Eugene Youngblood was 16 when a car accident caused his two front teeth to hit the steering wheel, causing damage that would slowly kill his incisors. Youngblood, however, didn’t see a dentist until two years later, when he received a routine checkup soon after entering prison in 1991.
The prison dentists gave him a root canal soon after and told him that they could provide dental implants or dentures if his teeth became brittle and break off.
His teeth did eventually give out in the early 2010s while he was still serving what was expected to be a life sentence. But despite the promise from prison dentists decades ago, Youngblood said newer policies around prison healthcare prevented him from receiving what the state now considered a “cosmetic” procedure.
“It was horrible,” he said. “It became a problem [to eat].”
While receiving prison health care, incarcerated people struggle in particular to get dental care. Though he eventually lost the teeth he injured, Youngblood was lucky to be approved for a root canal. Most often, prisons will instead opt for a cheap and quick alternative.
“Basically the answer is, ‘you have a toothache? Yank it,’” said Nanete Sorich, public affairs manager for Pioneer Human Services, which provides reentry services to people leaving prison.
This state of care is common in prisons across the country, where dental issues are either dismissed for too long or are quickly dealt with in a way that causes long term damage.
After leaving prison, the consequences of missing treatment fall on those formerly incarcerated individuals, since so few dental care resources are available, adding more expenses, more stress and more challenges to an already difficult transition to life outside.
History of poor care
Dr. Jay Shulman works as a correctional dental expert, participating in lawsuits against state prison systems around the country. He said there’s many reasons why those incarcerated enter prison with already poor dental care. More than 76 million adults in America do not have dental insurance, according to a 2021 report from Carequest Institute for Oral Health, which means many people likely enter prison with few visits or no visits at all to a dentist.
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The majority of prison populations also tend to come from poor communities, where Shulman said generations of families develop poor dental care habits. He said that many low-income families will place low priority on scheduling dental checkups, due to cost or time, and place less emphasis on dental upkeep such as brushing and flossing.
“In other words, there was no culture of preserving teeth,” he said.
Within the prison population, substance use disorders are also a widespread problem. Shulman specifically highlighted methamphetamines as a cause of poor dental health, explaining that people who misuse the substance tend to drink lots of sugary, acidic sodas while also dropping brushing habits, causing what’s colloquially known as “meth mouth.”
These factors mean many who enter a prison facility will likely need dental care. But even for people with good dental care throughout their life, prison can make it hard to maintain those habits.
Youngblood, who now works for the prison abolition and reentry program Freedom Project in Washington state, said the brushes and toothpaste you’re allowed to buy in prison are generic and don’t have specific formulas for different teeth. He also said people in maximum security can only get brushes “as long as your pinkie.”
“We can’t buy a higher quality product, we have what’s made available to us,” he said.
‘There are so many people in pain right now’
Israel Espinoza, who went to prison in 1996, said facility dentists will usually just provide a cleaning once a year and little else. And when an incarcerated person complains about pain or a serious problem, it can take months before the issue is confirmed and an operation is ordered.
“That’s how it is today,” he said. “There’s so many people in pain right now.”
Shulman said some prisons don’t even routinely perform an annual checkup. He said those incarcerated often need to make the appointment themselves and, due to staffing or budgeting shortages, the wait time can be months long. That means some individuals expecting to schedule an appointment soon instead face a six month wait.
Espinoza said he brushed and flossed everyday while in prison, but still developed a cavity in one of his molars. He was able to get a filling to fix it, but he said the filling eventually cracked, causing him extreme pain. When he asked for a repair, the dental officers originally said they would just pull the tooth out, but Espinoza was able to convince them to instead repair the filling.
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Sorich said that many prisons will wait till a tooth problem is an absolute emergency before they do something. Even then, many of the formerly incarcerated people she works with have talked about having to wait for appointments even while having swollen faces and clear abscesses..
“I heard that again and again, they’re waiting and waiting, but what are they waiting for?” She asked.
Even after a dental procedure is approved by the prison, it’s often a quick or temporary solution. Shulman explained that, when faced with a heavily decayed tooth, dental officers have a choice on whether to provide a full root canal or simply pull the tooth.
“You can assume which the prison will choose,” Shulman said. “The courts have held that that’s an adequate alternative treatment.”
Franklyn Smith, another formerly incarcerated person working with Freedom Project, said quality of care can depend on which facility you’re being held in. He said some dental officers will be more compassionate, while others will want to perform the easiest procedure they can, or just give you painkillers.
Youngblood was able to get a root canal early in his sentence. But said over the decades he was in prison, he observed a shift towards poorer and poorer care and said a person is lucky if they can get a root canal or good replacement teeth.
“We could no longer get any kind of treatment that was considered ‘cosmetic,’” he said.
Shulman explained that, when telling the difference between a necessary and a cosmetic request, prison systems will look at a person’s ability to chew. Within the Federal Bureau of Prison’s official policies, an incarcerated person doesn’t qualify for dentures if they still have eight or more back teeth that come in contact with each other. That means a person can have nearly every tooth removed on one side of the mouth, but as long as they have enough teeth to chew on the other side, then they don’t qualify for dentures.
