Ahmed Almusa didn’t think much about his teeth as he was growing up. He first went to the dentist when he was 6, after his family arrived in the U.S. from Iraq as refugees.
Twenty years later, Almusa was sentenced to an 11-year prison term after a possession and distribution of cocaine conviction. As part of the routine prison intake process, Almusa met with a dental hygienist who cleaned his teeth. During the cleaning he learned it would be difficult to get future cleanings, care for cavities or treatment for other dental concerns that might arise during incarceration.
“They're like, ‘We don't do no cleaning, no filling,’” he said. “If there's something wrong with your tooth and they can fill it, or they can fix it, they don't do that. Either they extract it, or you live with it. That's your choices.”
Almusa served seven years at three facilities in the state’s prison system. He saw a dental hygienist for a regular cleaning once after the first intake cleaning. A dentist extracted two of his wisdom teeth in separate procedures in subsequent years, he said.
Almusa’s experience is far from uncommon.
Nebraska News Service interviewed 10 currently or formerly incarcerated individuals and anonymously surveyed another 6 currently incarcerated individuals separately, using the same questions about their dental care. The survey was non-scientific, but of the 16 people interviewed and surveyed:
- No one received the ADA-recommended two dental cleanings per year.
- A backlog of requests (called kites) meant 10 of the 16 interviewed and surveyed said they waited months or years to sit in a dental chair for any kind of treatment.
- Five of the six people anonymously surveyed said they had to wait at least a year for their intake cleaning.
- Three of the 16 total people interviewed recalled a positive or timely experience with dental care while in prison.
- Every person interviewed and surveyed said in the case of a dental emergency like extreme pain, dental professionals would pull teeth to solve the problem.
“They pull teeth. You're guaranteed to get your teeth pulled,” said Jesse Henry, who is currently incarcerated at Lincoln Correctional Center.
“You got a problem, they'll pull it within the week, but that's all you're getting.”Jesse Henry, incarcerated at Lincoln Correctional Center
The American Dental Association advises people to visit the dentist for a cleaning once every six months. That means outside of prison, Almusa should have seen a dentist or dental hygienist for a cleaning 14 times. Almusa received two cleanings in seven years in the Nebraska correctional system.
Cavities and plaque build up can become gum disease, which is linked to more serious health concerns such as respiratory disease and coronary artery disease.
Dental care, staffing national issue
A lack of dental insurance and a national shortage of dentists are fueling a crisis in preventive dental care across the nation — and not just behind prison walls, experts say.
In 2020, more than 69 million Americans had no dental coverage, so many don’t receive routine dental care, according to the National Association of Dental Plans.
In addition, 1.7 million Americans live in ‘dental deserts,’ with another 24.7 million living in dental care shortage areas, according to a 2025 Harvard study. Those areas are largely rural or are in low-income communities.
By the end of 2023, the Health Resources and Services Administration (HRSA) reported a shortfall of 10,877 dentists across the nation.
As the nation goes, so goes Nebraska’s prison in recruitment of dentists and hygienists, positions that are challenging and often pay less than private practice, experts said.
Nonetheless, Nebraska law requires the state to provide medical and dental care to prisoners. Preventive care is less expensive than treating several dental emergencies or related medical conditions caused by lack of care, according to the National Institutes of Health.
Brett Kessler, the president of the American Dental Association, said in a January letter published in the Washington Post, that good dental care is about more than a sparkling smile.
“Research conducted by the ADA’s Forsyth Institute and the National Institute of Dental and Craniofacial Research have established a clear connection between oral health and various systemic diseases, including heart disease, Alzheimer’s disease, diabetes and hundreds of other associated ailments,” Kessler wrote in a call for the nation to prioritize oral health.
“Imagine not being able to chew food, speak clearly or smile because of pain, infection or missing teeth,’’ he wrote. “The impact on quality of life is undeniable.”
What happens 'on the inside'
Carla Walker was incarcerated at the Nebraska Correctional Center for Women in York from 2015 to 2018 on a conviction for burglary and second-degree assault. She said her initial dental screening was similar to Almusa’s. She, too, was told to not expect much.
“I found it more of an intimidation. If you said you had a problem, they would encourage you to not have a problem,” Walker said.“The impression was number one, they didn't believe you. And number two, they didn't have the resources or skill to follow through.”
The state’s Department of Correctional Services health care policy details regulations for dental care. Its scope includes a screening within seven days of being admitted, a complete exam by a dentist within a month and, when necessary, consultation and referral to specialists for special circumstances like wisdom teeth removal.
The policy also says “routine” care should be provided to people who are incarcerated in Nebraska prisons under the direction of a licensed dentist.
The Nebraska Department of Correctional Services does not define what “routine care” should look like in its healthcare policy.
Further, state law mandates that people who are incarcerated are legally entitled to a “community standard of healthcare,” which means the “type, quality, and amount that any individual residing within the community in question could expect to receive in that community.”
To some, it’s unclear which community the law’s language refers to. To Walker, the language of the law wasn’t protecting her, nor those around her.
