For the better part of four years, David Ford has not had much in the way of teeth.

When he first came to state prison, the Houston man had just enough molars to hold in place his partial dentures. But then he lost one tooth to a prison fight and the rest to a dentist.

Now, five years into his stay, Ford has no teeth at all — and no dentures. And, despite his best efforts and insistent requests, he’s been repeatedly denied them and told that teeth are not a medical necessity.

In the Texas prison system, toothless and nearly toothless inmates are routinely denied dentures and instead offered blended food — often regular cafeteria meals simply pureed. Sometimes they’re told they can’t get teeth unless they become underweight, at which point dentures might be considered a “medical necessity.” In 2016, prison medical providers approved giving out 71 dentures to a population of more than 149,000 inmates, many of whom are elderly, have a history of drug use or came from impoverished backgrounds with sub-par dental care to begin with.

It’s a sharp decrease from 15 years ago, when there was still a denture-making program in-house and Texas prison medical practitioners approved more than 1,000 costly dental prosthetics. California, the next-largest prison system, gives out a few thousand dentures in a typical year.

“Generally speaking, someone with no teeth should be offered dentures,” said Dr. Jay Shulman, a Texas A&M adjunct dentistry professor who’s been an expert witness in multiple lawsuits over prison dental issues. “The community standard for dental care has not been applied to prisons.”

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More than two dozen toothless and nearly toothless prisoners unable to get dentures in contact with the Chronicle over the last year provided similar accounts: Sometimes, they had their teeth removed in prison with the false promise of dentures ahead. Other times they came in with dentures that broke.

Since a policy change around 2003, once inmates find themselves toothless, there is often little the prison medical staff will do. In other corrections systems, dental care complaints have spilled over into lawsuits — but Texas prison officials in June said they had no immediate plans for change.

“Ultimately, it is a medical decision,” said Texas Department of Criminal Justice spokesman Jeremy Desel.

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In Texas prisons, denture policies are set by the Correctional Managed Health Care Committee, a nine-member board including officials and physicians from the Texas Department of Criminal Justice and the two entities that provide health services to the agency’s inmates — the University of Texas Medical Branch and Texas Tech University Health Sciences Center.

The guidelines get revised about every two years, but for at least the past decade, prison policy has only mandated giving out dentures only when “medically necessary” — and chewing is not considered a medical necessity.

The policy recommends inmates with fewer than seven teeth be reviewed, but there have to be additional health needs at play to merit serious consideration for one of the few dozen sets of dentures doled out per year.

“The patients that we’re really focused on are ones that truly have other challenges,” said Dr. Owen Murray, UTMB’s vice president of offender services, “like patients with head and neck cancer that have had treatment that have changed their construction in that area and then dentures become more about preserving the structure.”

Typically, medical staff instead recommend a blended diet.

“There’s this misunderstanding that dentures are the only way to be able to process food,” Murray said. “And our ability to provide that mechanically blended diet is actually a better solution than the mastication and chewing process.”

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For inmates without other medical complications, the policy recommends dentures when general nutritional status is compromised even with a blended diet. At one point, the policy suggested measuring that by weight loss; inmates who were in a healthy range and losing weight or already 10 percent below the recommended Body Mass Index were recommended for review.

But toothless prisoners can suffer in other ways, Shulman said. Sometimes a lack of teeth can cause headaches or jaw pain, as well as impact speech and potentially mental health.

“The issue is, ‘Is edentulism a serious medical need?’ and I would argue that for most patients it probably is,” he said. “If someone claims to be having chewing or eating difficulty, giving them a soft diet for 10 or 15 years is certainly inadequate care, in my opinion.”

And, though some patients do just fine without dentures, Shulman said literature shows a full set can increase chewing ability by 25 to 30 percent.

“Prison shouldn’t be just about bare physical survival,” said Fred Cohen, a retired law professor who authored a book on Correctional Managed Health Care and the Law. “That’s the outer fringes of how a civilized society would operate.”

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Ford first got a tooth pulled in prison back in 2014, the year after he’d come to the Texas Department of Criminal Justice on an aggravated robbery charge. It wasn’t the now-58-year-old’s first prison stay; he’d served time for a similar charge back in 1989, and done a brief stint on a drug charge in 2012.

This time around, he came into prison with partial dentures on the top and bottom. But once that top “tiger” tooth got pulled, he didn’t have anything to keep the top dentures in place — and quickly discovered he couldn’t get new ones made.

That same year, his bottom dentures broke. At that point, he still had a few teeth — but then in 2017 he broke one in a fight. Afterward, he was transported to the prison hospital unit in Galveston, where a dentist pulled the rest of his teeth, promising he’d get dentures, Ford recalled.

Instead, when he got back to his regular unit, medical staff told him that to get teeth he’d have to be losing weight, he said. So he lost more than 25 pounds, he said, but still couldn’t get approved.

“I let them know some foods I was eating was too hard on my gums,” he said, “and they wanted to give me a blended diet.”

But the idea of a meal served in four cups didn’t suit him - so he rejected it. Now, sometimes he soaks his food in milk to eat it. He puts up with bleeding gums. Peanuts and corn are out of the question, and meat is difficult.

“I do more swallowing than I do chewing,” he said during an interview at the Huntsville Unit. “That’s just the way it is.”