Shulman also said, in some state prison systems, that number requirement is six, making it even harder to qualify for dentures.
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Many states have shifted from state-run health care to contracted privately-run health care, a change that began in the late 1970s. This has been the focus of several lawsuits in the last few decades, most recently in Arizona, where observed inadequate care under a private company has caused several deaths and injuries.
Alison Hardy with the Prison Law Office, a nonprofit that advocates for incarcerated people, was an attorney in a similar lawsuit in California, focused on inadequate dental care, which came soon after a broader health care legal fight that began in 2001.
“One of the biggest barriers that we found to the delivery of health care was that they were not paying their dentists enough,” she said.
The case was dropped in 2011 after California’s Department of Corrections increased pay, on top of other changes. Still, Hardy pointed out that some treatments, like orthodontic care, just aren’t addressed in prison.
“There are certainly people who I think could probably use it, but they’re not going to get it in prison,” Hardy said.
Shulman said the extent of orthodontic care is to simply relieve tension in braces so that, while they aren’t removed, they’re also not doing anything corrective.
Living with pain
Untreated dental issues that begin, or are exacerbated, in prison can carry forward into a person’s life after prison, which can affect a person’s ability to find jobs and build relationships.
Michelle Smith, president and COO of Concordance, a reentry program in St. Louis, Missouri, said finding treatment can be difficult, especially for people who have been in prison for a long time and are unfamiliar with the way the health care system works.
For people who do have a history of substance use, Michelle Smith said that untreated dental problems can reawaken addictions, because it’s an easy or familiar way to cope with pain.
Concordance works with newly released people by helping them find appointments and navigate the whole process, even covering co-pays throughout the early process. Smith said this approach is important to give formerly incarcerated people a better start to their transition and ensure that they don’t end up incarcerated again.
A more hidden pain associated with poor oral care is the potential blow to self-confidence.
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For those leaving prison, low self-esteem is often a major roadblock to moving their life in a different direction.
“There’s a lot of things that happen [to formerly incarcerated people] that, in our minds, make us feel like we’re worthless,” Youngblood said.
Franklyn Smith said many people who leave prison have a “hardened” mentality, or feel worthless because they’ve been to prison. That mentality, he continued, makes it difficult for a person to reach out for help or find a job.
“Throw on top of that that I’ve got these holes in my mouth — it can stagnate growth,” he said.
There are several studies that indicate dental problems cause a profound impact on a person’s self esteem. One study from the British Dental Journal found that half the people questioned who have missing teeth avoid looking at themselves in a mirror without their dentures in place. More than 30 percent of people in the same study avoided letting their partners see them without their dentures in place.
Another study from American College of Prosthodontists says while there’s a clear connection between psychological distress and tooth loss, there’s very few tools to identify and treat the issue within medical circles. For formerly incarcerated people, who already struggle with physical and mental health care access both during and after serving time in prison, there’s high risk of this kind of issue flying under the radar.
One of the most difficult challenges formerly incarcerated people face when leaving prison is finding a job. A combination of low education, social stigma and poor self-esteem can create roadblocks to finding steady work.
According to the Prison Policy Institute, the unemployment rate for formerly incarcerated people is 27 percent, more than seven times the U.S. average of 3.6 percent.
This already difficult process can be further exacerbated by any perceived flaws in appearance, like missing, broken or decaying teeth.
That can be especially true for public-facing jobs such as those in the restaurant and service industries.
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Among low-income adults, who make up the vast majority of the nation’s prison population, 29 percent believe their teeth quality affected their ability to interview well for jobs, according to a study by the American Dental Association.
Youngblood said many people associate missing teeth with a history of violence or fighting.
“It’s like having a tattoo on your face,” he said.
He also said poor oral care is often associated with drug use, a stigma he said he has had to deal with despite never taking illegal drugs.
“That’s hard for me because I don’t use drugs,” he said. “It did something to my self-esteem.”
Michelle Smith, the reentry program COO, said even if a formerly incarcerated person can find a job, poor dental care and pain can cause absences, which can hurt their chances of keeping the job.
Youngblood was lucky with his teeth. While in prison, he worked as a community engagement specialist for Freedom Project, which helped convince the state to grant him clemency and ensured a job was waiting for him within the organization.
“It turned out to be a fantastic space for me,” he said.
Yet under Freedom Project’s dental plan, the copay for his procedure took nearly a year to pay off.
“I make a sustainable living wage, whereas somebody who makes $16 to $17 an hour … I can’t imagine how they’re going to be able to get theirself back in a good space,” he said.
Michelle Smith believes changes are needed well before anyone enters prison, since low-income communities, which include many formerly incarcerated people, tend to have widespread unmet dental needs.
In the meantime, Franklyn Smith said there’s very few resources for dental care after prison beyond those that already exist for homeless or marginalized communities.
Charles Hopkins, who was in prison from 1972 to 2019, said it took seven months to repair the damage caused during his time in prison, but afterward, he said he’s finally “comfortable enough to smile.”
“My speech is different, my attitude is different and my confidence is different,” he said.
Franklyn Smith believes getting those issues taken care of can do wonders for a person’s self-image.
“It empowers a person when you’re able to get your smile back,” he said.