“When you have policy books and rules that tell you this is the procedure, and you try to follow that procedure, and you're denied and brushed off and lied to, then we have a problem,” Walker said. “Now the institution that's responsible for rehabilitation is breaking the law, and if you're violating civil rights, then come on in the inside with me, because you're not doing what's required of you.”
In a 2018 report by The Marshall Project, David Fathi, the director of the ACLU National Prison Project, said that “if a tooth or gum problem is causing more than minimal pain, facilities are required to treat it.”
“Even a few days of untreated dental pain is not allowed,” he said.
Jaimee Shropshire, a dental hygiene instructor at the University of Nebraska Medical Center School of Dentistry, said when people have more immediate concerns routine care should become more frequent.
“There's plaque and calculus that builds up on our teeth, and so if we do not get that removed routinely, then, or have good home care, then there's kind of two things that could happen,” she said. “We could get cavities, but also we can get periodontal disease.”
'You’re on the list'
In Nebraska’s correctional facilities, when an incarcerated person needs to see a dental provider, he or she submits a “kite” — an inmate request form. They aren’t able to see a dentist or dental hygienist until they receive the kite back.
“You might get that kite back in a week or two weeks, three weeks, you'll never know,” Almusa said. “Saying that you are on the list, that's all it says. Okay, so you're on the list. So that's what I kept getting back: ‘You're on the list. You're on the list.’ So I'm like, ‘Well, how long do I have to wait?’”
Almusa said he tried to schedule additional cleanings, but the waitlist was six months at the shortest.
“I tried to get my teeth cleaned again, and I never got in there,” Almusa said. “One of the lists is a year long.”
The Nebraska Department of Correctional Services could not be reached for comment on the language of the healthcare policy compared to peoples’ experiences while incarcerated.
Kylie Duncan, who was incarcerated for two years at the Nebraska Correctional Center for Women in York, said she didn’t receive a dental cleaning after her initial screening.
“Within your first month of being there, you're gonna see the dentist, and all he's gonna do is take some X-rays and see what potential mouth work you need done,” Duncan said. “They actually do provide you with an initial toothbrush, but if you want a regular-sized toothbrush, you gotta buy one off the canteen.”
She added the lack of urgency about dental care at York made her feel hopeless.
“You learn to set your expectations low, because in prison, they don't care,” Duncan said. “You go to prison feeling defeated out the gate because they don't care if you get your dental on some year. They don't.”
A dentist who provides care at the state’s prisons agreed to talk about the job, but said that interviews needed to be approved by the department’s communication professionals. Two phone calls and several emails over the span of months requesting that access were not returned.
Walker said the dental care she received, when she got it, was inadequate. What Nebraska’s Department of Correctional Services promises in its policies, she said, was not often not her experience in the women’s facility.
“When you have policy books and rules that tell you this is the procedure, and you try to follow that procedure, and you're denied and brushed off and lied to, then we have a problem,” Walker said. “Because now the institution that's responsible for rehabilitation is breaking the law.”
Too many prisoners, not enough dentists
Jason Kotas was incarcerated for a total of 13 years in Nebraska’s prison system for convictions of burglary, theft by taking, and statutory sexual assault. He said he didn’t have a negative experience with dental care.
“I had a front tooth that was chipped and they fixed it. And usually they don't do that. And I don't know why,” Kotas said. “They took the time to fix my tooth, when sometimes they don't.”
Though he got the care he needed, Kotas said he saw others struggle. People were embarrassed to talk because of how their breath smelled or because they had one too many teeth pulled due to decay, Kotas said.
Rob Jeffreys, director of the Nebraska Department of Correctional Services, acknowledged for healthcare professions workforce shortages at a visit with Nebraska News Service.
The number of dental care professionals who work at each facility varies, according to Dayne Urbanovsky, the director of strategic communications at NDCS.
A dentist at a Nebraska correctional facility can see about 10 to 15 patients daily, Urbanovsky wrote in an email. A dentist is at each facility one to five days each week, she said, depending on the dental needs of the people incarcerated at each space. Nebraska’s average daily prison population is more than 5,500, according to the Prison Policy Initiative, and the state incarcerates 591 per 100,000 people — more than most democratic countries across the world.
In 2017, the ACLU of Nebraska and Nebraska Appleseed, a nonprofit, sued the state’s Department of Correction and the Board of Parole, citing the state’s chronic prison overcrowding as the reason for lack of healthcare.
Dentist Jay Shulman served as an expert in the lawsuit to evaluate the quality of and access to dental care in Nebraska’s prisons.
His investigation found “inadequate dentist staffing and inadequate policies and procedures,” including inaccurate diagnosing of periodontal disease. Shulman said the state’s policies are often “below the standard of care,” and can place all people incarcerated “at risk not only of preventable pain, but also of advanced tooth decay, advanced periodontal disease, and unnecessary loss of teeth.”
