FARGO -The gums are often swollen and red. The teeth are cracked and decayed. Sometimes, they’re blackened or missing.

Nursing supervisor Heidi McLean has seen a lot of mouth misery in her 19 years of working with inmates at the Cass County Jail.

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The worst is damage done by the use of drugs, including methamphetamine and heroin.

“The teeth just rot down to become almost little nubs,” she said.

McLean, a Fargo Cass Public Health employee contracted to work at the jail, supervises the nursing staff there and coordinates medical and dental care for inmates at Family HealthCare in Fargo.

She said most inmates are underinsured or uninsured, so they haven’t had access to routine dental care.

Some suffer from mental illness, or make lifestyle choices that cause their mouth to deteriorate.

“They’re not thinking about their teeth and their dental hygiene,” McLean said.

Pain usually leads them to the dentist. With 10 to 15 inmates on the waiting list, however, it can take a month or two, maybe more, to be seen.

The inmate is transported by a sheriff’s deputy to the appointment, wearing the usual bright orange jail garb. The inmate's hands and feet remain cuffed the entire time.

Matthew Eaton, dental director at Family HealthCare, said the inmate patients are generally very respectful.

“They’re excited to have someone address their tooth pain because sometimes, it’s pain that they’ve been dealing with for a while,” he said.

There are six full-time dentists on staff at Family HealthCare in Fargo.

The procedures for inmates are limited, by design, to keep costs to Cass County taxpayers down.

That means extractions, mostly - no root canals, crowns or routine dental care.

Occasionally, Eaton will put in a temporary filling, if the inmate is soon to be released and has the means to have further dental work done once they’re out.

Since 2013, the number of dental visits by Cass County Jail inmates has ranged from about 50 to 70 per year, McLean said, at a cost of $100 to $800 per appointment.

Jail Administrator Capt. Andy Frobig said annual costs of inmate dental treatment have been relatively stable.

The jail spent approximately $17,600 on dental services in both 2016 and 2017.

It has spent about $17,200 so far in 2018, with November and December invoices still outstanding,

McLean said each inmate is responsible for a $7 co-pay, a charge that’s remained the same over the nearly 20 years she’s worked at the jail.

One thing that has changed is how well inmates respond to antibiotics.

McLean said one round used to be sufficient to treat someone with an abscessed tooth.

Now, it’s common for inmates to need a second round, or a different antibiotic altogether.

Inmate Joe Miller, 28, of Fargo, asked to see the dentist because of wisdom tooth pain he’s had since last spring.

He admitted to using drugs in the past, but doesn’t believe that history is related to his tooth problem. In fact, he said he has generally good dental health.

Eaton seconded that, saying besides the diseased wisdom tooth, Miller’s teeth looked in pretty good shape.

After injecting an anesthetic to numb the jaw, Eaton needed several attempts to prod and pry the tooth out of Miller’s mouth. He also put in a few stitches to close the wound.

Miller received only over-the-counter medication for pain relief, along with a topical gel or saline rinses back at the jail. Inmates have no access to narcotic pain relievers, McLean said.

Despite being incarcerated, Miller was grateful to have his tooth problem fixed.

“It was nice to be able to get it taken care of because it was pretty painful,” he said.