Dental Public Health Considerations for Prison Populations

Nicholas S. Makrides DMD, MA, MPH CAPT, USPHS Slides Provided by Jay D. Shulman, DMD, MA, MSPH

Correctional Systems in the United States

 Characterized by fragmentation  Prison –  Federal Bureau of Prisons (10%)  Individual state and territorial prisons  Jail  Federal Bureau of Prisons  County

Objectives

     Describe “public health approach” to correctional dentistry Demographics of incarcerated ‘community’ Discuss the absence of published studies Describe the oral health needs of inmates Provide recommendations for developing a correctional dentistry research agenda

Dental Public Health

 Focus is community, rather than individual  Community: a group with diverse characteristics linked by social ties, common perspectives, or geography.  A prison or correctional system is a community in public health sense  As correctional dentists, this is your community

Public Health versus Clinical Paradigms

Problems Common to all Public Health Clinics and Settings

   Limited Resources   Inadequate funding Dental budgets often subsumed in medical budgets Tremendous Oral Health Need   Periodontal disease High caries rate Professional Staffing     Salaries are not competitive Economic incentives of private practice are alluring Dentists do not want to work in a prison Support staff hard to recruit

Models of Dental Care

Free-Market Model

      Unconstrained resources Private practice Preservation and restoration of natural teeth Cost not a factor Implants, posterior endo, C&B, cosmetic restorations Maximize individual’s oral health

Institutional Model

      Constrained resources Military, community health centers, prisons / jails Preservation and maintenance of oral health Cost-effectiveness Not all missing teeth replaced Maximize community’s oral health

Considerations for Delivery of Care

 Standard of care must be established  Care must be prioritized  Classification system  Populations targeted  Prevention models  Oral Hygiene Instruction (OHI)  Use of fluorides (NaF)  Atraumatic Restorative Technique (ART)

Demographics

Understanding your Patient Population

U.S. Prison and Jail Census

The Breakdown

        Total incarcerated: 2,267,787 Federal & state prisons: 1,421,911 (62.7%)  State and federal inmates held in local jails: 74,378 Local jails: 713,990 (31.5%) Juvenile facilities: 102,338 US Territory prisons: 15,757 Homeland Security facilities: 9,788 Military prisons: 2,177 (excluding Guantánamo) Indian country jails: 1,826

Inmates by Race

Source: Bureau of Justice Statistics

Inmates by Gender

Source: Bureau of Justice Statistics

Impact of Demographics

      Large proportion of low-SES inmates Large minority population High prevalence of chronic disease  Diabetes, HIV associated with periodontal and mucosal disease Graying population ↑ oral cancer risk High prevalence of mentally ill Large unmet oral health needs based on anecdotal evidence and limited studies

Published Studies

NHANES Target Population

Total US civilian, non-institutionalized population

Surgeon General’s Report

The Invisible Population

   Usual sources of national oral health data (NHANES, BRFSS) exclude the institutionalized

Oral Health in America: A Report of the Surgeon General

acknowledged importance of characterizing oral health needs but stated that data were insufficient or lacking No Healthy People 2010 oral health objectives for incarcerated populations

A Void in Peer-Reviewed Literature

 Correctional dentistry is the academic backwater  6 papers relating to adults of which only three were published after 1977*  No national reports of inmate health  Not part of the US research agenda  No projects: oral health of incarcerated  CRISP search CDC and NIDCR  Robert Wood Johnson *Treadwell HM, Formicola AJ,

Am J Public Health

. 2005 Oct;95(10):1677-8.

Issues Surrounding Inmate Care

 Unpopular with taxpayers  Legislators may find it difficult to support inmate programs  May lose favor with constituents  “Hug a thug” not good electoral strategy  Dental Societies rally around causes that build consensus. “Give a Kid a Smile Day”  Public health communities often do not see prisons as a public health population.

What is Known

 There are approximately 15 known studies describing the prevalence of disease within prison populations.

 All studies reveal unmet needs (caries an periodontal disease)  Very few studies follow a cohort longitudinally to investigate preventative or intervention efforts.

Why is Conducting Research Difficult

 Research is a low priority for most clinical dentists  Coordinating efforts is often cumbersome  Reliability of data is often questionable  Inmates are mobile throughout the system  IRB will not permit clinical studies  Very few public health trained dentists working in corrections

Raising Awareness

METH MOUTH

Thinking Out of The Box

“Never, ever think outside the box.”

National Recommendations

     NHANES for institutionalized populations Inclusion of institutionalized populations in 2010 and 2020 initiatives Better working relationships with state dental directors and DOC dental directors Inclusion of oral health within the overall general health of inmates being released Establish level of care standards for correctional dentistry

National Recommendations

 Partner with academic institutions with strong Public Health programs (Shulman @ Baylor)  Increase the number of public health practitioners  Develop a fellowship in correctional dentistry  Increase the IT infrastructure to include electronic health records

Electronic Medical/Dental Records

 Assessing the problem  Collect accurate baseline data at intake  DMFT   CPITN Soft Tissue and Oral Cancer Examinations  The Electronic Health Record.

 Realtime DATA     Longitudinal Studies Information about access Waiting times Access to medical conditions that may be confounders

Transitioning Inmates into Society

 Individual’s constitutional right to dental care stops the day he leaves prisons (unique to US)  No safety nets for adult dental care   In US dentistry is a luxury good The last opportunity for consistent dental care is in prisons

Legal Basis

 Courts have held that institutions that show deliberate indifference to serious medical needs of inmates violate inmates’ right to be free from “cruel and unusual punishment” guaranteed by Amendment VIII of the US Constitution.

 Estelle v. Gamble (1976)

Special Thanks to Jay D. Shulman DMD, MA, MSPH

“The degree of civilization in a society can be judged by entering its prisons.”

Dostoyevsky