A January 2024 report from the University of Nebraska Omaha found five NDCS facilities operating at least 120% over capacity. One facility was operating at 300% of its designed capacity, according to the report.
“When you have that level of crowding, everything breaks down. All services break down, including, but not limited to, healthcare,” said Fathi, of the ACLU National Prison Project.
Fathi served as a litigator on the 2017 ACLU lawsuit, which was ultimately dismissed.
Nebraska has long been recognized as having one of the most overcrowded prison systems in the nation.
And it’s not getting better. The inspector general of the Nebraska Correctional System, Doug Koebernick, said the system is bursting at 140% of its design capacity in his 2024 report to state lawmakers.
In addition, Koebernick said while the prison’s population skews between 21 to 40 years old, he noted the growing population of people in Nebraska prisons older than 40 years of age.
With older age comes more cause for dental concern. The American Dental Association reported that 50% of people 75 and older have at least one tooth affected by decay.
And as the prison population increases, the number of health workers behind bars is decreasing.
The 2024 Inspector General report found there were two full-time dentists and three full-time dental assistants. There were four reported unfilled dentist positions and two unfilled dental assistant positions.
“In Nebraska, they just didn't have enough staff, either in terms of number or qualifications, to provide for the basic healthcare needs of the population,” Fathi said. “There were a number of vacancies among the dental staff, but even if all of the vacancies had been filled, they still wouldn't have had enough dental staff to take care of the dental needs of the population they had.”
Fathi also said this is not a Nebraska-specific problem. The healthcare systems in prisons across the country are often understaffed and lacking in accessible care, Fathi said.
“Nebraska is not alone, there are many states where prison healthcare is systemically inadequate, and incarcerated people are a very medically needy population,” Fathi said.
“There are people who typically haven't had a lot of access to healthcare in their lives, and so they have a lot of conditions that have gone untreated and therefore have gotten worse.”David Fathi, ACLU National Prison Project
Jeffreys said, too, that a majority of the state’s prison population have more intense medical needs.
“A lot of folks come through the door without having any type of health insurance coming in. So, when it comes to us, we're fighting from behind,” Jeffreys said.
The Nebraska Department of Correctional Services contracts dental work in order to meet patient needs, if necessary, Urbanovsky said. It was unclear how many dentists and hygienists it contracts with.
Provided but painful
Almusa, who received two cleaning and two pulled wisdom teeth, said that the treatments were painful. The first surgery left him in pain for weeks, to the point he said he was taking ibuprofen like “it was candy.” The second was far more traumatizing, he recounted.
“(The dentist) tried to pull the whole tooth out,” Almusa said. “So finally he took it out, and the nurse immediately covered it up. I'm like, ‘Can I see it?’ She’s like, ‘Oh, you want to see it?’ I'm like, ‘Yeah,’ and there's a piece of skin on my tooth. I mean, what am I gonna say? It’s already done.”
Henry, currently on job release, said he went through four separate procedures at the Nebraska State Penitentiary to remove all of his teeth because decay left them unsalvageable, he said.
That was more than a year ago and he’s still waiting for dentures from the Department of Correctional Services, he said.
“I still haven't been in for a fitting or nothing, they're just like, ‘You're on a list,’” Henry said. “It's been a year now, and they still haven't done anything.”
“If I knew that,” Henry added, “I wouldn't have my teeth pulled.”
Martin Seeley, incarcerated since 2022 on a conviction of possession with intent to distribute fentanyl, said he needed filling for a cavity in the back of his mouth. Instead, the teeth were pulled and during that process, he said, other teeth were chipped.
“When they went to pull this one, they chipped the one next to it. And then over my duration in prison, it kept getting worse and chipping throughout. And then they gotta pull that one too,” Seeley said. “I have a gap. I'm missing all my back teeth.”
He said he hasn’t submitted a request to see a dentist for partial dentures because he’s convinced that day will never come.
Urbanovsky of the Department of Correctional Services said in an email that because of the number of requests for follow-up questions and comments for this project, the department was unable to respond.
“Given the significant number of follow up questions that have been submitted to our office from the class, we are unable to dedicate any additional time to this project. Our number one priority has been and must continue to be the care and rehabilitation of those incarcerated in our nine facilities,” Urbanovsky wrote.
Walker, who was transferred from the Phelps County Correctional Center to the state’s women’s prison in York due to nutritional concerns, said she often advocated for the people around her when they didn’t receive the dental care they needed.
She said she got a dental appointment once a year, but she sometimes would not go in order to help someone with more pressing concerns potentially move up on the list of requests.
“I knew that there were people that needed it a lot more than me. I didn't have holes, I didn't have teeth falling out or missing. And there were people that did. They had people that were losing their teeth due to genetics, due to former drug use, all kinds of stuff,” Walker said. “I really was afraid that my teeth were eventually going to rot, if you're not getting the proper nutrition, your body starts to deteriorate.”
Nebraska Behind Bars
These audio stories are part of a series produced by the University of Nebraska-Lincoln College of Journalism and Mass Communications 2025 in-depth reporting class.
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