Poor oral health has been described as “a national symbol of social inequality” and contributes to chronic diseases including cardiovascular disease, diabetes, obesity, depression, addiction, and other medical and behavioral health conditions (Northridge et al., 2020). Barriers include cost, transportation, and access to care (Northridge et al., 2020). While dental health is often considered separate from public health, the intersectionality between substance use and systemic health makes oral health a vital public health issue, especially in marginalized populations.

Advanced dental disease, especially missing or broken teeth, provokes stigma and shame (Abideen et al., 2024). Social stigma associated with teeth affects nearly one-third of low-income Americans who reported that the condition and appearance of their teeth inhibited their pursuit of job interviews (Centers for Disease Control and Prevention, 2021). People with substance use disorder (SUD) face stigma from both medical and dental providers, causing delays in seeking care and worsening oral health. Moreover, dentists may feel uncomfortable treating individuals with SUD (Brondani et al., 2017).

People in the criminal justice system, especially those in drug treatment courts, have complex health profiles and limited access to medical, dental, and behavioral health care, including treatment for SUD (Hawks et al., 2022). Over 25% of people in the criminal justice system have been charged with a drug-related offense, and approximately 65% of the US prison population has an SUD (Mukherjee & El-Bassel, 2020). SUD exacerbates dental caries and peridontal disease (Yazdanian et al., 2020). Emerging evidence suggests that improving dental care among people with SUD may facilitate and sustain recovery (Uthurralt et al., 2024). Improvement in dental health among justice-involved people with SUD might also promote community reintegration and reduced recidivism and relapse (Herlick et al., 2020).

Drug treatment courts (DTCs) began in the late 1980s as an alternative to incarceration for people charged with nonviolent drug-related crimes (Mitchell et al., 2012). DTCs offer clients a structured regimen combining judicial case processing with SUD treatment (Marlowe et al., 2016). Drug court judges work closely with multidisciplinary leadership teams that often include program coordinators, treatment providers, social service agency representatives, probation officers, and attorneys to address clients’ recovery progress and needs (Marlowe, 2021).

To our knowledge, few studies have examined issues pertaining to dental care and oral health among DTC clients. This research study addresses this gap and examines dental care and oral health disparities among community-dwelling justice-involved people with SUD enrolled in the drug treatment courts. Factors such as limited income, lack of insurance, and community resources may affect access to care, while perceived and self-evaluated dental needs influence health behaviors. Overcoming barriers such as fear of the dentist is crucial for seeking and obtaining treatment. Improved access to dental care can enhance oral health and overall quality of life for these clients.

Self-report surveys were administered to leadership teams and clients in four DTCs in a Western New York county from March-July 2024. Two surveys were developed by an interdisciplinary research team that included a treatment court judge, a professor of dental medicine, a medical anthropologist, a public health professor, a social worker, the director of a transitional case management program, an epidemiologist, and a masters-level research associate. The county includes a metropolitan region, suburbs, and rural areas. The four courts served adults with SUD charged with non-violent offenses. One of the four courts was a veteran’s drug treatment court.

The Drug Court Leadership Survey asked judges and teams to assess their clients’ oral health, access to dental care, and the oral health resource needs of their court. This survey was administered electronically to the leadership teams, comprised of judges, court coordinators, case managers, treatment agency and social service representatives, and public defenders. Team members received an email invitation with an electronic link to the survey programmed in REDCap, to capture responses. The survey was anonymous and only collected the respondents’ roles on the leadership team (e.g., agency representative).

The Drug Court Participant Survey asked clients about self-reported oral health, symptoms, fears, habits, and barriers and enablers to dental care. We incorporated questions from the structural vulnerability index (Bourgois et al., 2017), which assesses employment, social support, financial resources, and housing.

A trained research assistant administered the client surveys in person. During drug treatment court, judges made an IRB-approved announcement about the survey, alerting clients to the research assistant distributing the paper surveys. Flyers promoting the study were also distributed. All actively enrolled participants in the four treatment courts were invited to participate. The surveys were anonymous; no personal identifying information was collected. Clients completing the survey received a “home dental care kit” from the research assistant.

At the end of each court session, the research assistant collected the paper surveys, and the research team entered the data into REDCap. The University at Buffalo Institutional Review Board granted human subjects’ approval (ID: UBIRB STUDY00007972). Approval was also obtained from the 8^th Judicial District Courts Administration and New York State Courts.

A total of 59 clients responded to our survey (Table 1), yielding a response rate of 48%. There were 23 leadership team members responding to our survey: a 58% response rate (Table 1).

The aim of this research was to investigate dental care and oral health disparities among community-dwelling justice-involved people with SUD. To our knowledge, this is the first study to examine oral health issues from the perspective of DTC clients and leadership team members. Survey responses from both groups in this novel study underscore significant oral health disparities and high need among treatment court clients.

Most clients rated their oral health as fair to poor, and 20% were living with severe or very severe oral pain. In a recent national survey (Heaton, Santoro, et al., 2023), 74% of respondents rated their oral health as excellent, very good, or good compared to only 39% of clients in our survey. Fewer than half of our client respondents (47%) had seen a dentist in the last year, compared to 67% in a national sample of US adults (Heaton, Santoro, et al., 2023). Only 41% of our survey respondents indicated that they were brushing their teeth twice a day compared to 66 % of US adults (Heaton, Santoro, et al., 2023).

Court leadership team members’ responses aligned with those of clients. Among leadership team respondents, 73% indicated that clients expressed the need to see a dentist. Oral pain may be associated with missing court, with nearly one-third of court leadership team members reporting that client dental pain resulted in missed court appearances.

The barriers to dental care reported by clients and leadership team members mirror those documented in other studies. These include the structural barriers of cost and transportation, as well as individual barriers of fear, self-esteem, and stigma (Uthurralt et al., 2024). Dental care imposes a heavy financial burden which is a major reason patients avoid seeking care (Northridge et al., 2020; Vujicic et al., 2016). Even with Medicaid dental coverage, finding a dentist remains difficult because only 20% of US dentists accept Medicaid (Northridge et al., 2020). Moreover, Medicaid and private dental insurance plans often limit the number of dental procedures covered, causing patients to forgo dental care due to cost (Vujicic et al., 2016). The downstream effects of limited access to dental care include more and costlier emergency room visits, which often result in tooth loss instead of restorative dentistry work (Vujicic et al., 2016).

Transportation and time pose additional barriers. Transportation cost and dependency on others for rides present obstacles to dental care among low-income groups (McKernan et al., 2018). DTC clients often have a very regimented schedule, and finding transportation can be burdensome.

Fear of the dentist is a common barrier and is estimated to affect 36% of the general population, with an additional 12% experiencing extreme dental fear (Beaton et al., 2013). People with SUD also experience stigma and shame (Doughty et al., 2023), which may be exacerbated by poor oral health, evidenced by broken or missing teeth, promoting feelings of humiliation when seeking dental care (Doughty et al., 2023).

There are several limitations to this small pilot study. Participants represented a convenience sample of volunteers from a Western New York county and may not be generalizable to all DTC leadership teams or clients. The self-report surveys were anonymous and collected at a single point in time.