Liverpool study highlights dental health disparities among street-based sex workers and the need for accessible dental care

Overview

The Conversation originally published this analysis of a Liverpool study that explored the oral-health needs, experiences and priorities of 21 street sex workers. The piece discusses how damaged or missing teeth go beyond health concerns, serving as visible reminders of lives women were trying to change and of the stigma they endure.

Key insights

• Barriers to care: long waiting lists, high costs, travel, and fear of dental treatment hinder beginning or continuing care.
• Stigma and appearance: poor dental health can reinforce stereotypes about drug use and sex work, affecting social interactions and self-perception.
• Support networks and access points: dental buses, prison treatment, and outreach clinics help, but often focus on emergencies rather than restoration.
• Policy direction: outreach, trauma‑informed care, and pathways into ongoing treatment are essential to repair or replace damaged teeth.

Author: The Conversation

Background and study design

The article reports on an Oral Health of Sex Workers project conducted by the University of Liverpool. The study recruited 21 women involved in survival-based street sex work in Liverpool, with participants recruited through community support services. The researchers collaborated with participants to create artwork reflecting their experiences, which the women helped interpret and refine. At the time of the research, all participants lived in temporary accommodation and used at least one drug, with many using several. The study situates oral health within a broader constellation of disadvantage, including insecure housing, violence, mental health challenges, and early-life neglect.

Oral health within the context of disadvantage

Participants described how damage to their teeth persisted as other life circumstances changed. Teeth could remain damaged even after detoxification, and their appearance could lead others to assume ongoing drug use. For some, restoring their teeth symbolized a possible break from drug use and street sex work, signaling progress in rebuilding family relationships and moving beyond previous life paths. The authors connect these individual accounts to broader evidence showing higher tooth decay and gum disease among people with substance-use disorders, as well as enamel erosion from repeated vomiting and tooth decay linked to high sugar consumption.

Mechanisms of dental damage

The accounts point to a combination of factors: childhood adversity (parental substance use, neglect, instability) and adult experiences (drug use, sugar-heavy diets, vomiting, violence). Heroin use was linked to sugar cravings for some, while others reported dry mouth associated with crack cocaine or methadone use. Periods of heavy drug use could cause forgetfulness about brushing, reducing oral hygiene to a low priority, and in some cases leading to a sense that continuing dental care was pointless after losing multiple teeth.

Health consequences and social implications

Beyond pain and functional limitations, poor dental appearance could reinforce stigma and misconceptions about sex work and drug use. The article notes that other studies have found similar inequalities, including a 2024 clinical study showing more missing teeth and tooth decay among female sex workers compared with peers. The participants’ experiences illustrate how oral-health problems can persist even after changes in other life domains, highlighting the need for integrated approaches that address social determinants of health and access to care.

Barriers to treatment and current services

Most participants reported substantial challenges obtaining needed dental care. Barriers included long waiting lists, treatment costs, travel distances, and fear of dental procedures. Crises and life disruptions sometimes caused loss of dental care access, with some turning to self-treatment or drug use to manage pain. Some services did exist, such as a dental bus run by the charity Dentaid and dental care in prison, but care often focused on emergencies rather than repairing or replacing damaged teeth. Even dentures could be lost or stolen for those living in hostels, complicating attempts at restoration and ongoing maintenance.

Pathways to more accessible care

The study’s findings support outreach, drop-in clinics and mobile dental services, especially when they partner with trusted community organizations. Importantly, such services should provide pathways into continuing treatment, enabling teeth to be repaired or replaced rather than merely addressing acute pain. Practical supports—like reminders for appointments and flexible scheduling during crises—play a crucial role in maintaining continuity of care. The article references UK research showing that flexible services and partnerships with trusted organizations improve the ability to meet people’s healthcare needs, and emphasizes trauma-informed care as a foundation for delivering dental care that feels safe and respectful to patients who have experienced trauma.

Policy implications and care priorities

Participants stressed the desire for care that would restore function—eating, speaking, living without persistent pain—and for changes in appearance to reflect broader life changes. The article argues that dental professionals should approach patients without judgment and recognize trauma’s potential impact on treatment experiences. It calls for more comprehensive strategies that connect immediate pain relief with longer-term restorative or replacement treatments, and underscores the need for sustainable care pathways within community settings and the criminal justice system to reduce disparities in oral health among vulnerable populations.