At the end of 2015, I saw a dentist for the first time in five years. I’d had a cleaning once after starting college and now, fully graduated up and working, finally ventured out to see a local practitioner. This particular dentist had been serving my neighborhood of Los Angeles for well over 20 years. He had attended and graduated from USC and, in order to connect with many of his patients, worked tirelessly to perfect his Spanish. While I lay in The Chair with no less than six metal utensils sticking out of my mouth, I asked the dentist which three languages he spoke.

“English, Spanish, and Ah-Wahg,” he said.

“What’s Ah-Wahg?” I asked.

The dentist proceeded to drill.

“Ah-WAAAAHGG!!”

…This may or may not be one of my reasons, like many other folks, why I waited so long to finally see a dentist. It’s terrifying to have someone in a partial face mask stick their hands and other foreign objects into your mouth only to tell you that there’s something wrong (a cavity, an overbite, wisdom teeth) and you’ll need to return (i.e. spend more time and money). The very reason that got me to finally go to the dentist after half a decade was that I finally had dental insurance, something that used to be an additional (and pricey) fee to add to general student health coverage when I was in college. Without insurance, dental care was another expensive thing to pay. And when I didn’t have any toothaches or clear signs of something serious, it seemed like a waste of money.

In fact, this perceived lack of need is one of the leading causes of why many legal adults do not seek regular dental care. Additionally, the percentage of Americans with private dental benefits declined from 2000 through 2012, with more adults and children moving into Medicaid or CHIP. Finding dental offices that accept Medicaid can be another obstacle that makes seeing a dentist not just inconvenient but also challenging to low-income families that need assistance to be readily accessible. However, it’s minor issues, like cavities and infections, that can erupt into larger, more serious conditions. Essentially, society reiterates to those who can’t afford the regular care and check-ups required by one of the most vulnerable areas of your body (literally inside of you), “If you’re not dying, you’re fine. No need to see a doctor.”

Now, let’s put this in the context of being homeless. Of all the things going on in your life, having one more thing to put money into (and likely receiving more bad news about) is the last thing you need. In fact, according to a 2010 National Institutes of Health report, 41% of homeless people surveyed said they lacked dental care. The obstacles are often overwhelming  because homeless folks typically don’t have insurance, or dentists say they can’t afford to treat them.

However, healthy teeth are indeed part of the appearance that makes someone seem professionally qualified at a job interview. Healthy teeth and a good smile are a huge factor in how a person is perceived, whether in an informal setting or a professional one. According to 2012 study conducted by Kelton Global, Americans perceive those with straight teeth to be 45% more likely than those with crooked teeth to get a job when competing with someone who has a similar skill set and experience. The sample size was fairly substantial (over 1,000 nationally represented respondents). This means that when a majority of the survey participants feel that people with straight teeth are more likely to be successful and/or wealthy, you can bet there’s a fair likelihood that the people around you feel similarly.

This principle was not lost on any of us at the Pound. There was one father in our shelter, Marty*, who suffered from a degenerative bone condition in his jaw. He had already lost a couple teeth before and, while at the Pound, lost his front teeth. He couldn’t afford dentures and rather than walk around with missing teeth, would jam the front teeth (one of them being an old crown) back into his gums before going out in public.

“That could get you a nasty infection,” my dad pointed out to Marty.

He nodded, but had his own very clear reasons. “Because if I don’t got any teeth in my head people are going to think I’m doing meth or some shit.”

The stigma of homelessness – the assumptions that our society attaches to it – is more painful to endure than jamming your teeth back into your gums. Tragically, appropriate oral healthcare is not readily available to adults on Medicaid. According to Medicaid.gov, “States have flexibility to determine what dental benefits are provided to adult Medicaid enrollees. While most states provide at least emergency dental services for adults, less than half of the states currently provide comprehensive dental care. There are no minimum requirements for adult dental coverage.” So, unless you need emergency oral surgery, you’re out of luck. Additionally, just staying enrolled in Medicaid can be a challenge all its own. Think about it: How would you track someone who doesn’t have a permanent address, lacks consistent access to a phone or email, and doesn’t always have funds for personal/public transportation? This is the Herculean task of getting (and keeping!) people in homeless enrolled in Medicaid or other healthcare.

If you’re under 18, there is some reprieve. Programs like Smiles Change Lives are available in all 50 states. For homeless youth, not getting to see a dentist can be detrimental early oral health and development. According to one study, homeless children living below the poverty level were increasingly prone obesity and dental caries as they age. Poverty contributes to poor dental health by limiting access to nutritious food, refrigerators to preserve food and even running water in some homes. In turn, painful gums and teeth can lead to malnutrition, making it difficult to consume fresh, healthy food. Vicious Cycle Level 80. On the overall, dental care can become inaccessible and so actively attending to it can be delayed.

This habit of putting off visits to the dentist, the physician, the optometrist, develops into a culture. A repeated line of, “It’s not serious, so I must not need to see a doctor.” And so, people who can’t reasonably afford dental care come to believe that they can do without because of the lack of regularity and perceived lack of necessity. Braces, for example, are considered to be a fairly common and “normal” part of development with many kids getting them in middle school or high school. Braces are also expensive, usually ranging from $3,000-$7,000. The extent of Medicaid coverage and services for children can vary by state. In some cases, your teeth must be moderately to severely crooked. In other words, your teeth or jaw alignment must need some serious attention. Of course, neglect of early warning signs (i.e. being at the point where you should probably get braces, but don’t qualify because your need isn’t “moderate or severe”) can also cause dental problems later in adulthood.

Organizations such as Homeless Not Toothless are attempting to change this landscape. With nearly three dozen dental offices participating in the greater Los Angeles area, the nonprofit has provided over $3,000,000 in services. According their website, the dentists who volunteer their time and either pay for laboratory expenses themselves or work with labs who donate dental work as their way of contributing to this cause. It’s not just a matter of awareness or accessibility alone — it’s getting the two to work in tandem that assists individuals and families navigating homelessness in caring for such a delicate and detrimental area of personal health.

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*Please note that names have been changed to protect identities.