that dentists' ranks will begin to decline in about 10 years as the number of dental school graduates, now about 4,000 annually, falls below the number of dentists leaving the work force due to retirement or other reasons.
To reverse the trend, dental schools would need to graduate more students. But many of the nation's 56 dental schools are struggling just to maintain current operations; there are more than 350 vacant faculty positions because of an exodus of teachers into better-paying private practice.
Even now, there are severe shortages of dentists in certain regions - a huge swath of the Great Plains, southern Texas, much of Nevada, northern Maine, and poor, rural counties in many other states. The U.S. Department of Health and Human Services says more than 31 million people live in shortage areas; officials estimate that 4,650 dentists would be needed to provide the proper level of service.
Senate Minority Leader Tom Daschle, D-S.D., drew attention to the dentist shortage while touring his home state last month. "I've heard horror stories from South Dakotans who were forced to travel more than 100 miles for a simple dental procedure," he said.
A recent South Dakota Dental Association survey projected that the number of practicing dentists in the state under age 65 could drop from 308 now to 217 by 2020.
Many of the nation's problem areas have large minority populations, yet only 3.4 percent of the nation's dentists are black and 3.3 percent are Hispanic.
Dr. Eugene Kruysman, one of the two practicing dentists in Berlin, has hired a headhunter agency to recruit an associate to help him with his overbooked practice. He is unable to take on new patients, and even his regulars sometimes have to wait several months for a routine visit.
Kruysman, 49, has been practicing profitably in Berlin for 22 years; he raves about the appreciative attitude of his patients and the outdoor attractions of the surrounding White Mountains. But he knows it won't be easy to lure a partner to an economically struggling town several hours' drive from the nearest big cities.
"It's tough to draw someone up here," he said. "The problem only worsens, the more remote the location."
He serves on a local dental-care task force and pitches in by treating some low-income emergency patients. His regulars include some Medicaid-covered families. But he knows that many children and adults in the area are suffering from lack of dental care.
"I don't have an answer," he said. "I see no solution to this shortage anywhere on the horizon."