For women involved in street sex work who took part in our research , damaged or missing teeth were more than a health problem. They could become visible reminders of lives they were trying to change.
Authors
- Janine Doughty
Clinical Lecturer Dental NIHR, School of Dentistry, University of Liverpool
- Gemma Ahearne
Senior Lecturer Sociology, Social Policy and Criminology, Part of School of Law and Social Justice, Faculty of Humanities and Social Sciences, University of Liverpool
Our study explored the oral-health needs, experiences and priorities of 21 street sex workers in Liverpool. We interviewed participants recruited through community support services and worked with them to create artwork reflecting their experiences, which they then helped us interpret and refine.
The experiences discussed here are those of women involved in survival-based street sex work. This means selling sex during acute hardship, when someone has few realistic alternatives for meeting an immediate need, such as obtaining food, drugs or somewhere to stay.
At the time of the research, all the women were living in temporary accommodation and using at least one drug, with many using several. Drug use was one part of circumstances that also included insecure housing, violence, mental ill health and earlier experiences of neglect and instability.
Crucially, the damage to their teeth could remain after other parts of their lives had changed. Women described how, even after detoxing from drugs, the appearance of their teeth could lead other people to assume they were still using them. For some, restoring their teeth was closely connected with stopping drug use and street sex work, rebuilding family relationships and showing that their lives had moved on.
How women's teeth became damaged
Participants described childhoods affected by parental substance use, neglect and instability. Some recalled that brushing their teeth or attending a dentist received little attention because their families were struggling to meet more immediate needs.
In adulthood, women linked their deteriorating oral health to overlapping experiences including drug use, diets high in sugar, vomiting and violence. Some said heroin made them crave sugar, while others described developing a dry mouth when using crack cocaine or methadone. Brushing could be forgotten or feel unimportant during periods of heavy drug use. Some women who had already lost several teeth felt there was little point in continuing.
These experiences are consistent with broader evidence. People with substance-use disorders have higher levels of tooth decay and gum disease . Repeated vomiting associated with some eating disorders can erode tooth enamel , while higher sugar consumption is associated with greater tooth decay .
Women in our study described teeth breaking, crumbling or falling out, alongside abscesses and persistent pain. One said teeth had fallen into her hand. Another filed down a sharp, broken tooth with a nail file because it was cutting her tongue.
Poor dental appearance could lead other people to assume that women were using drugs and involved in sex work, reinforcing the stigma attached to both.
Research elsewhere has found similar inequalities. A 2024 clinical study comparing 40 female sex workers with 40 people of a similar age and sex found substantially more missing teeth and tooth decay among the sex workers. A systematic review of international research also identified tooth decay, gum disease and other oral-health problems among sex workers.
These studies cannot show that sex work itself caused the differences. Our participants' accounts suggest that oral-health problems developed through a combination of disadvantage, disrupted care and experiences that could reinforce one another.
Why treatment remains out of reach
Almost all the women described serious difficulties obtaining the dental care they needed. Long waiting lists, treatment costs, travelling distances and fear of dental treatment could all prevent them from starting or continuing care.
A few said they had lost access to a dentist after missing appointments when their lives were disrupted by crises. When dental pain became unbearable, some used drugs to manage it. Others attempted to treat the problem themselves.
Some frontline services were already available. Participants had encountered a dental bus run by the charity Dentaid, and several had received dental treatment in prison. Women valued being able to obtain care through these routes, but said it often concentrated on emergencies rather than repairing or replacing damaged and missing teeth. Participants reported that more extensive treatment in prison was generally available to women serving longer sentences.
Even receiving dentures did not always resolve the problem. Women living in hostels said dentures could be lost or stolen.
This helps explain why oral-health problems could persist when someone stopped using drugs or left street sex work. Emergency treatment might relieve immediate pain, but changing the appearance and function of badly damaged teeth could require several appointments and continuing care that remained difficult to obtain.
Making dental care more accessible
Our findings support outreach, drop-in clinics and mobile dental services, particularly when they work with community organisations that women already know and trust. These services need pathways into continuing treatment so that patients can have damaged or missing teeth repaired or replaced.
Practical support can also help people remember appointments, rearrange them during crises and travel to treatment. Previous UK research with professionals supporting street sex workers found that flexible services and partnerships with trusted organisations were better able to meet people's healthcare needs.
Dental professionals can contribute by providing care without judgment and recognising that previous trauma may make treatment frightening or difficult. A review of oral healthcare for people who have experienced trauma describes ways practitioners can help patients feel safer and retain more control, although further research is needed to establish which approaches work best.
Participants wanted care that would allow them to eat, speak and live without persistent dental pain. They also wanted their appearance to reflect the changes they were making elsewhere in their lives, instead of continuing to identify them with circumstances they were trying to leave behind.
Janine Doughty has volunteered for and is a member of the Green Party. She has received prior research funding from the National Institute for Health Research, NIHR, and is presently employed as an NIHR Clinical Lecturer. Janine currently holds active grants from the Academy of Medical Sciences and the UK Research and Innovation Impact Accelerator Accounts scheme. She is also a Fellow of the College of General Dental Practice.
Gemma Ahearne receives funding from UKRI and has received prior funding from the ESRC.
