Crystal Clements grabbed hold of her grandmother's hand as the dentist started the drill.

"Ow! That hurts!" Crystal cried.

The tears fell, and the dentist, Dr. Frederick Meyer, stopped his work. The Novocain had taken hold -- as evidenced by Crystal's swollen lips -- but she still felt pain as Meyer attempted to fill several cavities. With no nitrous oxide available at the small dental clinic in Louisa County, Meyer had to refer his 11-year-old patient to Charlottesville.

"It's frustrating," Meyer said. "There are some people we can't do anything for. We are just fixing what we can."

Many rural dental clinics face similar challenges. Their limited resources can't keep up with the relentless demand.

"They do the best they can, and a lot of people go without care," said Debbie Oswalt, executive director of the Virginia Health Care Foundation. "That's just the way it is."

Free clinics, community health centers and local health departments -- often run by volunteers -- offer free and reduced-rate dental services to low-income families across the state. Sixty-five of the state's 135 localities have these safety-net clinics, but that's not nearly enough, Oswalt said, because more than 3 million people in the state lack dental insurance.

"Free clinics are wonderful," she said. "They pull in superhuman volunteer efforts. But the demand is much more than the supply can handle."

The Louisa clinic, for example, is open one day a month for about six hours. Meyer volunteers each month along with two other dentists, but they are limited in the number of hours they can contribute because they all work in private practice.

That means patience is a virtue. More than 30 people are on the waiting list.

That pales next to King William County, where the waiting list stands at 154 at the St. David's Free Medical Clinic in Aylett. That translates to a two-year wait for some. The free clinic also serves residents of King and Queen County and the Northern Neck.

"Lord knows, I'd like to get my teeth fixed," said Susie Holmes, a King and Queen resident. She hasn't seen a dentist in three years. "It's hard to smile and talk to people with bad teeth."

Holmes, 65, has been waiting for more than a year for an appointment. She has cavities that need filling and gums that bleed, she said. Still, she understands the waiting game.

"I know there are a lot of people ahead of me, and I know they are doing all they can," she said. "Still, I'm anxious."

Like the Louisa clinic, St. David's is run by volunteers and is open limited hours -- Saturdays from 8 a.m. to noon.

"We'd love to hire a full-time dentist, but we don't have the money for it," said Sheila Iswariah, St. David's president and executive director. "Most of our patients are happy to wait."

Louisa is looking to hire a dentist, a luxury it has had in the past but couldn't keep. One dentist fell ill, and another didn't like working in such a rural area.

"I've been trying to get in for a year," said April Shifflett, 39, an attendant at the Louisa County Animal Shelter. "One time, I got an appointment and the dentist didn't show. Then I had another appointment, but it got canceled because the dentist quit."

Finally, she had a cavity filled in November. She was back last week for a cleaning, her first in three years.

"Hiring a dentist is the way to go because it opens up availability of care," said Donna Isom, executive director of the Louisa County Resource Council, which oversees the clinic. "That's what this is all about."

But hiring a dentist costs about $125,000 or more a year, Isom said. Most rural communities can't raise that kind of money.

"We can do it," said Isom, who is counting on grant money and private donations. "It's important we do so we can provide dental care to those who otherwise would be unable to access it."

Louisa charges a $25 co-payment from those patients who can afford it. Other clinics operate on a sliding scale or provide free services. Local health departments primarily serve children on Medicaid. Free clinics and community health centers primarily see adults, with eligibility based on federal poverty guidelines. For a family of four, that means an annual income of $20,650 or less.

"This sure makes life a little easier," said Joyce Morris, Crystal Clements' stepmother. "It would just be too expensive to take her to a regular dentist."

Fillings can run several hundred dollars, and a cleaning $80 or more.

"I don't have that kind of money," said Holmes, the King and Queen resident. "As you get older, it's hard to keep up with things. It breaks my heart to keep waiting, but I know there are a lot of other people out here who need help, too."
Contact Janet Caggiano at (804) 649-6157 or jcaggiano@timesdispatch.com.