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Medical providers in Texas prisons haven’t always been so stingy with dentures. At one point, inmates even made them in-house, as part of a vocational program.

But in 2003 the program was cut — though it’s no longer clear why, according to Desel, the prison spokesman.

Afterward, the availability of dentures fell sharply. In 2004 — the earliest year for which UTMB and Texas Tech could supply data — prison medical providers ordered 1,295 dentures. It’s not clear whether those figures include partials as well.

The following year, that number fell to 518 and then 258. The two providers combined have ordered fewer than 100 dentures every year since 2010, according to data obtained from open records requests.

“We’re always trying to align services with funding,” Murray said, explaining the “medically necessary” policy. “We’re always looking to be more efficient and that is a sign of a good business. That is freeing up dental time so we can see more patients and save more teeth.”

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Texas Tech, which provides medical services for about a quarter of the state’s prisons, was not able to make anyone available for comment.

Not all states run their dental programs the way Texas does. New York routinely gives dental prosthetics to toothless prisoners, and Cohen said Ohio relies on inmate-made dentures the way Texas once did.

In California — where prison health care has been at least partially under court-appointed oversight since a 2006 after a class-action lawsuit — the prison system provided a total of 4,818 complete and partial dentures in 2016, according to California Department of Corrections and Rehabilitation data. That’s roughly six times as many dentures as Texas has given to prisoners in the past decade — even though the Lone Star State has nearly 19,000 more prison inmates than California.

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Over the course of the past year, more than two dozen inmates wrote letters or spoke to the Chronicle to detail the problem. Some sent their medical records and grievances as proof; others offered contact information for family members to speak on their behalf.

“God knows I would love to be able to chew my food before swallowing it,”’ wrote an inmate at Boyd Unit.

Paul Devoe, a death row inmate, copes by soaking crackers and cookies in his coffee to eat them with the few remaining teeth he has.

“I had four, but now I got three,” he said earlier this year. “I have a problem chewing my food with only three teeth.”

Devoe and other prisoners complained about bleeding gums, sore mouths, problems with choking and an inability to eat. Many echoed Ford’s story, saying they’d been promised dentures to replace pulled teeth — only to find that wasn’t really the case. And some also recounted being told — even in recent years, since the policy change — that they could only get teeth if they lost weight.

“Per policy BMI has to meet certain criteria,” a UTMB dentist wrote last year to inmate David Hughes, who says he lost his teeth when he started grinding them under heavy psychiatric medication. UTMB did not offer comment on that case, but Murray said that weight “rarely” is a factor in the decision-making process.

“If we were looking at just that, probably nobody would be getting dentures,” he added.

Other inmates sent the Chronicle denied grievances, and one passed along a form on which an official told him the department had stopped giving dentures altogether more than 10 years earlier.

“Do not know why,” the note said.

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As is often the case with prison medical care, one of the constraints is cost. It’s not clear how many prisoners are in need, but at the low end of the pricing spectrum, top or bottom dentures around $1,000, according to the Healthcare Bluebook.

Just to meet the minimum standards of medical care, the agency said in a recent budget request, would require an additional $281 million for the 2020-2021 budget cycle.

Whatever the price tag, a 1976 Supreme Court decision found that prisons are only constitutionally required to avoid showing “deliberate indifference” to “serious” medical needs, a vague standard with varying interpretations.

“Texas has decided that (not having teeth) is a serious medical need if and only if it’s related to an underlying medical problem,” Shulman said. “But the issue is up in the air.”

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In Washington, a toothless prisoner filed suit after he was denied dentures. After two years of litigation, the state agreed last year to a $15,000 settlement in the case, according to federal court records.

Nearly a decade ago, a toothless Texas prisoner sued over his inability to get dentures. Though the 5th Circuit in part agreed with his arguments, the suit was ultimately tossed when the inmate got out and neglected to give the court his updated address.

And, more recently, a Harris County jail inmate netted a confidential settlement after suing the local lock-up for not giving him dentures. But, despite misinformation to the contrary that circulated inside the prison system, the suit did not mandate any policy changes in the Texas Department of Criminal Justice — even though it raised the hopes of some ill-informed inmates.

“A class-action lawsuit is the only way they’re going to get anywhere,” Cohen said.

For now, the Texas prison system doesn’t have any immediate plans to change its policy.

“The current dental prosthetic policy was last reviewed in April of last year,” Desel said earlier this year, “and there are no plans for it to be reviewed again in the future.”

But, even if it were up for review, the Texas Department of Criminal Justice can’t change it unilaterally — that’s up to the Correctional Managed Health Care Committee.

“Unfortunately, too many people don’t care,” said state Sen. John Whitmire.

Like his colleague in the Senate, Rep. James White, R-Hillister, said legislators would continue paying attention to dental and other medical care concerns. But ultimately, he said, he’d defer to the opinions of UTMB professionals.

“Obviously, I’m not a dentist or medical practitioner so on these matters I have to start where these licensed practitioners lead me,” White said, adding that the primary concerns is meeting constitutional standards.

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A few weeks ago, after the Chronicle put in a request to interview Ford, he got called to see the warden.

The unit’s top brass wanted to know what prompted the media interest — and Ford told him.

A few days later, Ford said, he got called down to dental. There, after four years of trying, he was finally told he qualified for teeth.

“I haven’t got ‘em,” he said during a mid-September interview. “But there’s this little bitty hope.”