Pain caused by dental problems is a leading cause of missed school days in Kentucky, according to state health officials, and almost half of the state’s children ages 2 to 4 have untreated cavities. About 1 in 10 state residents are missing all their teeth, according to 2004 federal data.

At his private practice, Dr. Smith said that at least once a month he sees a patient who has used Krazy Glue to reattach a broken tooth to the root or to an adjacent tooth. Just as often, he sees patients who have tried to avoid the cost of a dentist by swishing with rubbing alcohol to deal with a tooth infection or by rubbing crushed aspirin pills on gums to numb pain. Both tactics worsen the situation by burning the gums and creating ulcers, he said.

“Under Medicaid,” Dr. Smith said, “the only choice a person with a severe infection has is to have the tooth pulled, even if she’s 25 years old and the tooth is right in the middle of her face.” He added that the program does not pay for root canals or dentures, though it does help pay for a liquid diet for those without teeth.

Medicare, the federal government’s health insurance program for seniors, does not pay for dental services.

Dr. Smith said some people assumed that if their parents and grandparents lost their teeth before they were 40, they would too. They figure no teeth, no costly toothaches, so they pre-emptively pull them.

“Try finding work when you’re in your 30s or 40s and you’re missing front teeth,” said Jane Stephenson, founder of the New Opportunity School in Berea, Ky., which provides job training to low-income Appalachian women.

Ms. Stephenson said the program started helping women buy dentures 10 years ago. She said about half of the women who go through the program, most in their 40s, were missing teeth or had ones that were infected. As a result, she said, they are shunned by employers, ashamed to go back to school and to be around younger peers and often miss work because of pain or complications of the infections.