Homelessness and Oral Health

“It’s hard to brush and floss on the streets”

Persons who are homeless have more grossly decayed and missing teeth than the general population and even the impoverished population living in residences. Homeless persons are 12 times more likely than individuals with stable housing to have dental problems. Persons living in unstable housing, such as a hotel or the residence of a friend or relative, are 6 times more likely to have dental problems. Homeless adults have more intensive dental problems, such as periodontal disease and edentulism (a complete lack of teeth); however, their use of dental services is less than the general population’s. Only 53 percent of toothless homeless individuals have complete sets of dentures, compared with 91 percent of the general population. In addition, 83 percent had not had a dental cleaning in the previous 4 years, a rate 4.6 times higher than in the general U.S. population.

The Oral Health Status of Homeless Children
More homeless children have never seen a dentist than children from families with low incomes who were living in houses. Among homeless children ages 5 to 9 years, 96 percent required dental care and 44 percent had pain or infection. A Boston survey reported that untreated tooth decay in permanent teeth among homeless children in New England was 7.7 times above the regional average.

The Oral Health Status of the Homeless Population
Who Are the Homeless? The Department of Housing and UrbanDevelopment (HUD) defines the homeless as persons who are living on the streets or in shelters, as well as those who are at imminent risk for becoming homeless.Each year an estimated 2 million people in the UnitedStates lack access to a conventional dwelling or residence. Families with children constitute an estimated 38 percent of the homeless population; children account for 25 percent of the homeless population. Causes of homelessness include untreated mental illness, substance abuse and unmet treatment needs,domestic violence, low-paying jobs, changes and cuts in public assistance, and lack of access to affordablehealth care.

Concerns and Consequences
In a national survey, ninety-eight percent of shelter staff said that dental services are important in returning homeless persons to mainstream American society. Tooth extraction is the least expensive type of dental care and is often the only choice for homeless individuals. Missing teeth diminish self-esteem and impair an individual’s ability to eat, get a job, and, ultimately, return to mainstream society.

This publication has been produced by Michelle Clark at the National Maternal and Child Oral Health Resource Center, supported at the National Center for Education in Maternal and Child Health under its cooperative agreement (MCU-119301) with the Maternal and Child HealthBureau, Health Resources and Services Administration, U.S. Department of Health and Human Services. June 1999.

Access to and Utilization of Health Services
Among all vulnerable populations, the homeless population probably has the least access to health services. They have no money, health insurance, or permanent residence, and health care providers are often unwilling to serve them. A recent study in Montreal showed that even if the homeless have the right to free basic dental services, dentists are reluctant to see them in their private offices, especially duringnormal office hours. Most homeless adults and their children are eligible for dental services through programs like Medicaid and CHIP. However, current outreach efforts are not adequate to reach manyhomeless families. Homeless persons with Medicaid coverage are more likely to receive dental services; however coverage varies from state to state. For example, Medicaid covers dentures in New Mexico, but will pay for only extractions in Ohio. In fiscal year 1998, the federal Health Care for the Homeless (HCH) program providedsupport to 128 grantees in 48 states, the District of Columbia, and the Commonwealth of Puerto Rico. Because funding is not specifically provided for dental clinics, grantees are encouraged but not required to furnish most dental services.